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Board: 28 th January 2015 Attachment J0 TRUST BOARD Meeting Date: 28th January 2016 Title: Supporting Papers Available electronically on the website at http://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 Clinical Services & Healthcare Governance CH CH AM B1 (i) B2 (ii) B2(iii) Log of Complaints Received Qtr 2 2015/16 Professional Clinical Leads Group Notes of the Healthcare Governance Committee Operational Review (End of Life Care) held on 10th December 2015 (J1) (J2) (J3) Operations and Performance PB C2 (i) Integrated Board Performance Report (December 2015) (J4) Strategy, Resources and Engagement PB DL D2 (i) D4 (i) Month 9 Financial Position Report TDA Return (December 2015) (J5) (J6) Board Governance and Leadership No Items 1
TRUST BOARD - Home | Hertfordshire Community NHS Trust
TRUST BOARD Meeting Date: 28th January 2016 Title: Supporting
Papers Available electronically on the website at
http://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
Clinical Services & Healthcare Governance
B1 (i) B2 (ii) B2(iii)
Log of Complaints Received Qtr 2 2015/16 Professional Clinical
Leads Group Notes of the Healthcare Governance Committee
Operational Review (End of Life Care) held on 10th December
2015
(J1) (J2) (J3)
(J4)
D2 (i) D4 (i)
(J5) (J6)
Board 28th January 2016 Attachment J1
Log of Complaints received 1st October 2015 31st December 2015:
Total 62 East and North Herts CCG
ID Description Business Unit Service Locality
Is this a Red Flag
Complaint? Outcome
1073
2
Concerns raised about quality of loan wheelchair given to client.
The chair has damaged the client's flooring. Also issues regarding
the repair service provided.
Adult Services East & North
Wheelchair Service Herts Wide No
Apology provided for any distress caused. HCC will respond to
request for compensation as the issue related to the repair of the
wheelchair.
1075
2
ENHCCG leading - Concerns raised over the handling of a Continuing
Care Retrospective Review case and assessment made by the community
nurses.
Adult Services East & North
Community Team
No Continuing Health Care paperwork was completed appropriately by
the Nurses.
1077
2
Concern raised about difficulty in getting through to OT team on
the telephone and that once phone was answered it was left on the
side so that the caller could hear staff conversations.
Children’s Therapies
Children’s Occupational
Herts Wide No
Apology provided and appointment offered. Family did not wish to
pursue the complaint any further. The Service is reviewing the
Telephone system in order to improve functionality.
1
Is this a Red Flag
Complaint? Outcome
1080
2
ENHT Leading - Concerns raised regarding physiotherapy information
provided pre operatively. Patient advised therapist that they felt
the operation had not been successful and ENHT require information
regarding post-operative care.
Adult Services East & North
(Acute Therapies)
1084
2
ENHT leading - Concerns raised about the delay in receiving
physiotherapy whilst an inpatient at Lister Hospital.
Adult Services East & North
(Acute Therapies)
E&N Herts No Clinical care was appropriate as patient was
medically unwell and unable to participate in therapy.
1086
2
ENHT Leading - Patient is very concerned with the waiting times to
be seen by Women's Health Physiotherapy Service.
Adult Services East & North
(Acute Therapies)
E&N Herts No
Explanation provided that the Women's Physiotherapy service
received 4 referrals for patient for differing conditions which
have different waiting times. Apology that the 4 referrals were not
amalgamated into one.
1089
2
Complaint regarding difficulty in getting through to physiotherapy
department to make a follow up appointment.
Adult Services East & North
MSK Physio E&N / MSK
Triage E&N Herts No
Apology provided. Patient was offered an appointment and did not
wish to pursue any further.
2
Is this a Red Flag
Complaint? Outcome
1090 2
ENHT leading - Concerns raised regarding the circumstances
associated with mother's discharge from Lister Hospital. Specific
concerns relating to dietician advice, lack of post hospital OT and
physio and alleged disagreements at MDT meeting pre
discharge.
Adult Services
Herts Valleys
Nutrition & Dietetics Herts Wide No
Therapy: Apology given that it was not clear in the notes that
therapists had any active involvement in making recommendations or
a clear plan for discharge. Action: Discussion with therapists
involved requirement for accurate recording of their treatment,
findings and to make clear recommendations and suggestion for
further therapy. Dietetics: Action: Dietician should have checked
formulary list prior to prescribing - is now aware of the
importance of checking list.
1093
2
Concerns raised that letter was received stating that client had
failed to attend an appointment and would be removed from the
waiting list. Complainant states no appointment letter had
previously been received. Difficulty in accessing the service via
telephone also highlighted.
Adult Services East & North
Wheelchair Service Herts Wide No
Service had wrong postcode on system for patient which could have
accounted for appointment letter not arriving. Record amended with
correct information. Issues regarding no return on phone calls were
identified as not calls made to Wheelchair Service but to Herts
Equipment Service.
1097
2
ENHT leading - Concerns raised about length of time to wait for
physiotherapy appointment and referral for hydrotherapy but
subsequently advised there is no facility for this. Also, a delay
and confusion in getting required OT assessment.
Adult Services East & North
MSK Physio E&N / MSK
Triage E&N Herts No
Clinical Care was appropriate. There are no Hydrotherapy Pools
within the NHS in Hertfordshire. Confirmation received that no OT
referral has been received by the service.
3
Is this a Red Flag
Complaint? Outcome
1098
2
Concerns regarding care mother received whilst in Herts & Essex
Rehab Unit, ineffective therapy and sent home with limited care
package and no home assessment.
Adult Services East & North
1102
2
Concerns raised that the Specialist Diabetes Nurse has not returned
their mother's call and she requires support and advice.
Adult Services
Herts Valleys
Service Herts Wide No
Agreed with complainant and patient that the patient would now be
referred to the acute setting to manage their diabetes. Service
confirmed that they had been contacting the patient as
requested.
1107
2
Concerns raised about Stroke Early Support Discharge Team Services
particularly relating to treatment received from SLT and that no
Care Plan is in place.
Adult Services East & North
No
Information Leaflets have been updated to ensure that they include
accurate information regarding who will be attending home visits.
Apology provided that care plan was not in place at the time of the
complaint - processes have been reviewed to ensure that care plans
are shared and completed in a more timely manner. SLT provided was
appropriate based on clinical need.
1113
2
Concerns raised about lack of contact from the Wheelchair Service
despite leaving messages about acquiring a replacement chair for
complainant's son.
Adult Services East & North
Wheelchair Service Herts Wide No
Apology provided that the administrator had noted down the wrong
contact number for complainant and failed to cross reference.
Complainant was offered an appointment and did not wish to pursue
any further.
4
Is this a Red Flag
Complaint? Outcome
1114
2
Concerns raised regarding clinical care provided, patient felt they
were in considerably more pain after session.
Adult Services East & North
Awaiting correspondence from complainant - may not wish to
pursue
1117
2
Concerns raised regarding ability to contact Health Visiting Team
after a sudden child death and also concerns raised regarding
response received from unexpected child death team.
Children’s Universal
No
Explanation provided that Rapid Response team only respond to
unexpected child deaths and sadly this child had deteriorated and
their death was expected. Apology provided that the GP was unable
to speak to Health Visiting team but on review there was a fault on
the line the GP used to call. The number is not provided to the
public.
1127
2
Concerns raised regarding provision of equipment and continence
products on discharge from hospital.
Adult Services East & North
No
Explanation provided to the family that the community Nursing Team
did not receive a referral from the discharge team. Assurance
provided that carers could have referred patient for continence
assessment.
1128
2
Concerns raised regarding lack of contact and involvement from ICT
since discharge from Herts & Essex Hospital.
Adult Services East & North
Is this a Red Flag
Complaint? Outcome
1132
2
Concerns raised via MP about Wheelchair Services. Significant delay
in assessment and delivery of wheelchair. Complainant feels that he
has limited independence due to lack of provision.
Adult Services East & North
1133
2
Concerns raised that father has not received any physiotherapy
whilst an inpatient.
Adult Services East & North
(Acute Therapies)
Herts Valley CCG:
Is this a Red Flag
Complaint? Outcome
1076
2
Complaint regarding the way Family Health Visitor spoke to parents
when making a home visit. Complainant's partner was very upset by a
remark that was made, family felt that it was sarcastic.
Children’s Universal
Family Nurse Partnership Stevenage No Apology provided for any
distress caused. Family
continue to be support by the FNP Team.
6
Is this a Red Flag
Complaint? Outcome
1078
2
Unacceptable wait and difficulty in chasing up OT referral for a
replacement bath for son with Ehlers Danlos Syndrome. Unhappy with
response from therapist that stated the complainant was unreachable
and advised self-referral to Community OT. Also unhappy with
therapist's recommendations to school. Community OT had no record
of a referral. Complainant would like a new OT for son.
Children’s Therapies
Children’s Occupational
Therapy Services
Herts Wide No Family were offered another therapist and they no
longer wished to pursue the complaint.
1079
2
Complaint that Health Visitor was unprofessional. Telephone conduct
lacked compassion and that concerns were raised over patient
confidentiality and incorrect identification of the child that was
being discussed.
Children’s Universal
No
Apology given for conduct of Health Visitor during telephone call
to mother. Actions: Another Health Visitor has been allocated to
the family and a targeted piece of work is being offered to family.
Health Visitor concerned has reflected on the phone call and has
accepted the learning from this complaint.
7
Is this a Red Flag
Complaint? Outcome
1081
2
Concerns that a copy of the child's advance care plan was put in
child's school bag for all to see. Family are also concerned
regarding child's communication book that was sent home with
another child.
Children’s Specialist
West Herts No
Apology provided. All staff have attended a training day and
discussed the concerns raised and a number of actions have been
identified. All staff have been asked to file letters/reports
appropriately and not to leave paperwork inappropriately in
communal areas of the unit. All staff have been asked to review
paperwork before placing it in school bags in order to ensure that
it is appropriate to do so. Any paper information other than a
communication book will be placed in a correctly addressed sealed
envelope before being placed in a school / overnight bag. Shelving
with in/out trays has been installed and will be used to manage the
flow of paperwork within the unit.
1082
2
Concerns over the standard of care received by the community
nursing team and problems in receiving the correct equipment at
home in a timely fashion.
Adult Services
Herts Valleys
No
Service Lead met with patient and agreed that the nurse would not
visit the patient again. The Nurse involved was spoken to and
reflected on her practice.
8
Is this a Red Flag
Complaint? Outcome
1083
2
Concern raised that there is no wheelchair access at The Principle
Health Centre in St Albans and that children's audiology clinic is
situated there despite other clinics in the area having suitable
access.
Children’s Specialist
Children’s Audiology West Herts No
Principal Health Centre cannot provide full audiology services on
the ground floor due to specialist equipment being required. An
alternative venue is offered to wheelchair users. Estates are in
contact with St Albans City Council and Commercial developers to
deliver a new health facility which will replace the Principal
Health Centre. This will provide an improved range of service
within a high quality environment which will comply with all
statutory and NHS standards.
1087
2
HCC leading - Concerns raised over discharge planning from Sopwell
Ward, St Albans, to home.
Adult Services
Herts Valleys
Community Hospitals
Sopwell Ward No
Apology given that there was no communication to family member on
day of discharge and that there was poor communication with social
services. Actions: Discharge checklist changed to include - family
have been informed of any potential changes to discharge process
and assurance sought that care agency have visited patient prior to
discharge.
9
Is this a Red Flag
Complaint? Outcome
1088
2
Concerns about the care and treatment given by community nurses
during mother's final days of life.
Adult Services
Herts Valleys
No
Lessons learnt: Staff to reflect on the situation and acknowledge
what they would do differently if in a similar situation, consider
the 6 Cs Actions: Access Symptom management/control training for
these nurses and for other staff as appropriate. End of Life Care
as objectives.
1091
2
Adult Services East
Therapy Herts Wide No
Clinical care was appropriate. The decision for patient to have a
Radiologically Inserted Gastrostomy Tube would have been made by
the medical team.
1092
2
Family are concerned that the Health Visitor failed to take any
action when it became apparent child had not met milestones. Child
now requires an operation to a dislocated hip.
Children’s Universal
No
Appropriate clinical care given. Lessons learnt: The HV could have
had a more robust plan in place to provide further support by
offering regular phone calls or a follow up home visit during the
difficult time. A new health visitor has been allocated.
1094
2
Complainant wishes to make a complaint of Discrimination under the
Equality act 2010 stating that a health visitor, during a home
visit, said that he had 'a mental illness which is
Children’s Universal
Is this a Red Flag
Complaint? Outcome
1095
2
Adult Services East
1096
2
NHS England leading - Concerns raised by grandmother that grandson
is not receiving the appropriate medical attention whilst in prison
and is suffering an episode of psychosis.
Adult Services
Herts Valleys
HMP The Mount West Herts No
Clinical care was appropriate. Patient had not been engaging with
medical staff, despite extensive support.
1099
2
Adult Services East
MSK Physio & OT West West Herts No
Assurance provided that patient now has an appointment. Explanation
provided regarding current waiting times for therapy in West Herts
which is within the 18 week pathway.
1100
2
Concerns that no message on telephone line at Elstree Way Clinic to
say that there is no receptionist working today. Feels it
unacceptable that when one person is off sick the service does not
run.
Adult Services
Herts Valleys
No
Apology provided that there was no receptionist available to answer
calls. Complaint shared with team and apology provided that phone
had not been transferred over in order calls should be picked up
when receptionist is not on duty.
11
Is this a Red Flag
Complaint? Outcome
1101
2
Concerns regarding care provided to patient. Family feel an
infection was ignored by staff who they felt were
overstretched.
Adult Services
Herts Valleys
Community Hospitals
1103
2
Concerns raised about conduct of Consultant towards husband who is
an inpatient in Langley House Neuro Rehab (Holywell).
Adult Services East
Neurological Rehabilitation Holywell No
Apology provided that Dr was perceived to be rude. Dr has met with
family to apologise and family no longer wish to pursue.
1104
2
Complaint regarding the closure of inpatient ward at Gossoms
End.
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
Explanation provided that it was felt necessary in order to ensure
patient safety and the safe staffing of all of our Community
Hospitals in the Herts Valleys area. Assurance provided that this
is a temporary closure and Gossoms End is likely to remain
temporarily closed until the beginning of April 2016.
1105
2
Complaint regarding the closure of the inpatient ward at Gossoms
End.
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
Explanation provided that it was felt necessary in order to ensure
patient safety and the safe staffing of all of our Community
Hospitals in the Herts Valleys area. Assurance provided that this
is a temporary closure and Gossoms End is likely to remain
temporarily closed until the beginning of April 2016.
12
Is this a Red Flag
Complaint? Outcome
1106
2
Complaint regarding the closure of Chiltern Ward at Gossoms End
Hospital.
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
Explanation provided that it was felt necessary in order to ensure
patient safety and the safe staffing of all of our Community
Hospitals in the Herts Valleys area. Assurance provided that this
is a temporary closure and Gossoms End is likely to remain
temporarily closed until the beginning of April 2016.
1108
2
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
Explanation provided that it was felt necessary in order to ensure
patient safety and the safe staffing of all of our Community
Hospitals in the Herts Valleys area. Assurance provided that this
is a temporary closure and Gossoms End is likely to remain
temporarily closed until the beginning of April 2016.
1109
2
Complaint re closure Of ward at Gossoms End. Complaint forwarded on
by journalist from Hemel Hempstead Gazette.
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
Explanation provided that it was felt necessary in order to ensure
patient safety and the safe staffing of all of our Community
Hospitals in the Herts Valleys area. Assurance provided that this
is a temporary closure and Gossoms End is likely to remain
temporarily closed until the beginning of April 2016.
13
Is this a Red Flag
Complaint? Outcome
1110
2
Concerns raised by daughter of terminally ill patient who has had
several issues with Community Nursing Team. Complainant was ringing
community nursing office for an hour trying to request an urgent
visit and then was given a contact number for a nurse who is now on
secondment in a different area of the country.
Adult Services
Herts Valleys
1111
2
Concerns regarding service provision for Wheelchair Service. Client
has issues with lack of contact from repair service and general
poor quality of the care received. Client waiting replacement chair
and current chair does not fulfil her needs causing daily pain and
discomfort.
Adult Services East
Service requested that Millbrooks undertakes repairs as matter of
urgency. Repairs have been completed.
1112
2
Concerns raised by MP that their constituent feels the
administrative team for the Paediatric Audiology Team at Principle
Health Centre has inadequate provision now one member of the team
is on maternity leave.
Children’s Specialist
Children’s Audiology West Herts No
Assurance provided that HCT is taking action to reduce disruption
to the service due to members of staff being on maternity leave.
HCT has invested in providing cover for staff and will continue to
support service in the current financial climate.
14
Is this a Red Flag
Complaint? Outcome
1115
2
Concerns about the Palliative Care Team. Complainant feels that the
service is not fit for purpose giving examples of an incident with
a broken syringe driver and no replacement being available. Also
concerned that despite speaking to the CEO and being given the Team
Leader as a contact, he has not received any further contact.
Adult Services
Herts Valleys
Specialist Palliative
1116
2
Complaint regarding an entry made in a letter that was sent by
clinician to GP. Complainant concerned about the implication of the
term used and that trust in the team has now gone.
Adult Services East
1118
2
Concerns raised that due to an administrative error patient was
sent to the wrong location for CROPS appointment and therefore
incurred parking and travelling costs.
Adult Services East
1120
2
Complainant unhappy with lack of information from the PALMS service
about the work they have said they will do jointly with
CAMHS.
Children’s Universal
Herts Wide No
All clinicians have been reminded to ensure that they communicate
their plans clearly to families and checking understanding during
conversations. PALMS is working jointly with CAMHS to review
protocols and processes to ensure clear communication between the
two services.
15
Is this a Red Flag
Complaint? Outcome
1121
2
Parent not happy with the content of the letter from child's
Consultant Paediatrician. Unhappy that OT referral declined.
Children’s Specialist
Community Medical Staffing
West Herts No
Apology provided and a separate report to school regarding his
difficulties will be made as well as a referral to OT. Mother did
not wish to pursue any further.
1122
2
Concerns regarding immunisation programme and that their child was
not sent a reminder for their 16 week immunisations.
Children’s Universal
Child Health and
1123
2
Mother has raised concerns that the Health Visiting Service has
recorded Domestic Violence on her records when she feels that this
is not appropriate.
Children’s Universal
Complainant dissatisfied with son's Speech and Language Therapy
received in school and unhappy that son has now been
discharged.
Children’s Therapies
West Herts No
Speech and Language Therapy appropriate for child's needs. Apology
given that feedback between the SLT and SENCO was not communicated
to the parents. Further SLT referral offered as parent feels that
further help is required.
1125
2
ENHT Leading -Concerns raised over care father in law has received
post discharge from Holywell Neuro Rehab Unit. Community Nurse
failed to turn up on day following discharge and family unhappy
with carers.
Adult Services
Herts Valleys
No
Discharge date was not communicated to community nursing team
despite referral being made. Message received by team day after
patient discharge. Complainant happy with explanation.
16
Is this a Red Flag
Complaint? Outcome
Adult Services East
Apology provided and explanation provided regarding arrangements
for transferring patients between consultants. A review of this
process is being undertaken.
1129
2
Adult Services East
1130
2
Concerns raised that patient has been contacted by a private
physiotherapy company regarding therapy and he is concerned that
they have obtained his details from the NHS.
Adult Services East
MSK Physio & OT West West Herts No
Assurance provided that HCT does not hold patients email address on
our records and therefore can confirm that no information has been
shared by HCT.
17
West Essex CCG:
/Theme Business
Complaint? Outcome
Parents raised concerns regarding inaccuracies contained within
their daughter’s records. Concerns also regarding therapist’s
knowledge and expertise.
Personal Records
East Herts/West
Essex No
Apology provided. Member of staff has reflected on behaviour and
specialised support has been provided to the family. Complainant
did not wish to pursue any further.
1119 2
Concerns regarding manner of Dr and information provided. Family
have requested a different doctor
Staff Attitude Children’s Specialist
Community Paeds West Essex No Investigation on-going.
1131
2
Staff Attitude Children’s Specialist
Community Paeds West Essex No Investigation on-going.
Tricia Wren Mandy Massey Deputy Director, Quality & Governance
Patient Experience and Complaints Manager
January 2016
Professional Clinical Leaders Group (PCLG)
1. Introduction
The NHS is facing major transformational changes over the next 5
years which will affect the care that patients receive.
Professional clinical leadership is an essential requirement that
will ensure patient care is co-ordinated, evidence based, safe and
effective. HCT has a number of clinical and professional groups in
place to support service change and delivery of clinical care but,
as noted by the external CQC inspection in July 2015, ‘there is no
Trust-wide committee structure or process in place for
appropriately leading all professional staff in practice’. This
paper sets out the proposed framework and governance structure to
improve the effectiveness and coordination of professional clinical
leadership across HCT. The approach will strengthen and formalise
the existing clinical professional leadership, complete our senior
leadership development objectives, and ensure a system wide focus
on the delivery of safe, effective quality care for patients
accessing services in HCT.
2. Background
Currently the Trust has in place a variety of professional groups
including the quarterly Clinical Quality Leads forum led by the
Director of Quality & Governance/Chief Nurse; the 6Cs group:
Allied Health Professionals forum (AHP) and a Doctors and Dentists
Forum. Although these groups are delivering professional changes in
practice, there is limited engagement with all clinical leads
across the services provided by the Trust. One of the key findings
of the CQC inspection report in July 2015 noted that ‘staff lacked
understanding on the strategic and clinical vision for the
Trust’.
3. Professional Clinical Leadership
The proposed new Professional Clinical Leaders Group (PCLG) will
replace the Clinical Quality Leads forum and act as the overall
steering group to engage all clinical leads across the Trust. This
will ensure improved understanding on current Trust vision and
strategies and provide a platform for engagement with the
co-production and delivery of future strategies that directly
impact patient care. Key clinical professional groups including the
Nurses’ Forum (6Cs group), AHP Forum, Doctors & Dentist Forum
will report directly to the PCLG. This will provide wider
understanding and on all clinical developments that affect patient
care. The PCLG will complement the existing Senior Leaders’ forum
which focuses on service delivery and the leadership development of
staff.
Page 1 of 9
4. Purpose
An engagement event for the PCLG took place on the 18th December
2015 and clinical lead representatives from all services
responsible for front line patient care in HCT were invited to
attend. There was good engagement with 15 people participating.
Discussions took place regarding the purpose and anticipated
outcomes of the group and links with existing groups and work
streams across the Trust were explored. Clinical leads welcomed the
opportunity to form a bespoke group that focused on clinical
leadership and patient care. Clarity on the purpose of PCLG was
confirmed as a professional forum where clinical leads can: •
Develop strong professional clinical leadership within HCT that
influences the
delivery of safe, effective and improved care for patients • Create
a professional forum where lead clinicians contribute to the
development of a
learning organisation • Ensure a professional clinical voice is
reflected in all Trust strategies that have an
impact on direct patient care • Act as a forum to capture the views
of Clinicians in the Trust, to debate issues and to
make recommendations to other working groups, fora, sub committees
and ultimately the Board.
• Share good practice and ensure implementation of local and
national guidance on professional best practice across the
organisation.
Terms of Reference (TOR) for PCLG have been developed by the group
and require agreement by the Executive committee (TOR Appendix
1).
5. Reporting mechanism
The PCLG will be led by the Director of Quality &
Governance/Chief Nurse and supported by the Deputy Director of
Nursing and Lead AHP. The PCLG will report directly to the
Executive Committee with relevant information shared with the
Senior Management Team as required. The Nurses’ (6Cs) group, AHP
forum and Doctors and Dentists Forum will report key outcomes to
the PCLG to ensure clinical leads are made aware of changes that
affect patient care. The intention is that the Doctors and Dentists
Forum will also incorporate the Lead Pharmacist. Groups that report
directly to the Clinical Effectiveness Group and Patient Safety
& Experience Group will provide highlight reports only on
matters that have an impact on delivery of clinical patient care
(Appendix 2).
6. Recommendations The Executive and SMT are requested to: •
Approve the proposed framework for Professional Clinical Leadership
for the Trust
Page 2 of 9
• Agree the TOR for the Professional Clinical Leaders Group.
Tricia Wren Jill Callander Deputy Director, Quality &
Governance / AHP Professional Lead Deputy Chief Nurse Clare Hawkins
Director of Quality & Governance / Chief Nurse 7th January
2016
Page 3 of 9
PROFESSIONAL CLINICAL LEADERS GROUP
Version 3 – December 2015
1.0 TITLE AND FORMATION 1.1. Title: Professional Leaders’ Group
(PCLG) 2.0 STATUS & DELEGATED AUTHORITY 2.1 The Professional
Clinical Leaders’ Group of Hertfordshire Community NHS Trust (HCT)
is a
Group of the HCT Executive Team (Exec) 2.2 The Professional
Clinical Leaders’ Group is authorised to make decisions which
are:
I. Within these Terms of Reference II. Specifically referred by
Exec within the delegated authority of the members to
undertake on behalf of their area of representation including
ratification of clinical policies and clinical SOPs. The PCLG is
authorised to seek information it requires from any employee of HCT
relating to professional leadership
III. Specifically referred by Exec 2.3 All procedural matters in
respect of conduct of meetings shall follow the Trust’s
Standing
Orders. 2.4 The PCLG may recommend actions which require financial
expenditure but the PCLG itself
does not have any delegated powers of expenditure, and this rests
with the relevant budget holder or otherwise in accordance with
powers of authorisation as prescribed in HCT’s Scheme of
Reservation and Delegation
2.5 The PCLG may establish such working groups or project teams as
it considers appropriate to
support its objectives and duties. Any group or project team so
established shall have terms of reference, including reporting
arrangements approved by the PCLG.
3.0 PURPOSE
3.1 The purpose of the Professional Clinical Leaders’ Group
is:
To bring together senior representatives of each healthcare
profession within HCT to enable the organisation to:
• obtain the professional advice of the group to inform decision
making about clinical practice that directly affects patient
care
• strengthen clinical and professional engagement across the Trust
• make recommendations and implement local and national
professional guidance on
clinical practice • share best practice and ensure standards of
clinical care are maintained • ensure a professional clinical voice
is reflected in all Trust strategies. • create a learning
environment were clinical practice can be improved • engage with
all professions to capture the shared voice of the clinical
workforce
Appendix 1
4.0 ACCOUNTABILITIES 4.1 The Professional Clinical Leaders’ Group
is accountable to Exec. 4.2 The following will report into PCLG
(see also paragraph 2.5):
I. Operational services, working groups or project teams set up to
support its objectives and duties.
II. AHP Forum, Doctor/Dentist Forum, Nurse Forum (6Cs group)
5.0 DUTIES 5.1 The duties of the PCLG include but are not
restricted to:
I. Body of professional advice: provide a forum for professional
leaders to advise on: • Delivery of safe, effective patient care
and sharing best practice • Improving quality and clinical care •
Development of Trust priorities, including CQUINS, Quality
Priorities, Business
Unit business plans, Quality Strategy • Innovation • Research and
development • Professional regulations and code of conduct issues •
Professional education, training and development • Collaborative
working and learning • Specific initiatives as identified by the
Board, the ET and the forum themselves
II. Voice for the professionals: to provide a means for all
healthcare professionals across
HCT to contribute their expertise at all levels within HCT, in
order to achieve the strategic objectives of the organisation in
the delivery of improved care to patients and their families.
III. Body of professional opinion: to consider, horizon scan and
provide a professional
view on national and local consultations, policies, priorities and
strategies, and their impact on HCT.
IV. Professional resource: to provide professional expertise and
recommendations on
particular issues.
V. Professional champions: to promote the professions and
professional leadership in and outside HCT, enabling links with
external professional networks.
VI. Professional network: provide a forum for sharing best practice
and engaging with
HCT staff at all levels
VII. Duties or tasks as delegated from time to time by the Trust
working groups and committees
5.2 In fulfilling the objectives and duties under 3.0 and 4.0
above, the Group shall:
I. Be mindful of the principles of integrated governance and where
necessary consider and communicate risks and impacts that may
extend to the wider organisation and which arise through the
exercise of its delegated functions.
II. Link its programme of work to the strategic objectives of the
Trust
Page 5 of 9
6.0 MEMBERSHIP AND ATTENDANCE
• Director of Quality & Governance / Chief Nurse (Chair) •
Deputy Director of Quality & Governance / Deputy Chief Nurse
(Vice Chair) • Lead Allied Health Professional • Clinical Quality
Leads (nursing and therapy) Adult Services • Clinical Quality Leads
Children & Young People’s Services • Clinical Quality Manager –
Patient Safety • Clinical Quality Manager – Patient Experience •
Lead Infection Prevention & Control Nurse • Named Nurses for
Safeguarding Children and Adults • Chief Pharmacist • Learning
& Development Lead • Palliative Care medical lead • Clinical
Lead-Community Paediatrics • Learning & Development Lead
• Clinical Leads for services: • Clinical Psychology • Neuro
Physiotherapy • Neuro Occupational Therapy • Musculoskeletal Lead •
Nutrition & Dietetics • Bladder & Bowel Care • Podiatry •
Dental • Tissue Viability • Wheelchair Therapies • Acute Therapies
• Children’s Physiotherapy • Children’s Occupational Therapy •
Children’s SLT • Children’s Specialist Nursing • Beds Manager •
Prison services • PALMS/STEP2 • Adult SLT • Neuro- clinical lead •
Skin Health
6.2 Additional members with specific expertise may be co-opted as
required. Co-opted members
will not have voting rights.
6.3 Observers may attend meetings with the agreement of the
Chair.
6.4 All members will be invited to each meeting and co-opted
members will be invited to meetings (or part thereof) for the
specific expertise they bring.
6.5 Members shall be assumed to be attending a meeting of the PCLG
unless apologies are
sent in advance to the administrative support. If a full member
cannot attend, they must
Page 6 of 9
Board 28th January 2016 Attachment J2
appoint a suitably briefed alternate to attend in their place. Such
alternates shall contribute to the quorum and have voting rights as
per full members.
6.6 The Chair shall ensure that arrangements are in place for the
provision of administrative
support to the PCLG. 6.7 All members shall read documents prior to
attending the meeting and seek assurance from
their associated professional colleagues that: I. relevant impact
is assessed II. management actions are agreed
III. progress towards implementation is sought for feedback at
subsequent meetings IV. follow-up agreements from PCLG are reported
back to their associated professional
colleagues. 7.0 MEETINGS
7.1 Meetings will be a minimum of 6 per annum and as required at
the Chair’s discretion (extra-
ordinary meetings). Meetings will be 3 hours in duration.
7.2 Dates will be set with a minimum of one month’s notice. 7.3
Venues will be agreed and notified with a minimum of one month’s
notice.
7.4 Apologies will be sent to the administrative support and Chair
and members will arrange a
suitable alternate to attend in their place and notify the
administrative support and Chair of their alternate.
8.0 QUORUM
8.1 Presence of the chair or co-chair and 50% of the voting
membership shall form a quorum. 9.0 DECISION MAKING
9.1 The PCLG has joint and collective responsibility for agreeing
decisions. Decisions shall be
reached by consensus where possible, and where there is not
unanimous agreement a vote shall be taken and the results recorded.
The Chair shall have casting vote where applicable.
9.2 Co-opted members and observers do not have voting rights.
9.3 Members with declared interests in items of the agenda will not
have voting rights in respect
of that agenda item.
9.4 In the event of an urgent decision being required between
meetings on any matters within the Terms of Reference of the PCLG,
the Chair may take ‘Chair’s Action’. The action will be reported to
the next meeting and recorded in the notes.
10.0 PAPERS 10.1 The agenda for each meeting will be agreed by the
Chair and Co-Chair. 10.2 The deadline for agenda items will be
communicated prior to each meeting, with any urgent
business beyond the deadline to be agreed with the Chair in advance
of the meeting. 10.3 The agenda and associated papers/documents for
each meeting will be distributed one
week in advance of the meeting to all members and co-opted
members.
Page 7 of 9
10.4 Members have responsibility to manage the papers/documents in
accordance with the Records Management Policy.
10.5 Minutes/notes of each meeting will be drafted and agreed by
the Chair before distribution to
the members. 10.6 Actions arising from the meeting shall be noted
within the minutes/notes. 11.0 REPORTING 11.1 The Chair shall draw
to the attention of Exec any issues that require disclosure to the
Trust
Board and any issues that require executive action.
11.2 The notes/minutes of the PCLG meetings will be held
electronically and a chairs assurance report will be received by
Exec with a Chair’s assurance report.
11.3 The PCLG will receive reports from any project groups set up
to address areas of clinical risk
or implementation. Such groups include AHP Forum, Doctor and
Dentist Forum, Nurse Forum (6Cs group) ICT Leads meeting, Ward
Managers meeting.
11.4 The PCLG will integrate and coordinate with other groups
overseeing the quality agenda in HCT.
12.0 TERMS OF REFERENCE – RATIFICATION AND REVIEW 12.1 The Terms of
Reference will be agreed by the PCLG and ratified by Exec.
12.2 The Terms of Reference will be reviewed annually from date of
ratification or earlier at the
Chair’s discretion. 12.3 Amendments to the Terms of Reference will
not be required to be reported back to Exec
unless they are agreed by the Chair to constitute a significant
change. 13.0 COMMITTEE EFFECTIVENESS 13.1 At least once per year,
the PCLG shall undertake a self-assessment of its effectiveness,
and
the outcome from this assessment shall be reported to Exec. 14.0
DISSOLUTION 14.1 The PCLG will only be dissolved with the agreement
of Exec or by default in the event of
HCT ceasing to exist. Developed: December 2015 Revised: Jan 2016
Approved by PCLG Chair
Page 8 of 9
Appendix 2
Healthcare Governance Committee Operational Review
End of Life Care 10th December 2015 AM welcomed everyone to the
review and explained that the aim of the event was to review and
understand the progress made in light of the CQC report on End of
Life and Palliative Care. SAFE (Good) Mandatory training targets
(Palliative Care) Locality and Line Managers (LM) are responsible
for ensuring staff training is undertaken and updated within their
teams. It was reported that identified medical and administration
staff have attained 100% training.
Safeguarding: new Trust policy The Trust’s new safeguarding
policies have been amended ratified and disseminated. The training
has been amended accordingly and training champions are in
place.
Flowcharts to assist staff are available on the intranet and plans
are in place to circulate a paper copy with the January 16
payslips.
Staffing levels and caseload (mitigation)
Palliative care staffing levels and caseloads are monitored daily
against specific criteria. Issues are escalated when they occur to
ensure that patient care is maintained. It was confirmed that the
mitigations documentation is consistent across all areas in
HCT.
Action: Staffing mitigation/ criteria form to be shared with all
LMs PBr
Clinical Quality leads (CQL) and Locality Managers are working to
expedite recruitment issues. In the interim robust caseload
management is taking place. The main pressure areas were discussed
together with the actions being taken to ensure patient management
and service resilience.
JH advised that work is underway to develop partnership working
with Hospices. Principles of adopting a fairer distribution of
resources across the area linked to the population demographic have
been discussed at executive level and will be discussed further
with the CCGs. It was felt that if this model is not suitable the
Board will need to review the resources required to ensure service
resilience.
AD advised that once the Electronic Palliative Care Co-ordination
Systems (EPaCCS) and coordination data begins to flow in January 16
it will be easier to understand the level of service provision,
capacity and demand.
1
Board 28th January 2016 Attachment J3
It was acknowledged that there plan to continue support to staff to
ensure they retain competence and confidence to ensure a consistent
robust level of service.
Incident reporting differential knowledge of what constitutes an
incident
It was confirmed that there are still some limitations to incident
and near miss reporting and follow up. Reasonable assurance was
provided that work is underway to address this.
Effective (Requires Improvement) Summary
*Person centred end of life care planning process to replace LCP
not in place The SystmOne template for the Individualised Care Plan
for the Dying Person has been developed in conjunction with
independent sector, GPs, CCGs and has now been signed off. The
first information meeting to prepare teams is planned for 13
December. A further programme of train the trainer will be rolled
out in conjunction with the McMillan project to the ICT and bed
based units. The use of the Individualised Care Plan for the Dying
Person will go live in January 2016. Plans are in place to record,
review and show the improvement. It was confirmed that an
additional tool would be available in patient’s home for use by
other professionals/carers. Access to paper versions would be made
available for those professionals that currently do not have access
to or use of SystmOne. Resolving all the issues was not within the
gift of HCT alone. However good progress has been made in
conjunction with GPs, CCGs and HCT, it was acknowledged that Dr
Mark Andrews had contributed significantly to this work. AM advised
that she will undertake a review of the use of Individualised Care
Plan for the Dying Person, towards the end of January 2016 to
assess the level of implementation. Actions:
• Individual care plan for the dying person to be rolled out
formally MD • Personalised individual care plan to identify the
patients preferred preference of care
MD
• Check if individual care plans can be used on SystmOne and make
sure a paper based system is available if not. MD/TW
• Review the use of Individualised Care Plan for the Dying Person
AMc end Jan 16
* Specific End of Life Care Policy for staff to follow not in
place
2
Board 28th January 2016 Attachment J3
The End of Life Care Policy is in the final stages of drafting. SW
has provided support in respect of information relating to
medicines management and supply, a direct link regarding this has
been included on the Individualised Care Plan for the Dying Person.
Chair’s action will be required to sign off the policy to support
the SystmOne rollout. Once finalised the policy will be rolled out
to all staff and embedded to ensure that staff are able to
verbalise and demonstrate the policy and any changes
included.
• Chair’s action to sign off policy prior to SystmOne roll out.
TW/AMc
Detailed Section
Pain Relief
No formal pain scoring tool to ensure most effective pain relief
that had been audited quantitatively. A new national Information
Standard that will be implemented throughout the whole organisation
by June 2016. This will include several tools dependant on patient
need.
Work is planned with the information team to ensure that the
Information Standard requirements are included in the business
change phase four electronic records roll out across the bed bases
and beyond. It was advised that this will take some time; therefore
paper versions will be available in the interim.
TW expressed the need for assurance of current practice and interim
arrangements; this is to be undertaken during the next round of
quality assurance visits in quarter 4.
Action: EOL lead to review and ensure pain score current position
is within QAV EOL template. PB
It was noted that a universal pain score is not yet in place across
the organisation MD to lead operationally on pain relief and JH to
ensure the delivery of End of Life strategy.
Nutrition and Hydration
No formal structure or risk assessment in place to review or audit
nutrition and hydration needs.
It was confirmed that there is and was a formal structure and risk
assessment in place to review or audit nutrition and hydration
needs at the time of the inspection. However the need for all
Specialist Palliative Care Nurses to be competent and equipped to
undertake core assessments has been reinforced to ensure holistic
patient care.
Now that the Liverpool Care pathway has been removed the teams need
to know and demonstrate what is in place now. PB advised that in
early January and moving forward briefing sheets will be provided
to cascade clear messages to staff to support the delivery of high
quality end of life care.
The new Individualised Care Plan for the Dying Person requires the
plans for nutrition and hydration to be documented when the patient
is no longer able to eat or drink.
3
Board 28th January 2016 Attachment J3
It was noted that there has been significant progress in
development of a number of areas almost approaching the
implementation stage to support the holistic care approach to all
patients with personalised care plans
Monitoring Quality and people’s outcomes
Auditing systems to monitor and ensure evidence based practice
implemented and regularly reviewed (End of life care audit planned
but not yet initiated)
Staff unable to describe any quality audits
Palliative and End of life Care High Level Network 2014-2016 had no
reference to audit and quality monitoring
The audit team presented and reviewed audits that have been
undertaken and are planned at the Palliative Care team away day,
staff are now fully aware. There are also ongoing regular
discussions in team meetings on the use of audit outcomes to
improve the service.
The outcomes of the audits are feeding into the action plan and
will also be included in the new regular communication to teams
commencing in January to inform learning and provide feedback.
Healthcare Governance committee will require assurance that changes
identified in audits have been achieved. It was also acknowledged
that patient outcomes and patient acknowledgement of change should
be evidenced.
Competent Staff
Clinical supervision The palliative care team have a robust system
of clinical supervision, evidence can be provided to support this
at the re inspection.
HCT is working in partnership working with MacMillan to provide
training to all adult core staff ensure that core nursing staff are
able to undertake a holistic assessment and provide confident and
competent end of life care.
Appraisal only 50% in the West It was felt that robust evidence
needs to be provided to CQC to show where staff has been appraised
is disseminated to locality teams, where the appraisal
responsibility lies and the improvement made.
Mandatory training is now well above the target.
Multi-disciplinary working
All positive
All positive
Board 28th January 2016 Attachment J3
All positive with one comment on not auditing DNACPR forms – it was
noted that DNACPR forms are audited.
Caring Good All comments are positive on caring in both the summary
and the detailed section. It was felt that this is should be
conveyed to the staff as this is not usually the case within CQC
reports.
Responsive Good All positive in the summary
Detailed section
No evidence that the Trust had developed a plan to meet the needs
of people with dementia. It was acknowledged that the Trust have
been working on a plan to meet the needs of Dementia patients,
staff need to be able to communicate and provide evidence of the
plan.
Only 29% of patients have their preferred place of death recorded
and no trust target in place also gaps in recording preferred place
of care.
This was challenged as incorrect. It was acknowledged that the data
collected on End of Life is incorrect, further review of records
showed 60% of patient who had died had recorded the preferred place
of death recorded and on a one day audit 51% of records audited
stated the preferred place of death. The detailed audited data can
be provided as evidence to CQC on re inspection.
It was acknowledged that there are issues and delays in respect of
notification and recording of death which is a GP responsibility.
There are also coding inconsistencies. It is hoped that this will
improve with the implementation of the EPaCC sytem.
It was acknowledged that there will be a delay with the
implementation of EPaCCs for EMIS users in the West of the
county.
Time was needed to review educational support and engagement with
GP’s to undertake end of life discussions with patients who have
co-morbidity, and whose clinical records need to reflect End of
Life Read coding. Such Read coding would therefore support
integrated teams in delivery of timely personalised palliative
care.
It was confirmed that patient preference needs to continue to be
sought.
Action: • Business information reports to be reviewed to include
the preferred place of death coding
and support is required from GPs to ensure accurate coding when a
patient dies ( as only GP can code on SystmOne) MD/CS
5
Well –Led Summary
*Some disengagement between local leadership and staff working in
palliative care services
It was reported that locality management visibility was variable.
Where visibility has improved, integration has improved.
Not all the of Palliative Care Team members have been able to fully
embrace integrated working due to staff vacancies notably in the
West of the county. Representatives from the East & North
expressed the view that the integration is working well for them
and the joint working and learning is beneficial to patient care
and staff development staff.
Baseline evidence has been collect over a period of time from focus
groups, all the areas of concerns surveyed have improved and the
results show that staff felt clinically supported in their role.
One exception is that they do not feel supported in their
development as Specialist Nurses. The overall improvement and staff
engagement over the past 18 months has improved from 2 (not very
satisfied) to 6/7 (reasonably satisfied).
There is marked improvement in general however vacancies in the
West have hampered progress. Watford area continues to work on ways
to encourage, support and improve the integration both with teams
and individuals.
Discussions are underway to develop partnership working with local
hospices in the West to improve service resilience and promote
further integration.
Concerns were raised with the length of time that this integration
has taken and still not fully resolved; it was highlighted that
there are issues with Isabel hospice, who not engaging and have
limited communication with local NHS teams looking after Palliative
Care patients. The East & North CCG are aware of these
issues.
The Care Coordination Hub in Herts Valleys will be a big driver for
change.
CQC have acknowledged that work had been done to support staff with
integration, there is still more that can be done.
Action: Work to continue to integrate community teams and embed the
EOL policy MD/CS
Action: Contact to be made with the CEO of Isabel Hospice to foster
closer working with HCT staff for the mutual benefit of patients
and both organisations. DL
*Not a clear written development strategy or vision statement for
the service
*No clear goals set for the service that the staff could describe
to CQC
These are in place with aspirations and goals that have been
developed in conjunction with staff.
It was acknowledged that further communication with staff is
required to ensure staff can demonstrate and verbalise the
strategy, vision and goals.
6
Board 28th January 2016 Attachment J3
*Recent changes on integrating into the community locations had
resulted in staff leaving- progress is being made with staff in
line with HCT workforce plan.
* Staff had left as a result increasing the workload of the teams
this is common throughout the NHS as a whole not just limited to
this service.
*HCT Palliative and End of Life Care Network Plan 2014-16 lacked
detail about what the tasks were and how they were going to be
achieved
* Out of 48 actions in this Plan only 14 were marked completed.
This plan was a 3 year plan; it was acknowledged that progress
updates need to be clearly evidenced and demonstrated.
It was felt that progress has been made, and work will continue to
address all points.
Additional Notes
AD asked for support and guidance for GPs to develop integrated
unified care plans. AD suggested that the East of England checklist
might be useful in the home to identify the main areas required in
a care plan. DL suggested Integrated Care Programme board could be
used to promote and on and take responsibility for integrated
unified care plans encompassing Primary Care, Community Care and
Nursing and Care homes.
Action: ICPB to lead on integrated unified care plans DL
HCT are in discussion with the CCG to review and promote End of
Life care and the co-location of CNS’s within integrated care Teams
and further discussions are planned to discuss psychology
provision. Further support is required especially to more involve
hospices in the East. DL/ AMc
It was reported that Children’s Services experience a similar
patchwork of care provision involving the hospices with their
different goals, objectives and drivers from the NHS.
Follow up –
• Quality assurance visits will be organised to review the
developments which will include meeting with staff for feedback and
obtain evidence and that the policy and strategy have been
embedded. These visits will provide a balanced feedback
report.
• HCT will negotiate with CQC the re inspection date, it was noted
that there have been changes to the inspection team.
• Feedback will be given to the Health Overview and Scrutiny
Committee
Support Required
1. Support and involvement from GPs to develop and initiate the
implement the individualised care plan for the dying person.
o An education programme is underway with all GPs on a variety of
areas in the West. Trust needs to be built up; this could be
discussed further at the Gold Standard meetings.
7
Board 28th January 2016 Attachment J3
o The End of Life template is now live in all GP surgeries on
SystmOne in East &
North Herts. Lesson learnt to be shared with the practices in the
West. o Community Nurses can provide clear communication links with
GPs, all avenues
to be used to target the GPs. 2. Support to release staff from all
the business units for the training programme
commencing in February. It was suggested that this training be made
mandatory. All methods of training should be utilised and training
should be consolidated to maximise exposure and uptake. Children’s
Services advised they received a block of training and updates from
Great Ormond’s Street. A number of ideas were suggested to address
this priority a project lead has been appointed to take this
forward.
3. Support and prioritisation of SystmOne changes are required to
move this project forward. A designated performance data business
partner would be beneficial to facilitate the improvement in data
collection and reporting.
4. Support for the Communication team to stretch and improve both
internal and external communication.
5. Support from Senior Management 6. Support in the future from
Clinical Quality leads including Children’s Services to embed
Palliative and End of Life care in business units. 7. Support from
the hospice CNS’s to support the HCT teams. HCT are inputting into
a
meeting to discuss the discrepancies within the service provided by
hospices and develop equity in core service delivery. Further
support is required with hospices particularly in the East.
Any Other Business
JH express HCT’s thanks to the entire team for the immense amount
of work and commitment shown, to address the areas for improvement
within the CQC report. The End of Life and Palliative care service
is a very good service and it should not just focus on the
negatives.
Reflections:
• The meeting has been extremely helpful to the service and team as
a whole. • More clarity around the format of the meeting would have
helped to reduce anxiety.
Marina Sweatman Board Support Officer January 2016
8
INTEGRATED BOARD PERFORMANCE REPORT
Efficiency & Cost Effectiveness.
December 2015
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
1
Table of contents
Introduction Page 3 HCT Overall KPI Summary table Page 3 Trust
Scorecard Page 4 Performance summary Page 5 KPIs Consistent and
improving patient safety Infection control Inc. MRSA & C.Diff
Page 7-8 Quality Inc. Incidents and Pressure Ulcers Page 9
Mandatory training Page 10 Safety thermometer Page 11 Outstanding
Patient experience Complaints, PALs and Friends and family test
Page 13 18 week waiting times Page 14 Nursing & Therapy
Referral priorities Page 15 Excellent Clinical Outcomes
Safeguarding Children & Adults Training Page 18 DOLS, MCA,
PREVENT, IG and LAC assessments Page 18 New born hearing screening
& Retinal screening Page 20 Community Hospital Readmission
rates Page 20 Diabetes structured education sessions Page 20 Health
visiting KPIS Page 21 National child measurement programme Page 21
HPV child immunisation programme Page 21 EOL pathway Page 22
Appraisal rates Page 22 Smoking KPIs Page 22 Highly efficient and
cost-effective services Data Quality & rejected referrals Page
25 Community Hospital KPIs, Inc. Occupancy, DTCs & ALOS Page 26
Continuing Care Page 26 Nascot lawn Page 26 Workforce Inc.,
Headcount, WTE, vacancies and budgeted posts Page 28 Bank and
agency spend Page 28 Staff turnover and absence rate Page 28
Finance Inc., Risk rating, balance sheet, Cash flow and aged
debtors Page 30 Safe Staffing exec summary Page 32 Safe Staffing
December data Page 33 Community hospital metrics Page 36
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
2
INTEGRATED BOARD PERFORMANCE REPORT
ABOUT THIS REPORT This report is split into four sections,
reflecting the High Value Healthcare (HVHC) domains upon which
performance within Hertfordshire Community NHS Trust (HCT) is
based.
1. Consistent and improving patient safety 2. An outstanding
patient experience 3. Excellent clinical outcomes 4. Highly
efficient and cost-effective services
Each section provides a table of the key indicators, with
commentary by exception only. Underperforming KPIs will have an
exception report which includes an action plan and schedule to
bring performance within target levels. Throughout the report Red,
Amber and Green statuses are used to convey performance, where an
indicator is not applicable or not available in the month grey is
used. The trust RAG reflects the current performance in month, year
to date position and a forecast position. The Trust is monitoring
data quality routinely against a data quality plan and priorities.
KPIs Summary Table December 2015
KPIs measured GREEN AMBER RED
On Target or within range%
1. Consistent and improving patient safety 24 21 1 2 92% 2. An
outstanding patient experience 16 12 1 3 81% 3. Excellent clinical
outcomes 33 25 5 3 91% 4. Highly efficient and cost-effective
services 21 11 5 5 76%
94 69 12 13 86%
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
3
HCT Trust Scorecard
All patients to have smoking status recorded on system one
89% 90% 89% 89% A A G MRSA bacteraemia 0 0 0 0 G G G
C.diff cases > 72hrs 5 Full Year 6
Monthly trajectory 0- Nov
0 4 G G G
24 hr. Notification to GP 96% 95% 99.9% 99.8% G G G % of VTE
Assessments 99.6% 100% 100% 100% G G G Patient-related incidents
4760 332-460 403 3518 G G G Av. mandatory training 86% 90% 93.1%
93.1% G G G Harm free care Compliant Compliant 93.3% 93.1% G G G
CAUTI % infections 0.2% <1.00% 0.75% 0.46% G G G No of avoidable
category 2 pressure ulcers acquired in HCT care
46 YTD 30% reduction on 14/15
3 5 G G G safeguarding children training
90% 95% 97% 97% G G G level 1 safeguarding adults training at
Induction
95% 95% 96.3% 96.3% G G G Health Visiting - average caseload size
420 <500 370 370 G G G % 18 Weeks - Consultant led 98.0% 95%
97.0% 97.8% G G G % 18 Weeks - Non-Consultant led
99.5% 98% 97.3% 97.9% R R G Friends & Family Test 97% 90% 96%
96% G G G ALOS - Stroke (Rehab Pathway 29 days 30-35 days 36.2 32.7
A G G ALOS - Non stroke (Rehab Pathway)
21 days 19 days 19.9 18.9 G G G Community Hospitals - average
occupancy
91% 82%-88% 87.1% 90.1% G A G Community Hospitals - % of NHS bed
days lost due to delayed transfers of care
Total 8.6% (Health 4.8%
HCS 2.3% Both 1.5%)
5% for health delays
4% by Mar 16
Total 14.5% (Health 8.4%
HCS 5.6% Both 0.5%)
Total 17.9% (Health 8.0%
HCS 9.6% Both 0.2%)
R R G
COSR (Risk Rating) 4 4 4 4 G G G Appraisal % 86% 90% 87.1% 87.1% A
A G Absence Rate 3.50% 3.90% 4.09% 3.71% A G G Underlying Staff
turnover 11.70% 12% 13.66% 13.66% A A G % posts vacant (vacant
WTE/budgeted WTE).
2.30% For Information 9.40% 9.40%
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
4
December Integrated Board Performance Summary
The December scorecard demonstrates continued strong performance by
the Trust across a number of metrics. HCT continues to comply with
key national level targets such as Minor Injuries Unit waiting
times and 18 weeks. More detailed analysis and actions taken are
provided in the exception reporting sections of the HVHC
domains.
Performance highlights
• No MRSA and C.Diff cases reported in December under HCT care. •
Three category 2-4 pressure ulcers acquired in HCT care reported in
December, taking total to five; however still below trajectory
reduction. • Staff mandatory training levels above target
Areas for board review
• 18 week Pledge 2 at 97% and below 98% target • Smoking Cessation
indicators all below target. • DTOC rate above the 5% threshold for
fifth consecutive month with 8.4% health delays recorded in
December. • Stroke and Non-Stroke ALOS above thresholds in
December. • Patients discharged on or before Estimated date of
discharged is 41% in December against 90% target. • Staff turnover
at 13% and over the 12% threshold. • Absence rate above threshold
of 4.09% in December.
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
5
CONSISTENT AND IMPROVING PATIENT SAFETY
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
6
SAFETY SCORECARD (1 OF 3)
Ref Indicator 2014/15
year end Performance
S4
G
G
G
G
G
G
G
G
G
99%
Compliance with Hand hygiene in all Community Hospitals will be
> 95%
Compliance with Commode Audit in all Community Hospitals will be
> 95%
% of relevant patients screened for MRSA (excluding respite
patients).
S7
S3
% of patients observing staff washing hands
Compliance with Essential steps urinary catheter care and ongoing
care will be > 95% in all community hospitals
G
0.06
4
S1 Number of Avoidable MRSA bacteraemia cases in year for HCT
0 0 0 0 G GG
G
C.difficile cases occurring post 3 days following admission into
HCT bed based facilities (i.e. acquired in our facility)
5
99%
0- Nov
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
7
SAFETY SCORECARD (2 OF 3)
Ref Indicator 2014/15
year end Performance
R
0.29
R
GG
R
The percentage of SIs that have 72 hour report completed within 72
hours. Reported monthly
G
13
80%
G
<1
92
63
The total number of patient safety incidents that have resulted in
severe harm (Quarterly)
Requires Improvement
Requires Improvement
2014/15)
A
0.37
S13
85%
1%Proportion of Si's to patient related incidents 7% For
information 2%
Registered No conditions
GG
332-460 403 3518
The percentage of SIs that have 60-day RCA and action plans
completed and submitted to PCT within 60 days. Reported
monthly
CQC Registration
14/15 0.67
Registered No conditionsS19
The number of SI's that remain open to HCT 76 For information
262
50%
S14
82% Monthly
75% 89%
5S8 249 YTD For information 45 The number of Serious Incidents
reported in month to the CCG against the SI policy
0
S18
S17 Reduction in the number of Falls with Harm (Quarterly)
A
0
0
R
S15
14
0
0
G
G
Number of incidents in quarter which allege abuse of patients in
our care which have been reported.
0 Patient safety incidents that have resulted in a death whilst in
our bed based units and Nascot lawn (Quarterly)
GS16
R
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
8
Director
Reduction in the number of falls with Harm (Quarterly) 10%
reduction on 14/15 figures
Based on the 10% trajectory reduction set for 2015/16 we have
currently reported a total of 97 injurious falls at the end of Q3
compared with 86 for the same period last year , this equates to a
12.8% increase. Overall there has been an increasing number of
falls reported resulting in an increase in injurious falls
classified as low harm which can include minor abrasions, bruising
and skin tears. There has been a significant reduction in falls
categorized as severe harm i.e. Those resulting in fractures with a
total of eight reported by the end of Q3 across all bed based
units- 43% under the trajectory of 14 set by end of Q3
Q4 2016 Clare Hawkins
Number of incidents in quarter which alleged abuse of patients in
our care which have been reported
Three cases of alleged abuse of patients in our care were reported
in quarter three. Two were reported at our Langley and QVM
inpatient units and one for the Hertsmere Homefirst service. The
cases have been fully investigated and reports have been
submitted.
January 2016 Clare Hawkins
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
9
SAFETY SCORECARD (3 OF 3) Safety Thermometer / Harm Free Care
Ref Indicator 2014/15
year end Performance
ST4
ST5 % of patients with a urinary catheter and a new urinary tract
infection
0.2% 1.00%
1.88% For
information % of patients who have had a fall resulting in
harm
2%
% of patients with a new pressure ulcer
For information
1066 10981
0.75% 0.46%
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
10
OUTSTANDING PATIENT EXPERIENCE
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
11
OUTSTANDING CUSTOMER EXPERIENCE SCORECARD (1 of 3)
Ref Indicator 2014/15
year end Performance
Outstanding Patient Experience
P1 Number of complaints referred to the ombudsman in quarter from
total complaints
1 (0.5%)
<5% 4.8%
100% 98% G GG
G0 0 G G
EMSA breaches reported in month
% of patients reporting positively about cleanliness of environment
in a community hospital
Number of in patient survey returns received and % rating care
received as good or better than good
% of Patient appointment letters including day, date and time
(Quarterly)
Friends and Family test
Number of complaints received in month
Number of complaints closed in month
Number of PALS enquiries (for HCT services) reported monthly
Number of compliments received Quarterly
78%
99%
90%
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
12
OUTSTANDING CUSTOMER EXPERIENCE SCORECARD (2 of 3)
Performance Issue Action By when Responsible
Director
18 Weeks - non-admitted patients - % of patients being treated
within 18 weeks for HCT non consultant led services
HCT not achieving the 18 weeks pledge two with 97% recorded in
December. MSK Physio and OT WEST have reported 90 breaches, a
decrease from previous month. The service has reduced capacity due
to staff vacancies. Recruitment is on-going with interviews taking
place. This issue is on the Risk register and has been escalated to
HV CCG, with the MSK pathway review underway.
Jan 2016
Julie Hoare
Trend over time
P18 RTT- 18 Weeks - number of consultant led patients waiting over
18 weeks
N/A TBC 1.3%
(22 patients) 1.3%
(22 patients)
0 0 G G GP19 RTT -No of patients waiting over 40 weeks
G
97.3% R G
100%P22 Minor Injuries Unit - Herts and Essex hospital - patients
to be seen treated and discharged with 4 hours
95%
P17 RTT -18 Weeks - non-admitted patients - % of patients being
treated within 18 weeks for HCT consultant led services
98.0% 95.0% G97.0%
P15
18 Weeks - non-admitted patients - % of patients being treated
within 18 weeks for HCT non consultant led services
99.0% 98.0% R
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
13
OUTSTANDING CUSTOMER EXPERIENCE SCORECARD (3 of 3)
Ref Indicator 2014/15
year end Performance
P25
For supported self-care/priority 3 referrals, the patient will
receive a face-to-face response within 7 days for nursing services
and 2-4 weeks for therapy. All Herts
73% R
P28 Reduction in cancellation of outpatient appointments by
provider (All services)
98
target
P24
For planned /routine/priority 2 referrals the patient will receive
a face- to-face response within 24- 48 hours of HCT receiving the
referral for nursing services and 1-2 weeks for therapy. All
Herts
R86% (1186/1382)
92% G G
P23 44.8% For urgent/priority 1 referrals to the receive a
face-to-face response within 2-4 hours of HCT receiving the
referral. All Herts
100% (numbers)
90% (77/86)
60%
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
14
Director
P23,P24 and P25 Priority 1, 2 and 3 referrals. This includes
Nursing & Therapy referrals.
HCT reported 90% for Hertswide for P1 (ENCCG 94% and HV 87%). This
is after the data validation. Overall HCT are reporting 86% for P2,
an increase of 3% from previous month. HCT reported 80% for P3
(ENCCG Priority 3s were all validated and 88% of referrals were
seen within timescale. HVCCG Priority 3s have not all been
validated and 81% were seen on time.) Currently the therapies
element in Herts Valley has very long waiting times and a business
case has been put to the CCG. Both EN and HVCCG business units will
continue to focus on the validation of the referrals to ensure that
data quality and referral exceptions have been reviewed.
March 2016 Julie Hoare
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
15
EXCELLENT CLINICAL OUTCOMES
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
16
EXCELLENT CLINICAL OUTCOMES SCORECARD (1 OF 4)
Excellent clinical outcomes
Ref Indicator 2014/15
year end Performance
Trend over time
% of staff who have undertaken level 1 / 2 safeguarding adults
training every 3 years
97.6%
% of all clinical and medical relevant staff (all clinical staff
including staff in supervisory roles requiring a clinical
registration) will undertake Level 2 safeguarding adults
90%
% of staff who have undertaken level 1 /2 safeguarding adults
training at induction
G
A
80%
G
% Completed statutory review health assessments within 4 weeks
(Paeds, CUS and CLA)
95% 92.5% 92.5% A
66%
77%
% Completed medical CLA Initial Health Assessments within 10 day
timescale
92.3%
99.0%
G
G
G
90%
A
G
GC11
C14
C12
C15
C13
C10
C2
C3
90%
98%
G
G
G
G % of eligible staff who have undertaken safeguarding children
supervision appropriate to their role
G97.0%
96.0%
% of eligible staff trained at appropriated level of safeguarding
children in accordance with IC document Level 1, Level 2, Level
3
GC1 % staff who have undertaken mandatory training 86% 90% 93.1%
93.1%
83% % of relevant staff who have undertaken MCA training
95%
G
A
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
17
Director
Information Governance training
The training is now measured on a rolling month basis and expected
to achieve the 95% target by March 2016.
Mar 2016 Phil Bradley
% Completed medical CLA Initial Health Assessments within 10 day
timescale
Achieved 80% this month but YTD on target. Three missed timescales
by LAC GPs due to one DNA by young person, a translator DNA to
support asylum seeker and social worker failing to respond to
appointment offered within timescale due to holiday period.
Concerns have been raised with HCC. All assessments now
completed.
January 2016 Julie Hoare
% Completed statutory review health assessments within 4 weeks
(Paeds, CUS and CLA)
1% below target this month (84%). Delays due to Foster carers not
responding to appointment requests or cancelling appointments at
late notice and a delay in handover to appropriate professionals.
LAC pathway being reviewed to reinforce process to all staff
January 2016 Julie Hoare
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
18
EXCELLENT CLINICAL OUTCOMES SCORECARD (2 OF 4)
Ref Indicator 2014/15
year end Performance
87%
C26
Number of patients accepted onto the Community Matron caseload who
are offered a personal health plan with the aim of maximising self-
management and confidence
RR
G
100.0%
913
G
100%
63.9%
C23
C16
C18
C17
GG
G
99.0%
C27 Diabetes -Number of patients attending structured education
sessions - DAFNE
752
100%
<0.5%
99.0%
0.17%
% of babies requiring further assessment seen within 4 weeks of
screening
Retinal screening - % of diabetic cohort that has been screened in
2015-2016
West Herts Newborn Hearing Screening - % of babies screened within
4 weeks of birth
100.0%100% G
Community Hospitals - Readmission rates within 30 days
Retinal screening - % of diabetic cohort that has been offered an
annual screen
G
0.00%
Director
Diabetes – Number of patients attending structured education
sessions - DAFNE
Patients attending DAFNE training sessions are below trajectory to
achieve the 200 target for the year. The uptake of patients
participating in DAFNE is low. The service is not getting the
demand to translate into 200 actual attendances, due to the dropout
rate from referral. This has been discussed with the CCG and
highlighted to them. This is only an ENCCG target.
Mar 2016 Julie Hoare
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
19
EXCELLENT CLINICAL OUTCOMES SCORECARD (3 OF 4)
Ref Indicator 2014/15
year end Performance
G
% of children in reception year who have received vision and
audiology screening (subject to school participation)
C38 HPV - % of eligible children immunised
Year 8 T 0% dose 1 T 0% dose 2
T Dec 10%
% of 2.5 year health review undertaken as a proportion of total
cohort BEFORE VALIDATION
93.9%
95.0%
98%
% of 2.5 year health review undertaken as a proportion of total
cohort VALIDATED
% of 1 year health review undertaken as a proportion of total
cohort VALIDATED
For Information
C31
C34 % of 1 year health review undertaken as a proportion of total
cohort BEFORE VALIDATION
C29
G
G
G
G
G
G G370
N/A 88.3%
G Health Visiting - % of babies who have had a face to face contact
with health visitor within 14 days of birth - VALIDATED
Health Visiting - % of families with Children under 1 who transfer
into area from other counties receive an offer giving them contact
with a member of the HV service within 5 days of
notification.
93.9%
99.0%
98.3%
90%98.1%
Health Visiting - % of babies who have had a face to face contact
with health visitor within 14 days of birth - BEFORE
VALIDATION
<500420
98.8%
School Nursing - % of children who have had height and weight
monitored in reception and year 6
17.3%
98.8%
370
98.0%
97.7%
93.8%
G
G
G
G
G
G
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
20
EXCELLENT CLINICAL OUTCOMES SCORECARD (4 OF 4)
Ref Indicator 2014/15
year end Performance
1462Number of patients on end of life pathway
288 For information Number of patients with preferred place of
death recorded
336
594
Herts Stop Smoking Service
C45 89%
A A % of staff who have received an appraisal in the last 12
months
AAAll patients to have smoking status recorded on system one
A89%
89%
C50
C51 All patients who smoke to be offered support to quit
smoking
90% 95% by end Q3
99% 99%
90% by end of year
All patients who smoke to be given brief intervention advice which
includes second hand smoking advice
RR
C52 Improvement in people using intermediate care bed based
services. 90% of patients have recorded Northwick Park score (95%
from Q3)
381 23
T 50
C54
Increase in the number of patients who have a planned discharge, by
bed based unit at a weekend - % discharged
25%
Baseline to be established
11% 8% Increase in the number of patients who have a planned
discharge, by bed based unit before mid- day where this enables an
effective and safe discharge - % discharged
Baseline to be established
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
21
Director
Staff Appraisal Appraisal rates continue to increase and are 87%
against the 90% target in light of the tiered appraisal approach by
HCT this year. The target is expected to be achieved by Mar
2016.
Mar 2016
Alison Shelley
Smoking Metrics Performance remained at 89% of patient’s smoking
status recorded in December, which is just 1% below the target for
the year. New reports are being created by the performance and
information team to ensure that all services are recording status
and that advice is being provided and referrals to HSSS are being
made. The new reports will enable managers to performance manage
their teams and monitor staff activity in order to drive the
performance in these KPIs.
Q4 2016 Julie Hoare
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
22
HIGHLY EFFICIENT AND COST-EFFECTIVE SERVICES
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
23
EFFICIENCY & COST EFFECTIVENESS SCORECARD (1 OF 4)
Ref Indicator 2014/15
year end Performance
Trend
G
G
99.97%
% of rejected referrals recorded as insufficient capacity in East
& West Core services
For information
0.07% (39)
99.96% 99.96% G
Efficient & Cost effective
G
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
24
EFFICIENCY & COST EFFECTIVENESS SCORECARD (2 OF 4)
Ref Indicator 2014/15
year end Performance
G G
G
A
E11b
E14
Percentage of patients discharged on, or before, the Estimated Date
of Discharge set upon admission
N/A 90% 40%
29.5 A
Community Hospitals - Average length of stay in HCT community
hospital - Stroke (Rehab Pathway ONLY)
>95%
G
G
G
84.6%
G
G
Community Hospitals - Average length of stay in HCT community
hospital - ALL Stroke
Community Hospitals - Average length of stay in HCT community
hospital - Non Stroke
E13
E15
Patients admitted to a bed based unit who have an Estimated Date of
Discharge set and recorded within 3 days of admission
Children's Continuing Care - 95% of allocated hours are
delivered
Children's inpatient unit - Nascot Lawn - Bed occupancy
E12b
87.1%
45.4
32.7
Community Hospitals - % of NHS (health) bed days lost due to
delayed transfers of care
Community Hospitals - average occupancy
A
G
R
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
25
Performance Issue Action By
Director
DTOC HCT are over the 5% Health delay threshold for DTOC with 8.4%
recorded in December. This is a 4% reduction from previous month.
Herts Valley units recorded 10.2% health delays and East and North
5.9%. In Herts Valley - Langley (20%) and Sopwell (15.6%) had the
biggest health delays with a combined 225 bed days lost. In East
& North – QVM and Herts & Essex had health delays of 10%
which accounted for 125 bed days lost. The main delay reasons for
these units were CHC Funding (157 days), Awaiting assessment (46)
Self-funding residential placement (37) and Housing and Patient
choice both (30). HCT have introduced CHC and Therapy lead roles to
reduce health delays and increase flow through the pathway and this
is already having an impact on DTOC.
Jan 2016
Julie Hoare
Average length of stay in HCT community hospital - Stroke
Stroke ALOS was over the threshold of 42 days in December with 45
days recorded. A reduction of two days from previous month. Of the
21 stroke patients in December, six stayed over 50 days and one
patient was discharged over 150 days. The ALOS improved to 36 days
based only on the rehab pathway.
Jan 2016
Julie Hoare
Average length of stay in HCT community hospital - Non Stroke
Non-stroke ALOS was over the threshold of 21 days with 28 Days
recorded in December. A reduction of three days from previous
month. Twelve patients were discharged over 80 days and one patient
over 100 days. The cohort of patients includes sub-acute, DOLS and
Specialing patients that require one to one care. Patients on the
rehab pathway met the ALOS rehab pathway threshold with 19
days.
Jan 2016
Julie Hoare
Percentage of patients discharged on, or before, the Estimated Date
of Discharge (EDD) set upon admission
Majority of non-met EDD are linked with delayed transfers of care
issues with 40% of patients achieving their estimated discharge
date. When patients who did not have a delayed transfer of care are
excluded, 87% of patients were discharged on or before their EDD.
Q4 Julie Hoare
Hertfordshire Community NHS Trust – High Value Healthcare December
2015 IBPR Final
26
Workforce (3 of 4)
259
0 For information 1
1
0
E26
E28
2471
WTE by bank/agency
Bank & Agency spend - per