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Hertfordshire Community NHS Trust
Evidence appendix Unit 1a, Howard Court 14 Tewin Road Welwyn Garden City AL7 1BW Tel: 01707 388000 www.hct.nhs.uk
Date of inspection visit: 6 to 7 November 2018 Date of publication: 24 January 2019
This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.
Facts and data about this trust
Hertfordshire Community NHS Trust provides NHS healthcare services to a population of 1.2
million people in Hertfordshire. The trust provides community-based services for adults and older
people, children and young people, and a range of ambulatory and specialist care services. They
serve the communities of Broxbourne, Dacorum, East Herts, Hertsmere, North Herts, St Albans,
Stevenage, Three Rivers, Watford and Welwyn/Hatfield. In addition, the trust provides the
healthcare service to the Mount Prison in Bovingdon.
There were around two million contacts with people during a year and the services deals with
people from before birth until death.
The trust employs approximately 2,800 staff, one of the largest employers in the local area. In
2017/18, the trust had an income of £142.4m. Income for the trust for 2018/19 is £136 million.
For the financial year ending 31 March 2018, the trust reported a year-end surplus position of
£2,093k, which was £346k ahead of plan and delivered 100% of its Cost Improvement
Programme. At year end, its capital expenditure was £127k below the Capital Departmental
Expenditure Limit.
The surplus position included £916k of planned sustainability and transformation funding (STF)
income and an STF incentive bonus was received by the trust of £1,299k for over performing the
agreed control total by £79k.
For the current year 2018-2019, the trust was forecasting a year end surplus position of £1,966k.
The demographics in Hertfordshire mirror that of England, but deprivation in Hertfordshire is lower
than average. Life expectancy for both men and women overall is higher than the England
average, but in the most deprived areas of Hertfordshire, life expectancy is 7.0 years lower for
men and 6.0 years lower for women.
Hertfordshire Community NHS Trust provides the following core services:
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• Community adults
• Community inpatients
• End of life care
• Community dental
• Children and young people’s services
The trust has a total of 11 registered locations, although care and treatment is delivered from 347
sites across Hertfordshire. This includes nine sites offering inpatient services.
During 2017/18, the trust cared for 264,700 patients in the community and over 1,900 on their
inpatient units across the county. They carried out around 886,300 home visits, supporting people
with their health conditions and helping them to remain as independent as possible in their
community. Over the same period, staff made over 1.8 million separate contacts with patients, 1.4
million with adults and 480,000 with children.
Community hospital sites at the trust
Information about the sites and teams, which offer community services at this trust, is shown
below:
Location / site name
Team/ward/satellite name
Address (if applicable)
St Albans Rapid assessment; Leg
ulcer services 56 Waverley Road, St Albans, AL3 5PN
Howard Court
Integrated community
team; Lymphoedema
services
Unit 1a Howard Court, 14 Tewin Road,
Welwyn Garden City, AL7 1BW
Danesbury House Adult neurological centre,
inpatient units 75 School Lane, Welwyn, AL6 9SB
Hemel Hempstead
General Hospital
St Peters ward; Simpsons
ward
Hillfield Road, Hemel Hempstead, HP2
4AD
Hertfordshire and
Essex Hospital Inpatient units
Haymeads Lane, Bishop’s Stortford, CM23
5JH
Langley House Inpatient units 698 St Albans Road, Garston, Watford,
Hertfordshire, W25 9NQ
Potters Bar
Community Hospital Inpatient units Barnet Road, Potters Bar, EN6 2RY
Queen Victoria
Memorial Hospital
Intermediate care inpatient
unit School Lane, Welwyn, AL6 9PW
(Source: Universal Routine Provider Information Request (RPIR) – P2 Sites tab)
Is this organisation well-led?
Leadership
The trust had managers at all levels with the right skills and abilities to run a service
providing high quality sustainable care. There was a mix of experience within the executive
directors with some new to their executive roles at the trust and others with considerable
experience.
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To write this well-led report, and rate the organisation, we interviewed the members of the board,
both the executive and non-executive directors, and a range of senior staff across the trust. This
included a wide group of clinical and non-clinical service and specialty directors. We met and
talked with a wide range of staff to ask their views on the leadership and governance of the trust.
We looked at a range of performance and quality reports, audits and action plans; board meeting
minutes and papers to the board, investigations, and feedback from patients, local people and
stakeholders.
The trust had a strong senior leadership team in place, supporting the executive team, with the
appropriate range of skills, knowledge and experience. The trust board were a cohesive group of
executive and non-executive directors who supported each other and worked well together to
constructively challenge and ensure quality and safety was given sufficient attention. The trust
board included eight executive board members and six non-executive board members.
The previous chief executive resigned in May 2018 and the director of nursing acted in the position
as interim chief executive until October 2018, at which point was appointed as chief executive. The
deputy director of quality and governance and deputy chief nurse was acting as interim director of
nursing. The interim director of nursing had a large and challenging portfolio, which included the
roles as director of infection prevention and control and company secretary, in addition to the role
as director of nursing, quality and governance. However, the substantive post which was being
advertised during our inspection did not include responsibility for infection, prevention and control.
A series of executive (medical director and interim human resources director) and senior finance
personnel changes had taken place over 12 months before our inspection, including the departure
of the director and deputy director of finance. Despite this the trust described the head of
management accounts and the head of financial services as having provided sound support and
coverage during the period prior to the appointment of the current interim director of finance, who
joined the trust in July 2018. The current interim director of finance was a qualified accountant with
several years of experience and had supported the trust during a demanding period, which had
included support on a significant amount of tendering work.
The trust had recently successfully recruited a substantive deputy director of finance, who joined
the trust in September 2018 who had experience of working within a large accountancy firm. This
meant the finance team had five qualified accountants in place.
The trust had a historical track record of delivery of its financial plan and control total. However,
the underlying financial position of the trust remained unclear. Discussions with members of the
board indicated that this area was covered as part of the board’s oversight on financial
performance but a view on the underlying financial position was not offered during our inspection.
Whilst the trust had delivered its planned efficiencies in recent years, an element of this was non-
recurrent in nature and further non-recurrent efficiencies were being reported in 2018/19. Reliance
on non-recurrent efficiencies can erode the underlying financial strength of an organisation and
therefore it was important that the board were aware of its underlying trading position and regularly
reviewed for assurance within this area.
The board had an appropriate level of operational and financial experience and expertise across
both non-executive directors (NEDs) and executives. Sufficient board time was spent reviewing
the NHS trust’s finances and there was also separate monthly business unit performance review
(BUPR) meetings where divisional performance was discussed. BUPR meetings were chaired by
the interim director of finance and attended by the director of operations and the general
managers.
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The trust leadership team had a comprehensive knowledge of its current priorities and challenges
and acted to address them. There was clear strategic leadership from the board, with important
initiatives to support the trust’s strategy and sustainability owned by board members.
Non-executive directors were highly experienced with strong operational input. Several non-
executive board members had been in office in excess of eight years, including the chair and the
deputy chair. NHS trust NEDs are expected not to serve more than eight years in post, although
they can remain in post for up to 10 years, depending on individual circumstances. When we
raised the need for clear succession planning for the NEDs, the trust told us that this was a key
priority for the interim director of human resources, although the risk of losing all experienced
NEDs at one time was not recognised on the trust’s high-level risk register.
The board were viewed as accessible, approachable, visible, and supportive with transparent
accountability at decision-making levels. Staff spoke highly of local leadership within the trust and
felt supported by them. Middle managers we spoke with during the inspection and at focus groups
were supportive of senior managers. Management staff told us they were supported by senior
leaders to develop and improve their services.
The trust board and senior leadership team displayed integrity on an ongoing basis. We attended
a public board meeting prior to our inspection where we observed a good level of scrutiny and
challenge, with a focus on quality of service delivery, safety and finance in appropriate proportions.
We also observed the meeting was chaired in a manner that enabled all non-executive members
to ask questions. Members of the board we spoke with told us they felt challenged by others, and
felt able to challenge others in a professional and supportive environment.
The trust offered an extensive range of external and in-house leadership development, through
leadership programmes, masterclasses, coaching, mentoring, e-learning, bespoke team building,
action learning sets and leadership forums. Specific programmes were offered through Health
Education England (HEE) for black and minority ethnic (BAME) staff and women to develop
leadership. Development opportunities were communicated widely and data on ‘access to
leadership’ programmes was monitored for equity. Data provided by the trust demonstrated during
2017, 950 staff completed a leadership activity including 200 members of staff who completed
formal programmes. This included the Mary Seacole programme, making a difference band 6/7
programme, senior managers development programme, sustain, and the new managers
programme.
The trust applied a broad definition to leadership, aiming to support the development of leaders at
all levels. The trust’s workforce and organisational development (OD) strategy detailed their
strategic objective to ‘become a high-performance organisation through excellent leadership and
talent management’. Progress was monitored through the workforce and OD steering group and
monthly board reports. In addition, the board members were the first to undertake the new 360
healthcare leadership model (HCLM) assessment and created a case study with the Leadership
Academy and Health Education England.
The trust saw itself in playing a key role in shaping and supporting a system approach to
leadership development through the accelerated director development scheme. Internal staff were
identified and nominated for the scheme’s assessment process. The chief executive acted as a
mentor for selected candidates and career development opportunities were specifically
highlighted, and where appropriate, ring fenced for candidates
Fit and Proper Persons
Trusts are required to meet the Fit and Proper Persons Requirement (FPPR) (Regulation five and
19 of the Health and Social Care Act (Regulated Activities) Regulations 2014). These regulations
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ensure that directors of NHS providers are of good character and have the right qualifications and
experience to carry out this important role.
We carried out checks to determine whether appropriate steps had been taken to complete
employment checks for executive and non-executive directors, in line with the FPPR requirement.
During our core service inspection, we raised concerns surrounding the trusts compliance to
Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 Fit
and Proper Persons: directors. We reviewed the personnel files of eight executive directors to
determine the necessary fit and proper person checks had been undertaken. Files did not contain
evidence of ongoing Disclosure and Barring Service checks (DBS) monitoring by the trust for all
directors. We were concerned about the ongoing and overall governance of the trust’s
performance against this regulation. It was also disclosed that all clinical staff do not have repeat
DBS checks following the initial check at recruitment and we were not assured that the trust had
taken sufficient measures to protect patients from harm. We raised this as a concern at the time of
our inspection.
During the well led inspection, we saw the policy had been reviewed and updated. All HCT staff
were required to complete a fit and proper persons regulation form as part of their application
process, and would be subject to a DBS check relevant to their role. After this, directors were
required to make an annual declaration of their on-going fitness for their role, and all other staff
were ‘required to make the trust aware as soon as practicable of any incident or circumstances
that may mean they are no longer to be regarded as a fit and proper person’. The interim HR
director told us that she would rely on informal links with a local multi-agency committee (attended
by police and social services) to inform the trust if a member had become known to these
agencies and would follow this up to ascertain the staff members’ fairness to practice at the trust.
The trust provided us with their updated report on compliance to the Secretary of State
recommendations ‘’Themes and Lessons Learnt from NHS into Matters Relating to Jimmy Saville
(September 2017). This recommends all NHS hospital trusts should undertake DBS checks on
their staff and volunteers every three years. The trust had chosen to continue with DBS on initial
recruitment only, stating that staff are obliged to inform their managers of any changes that may
affect their status, and this was in line with CQC guidance.
Board Members
Of the executive board members at the trust, 18.2% were British Minority Ethnic (BME) and 54.5%
were female.
Of the non-executive board members none were BME and 50% were female.
Staff group BME % Female %
Executive directors 18.2% 54.5%
Non-executive directors 0.0% 50.0%
All board members 11.8% 52.9%
(Source: Universal Routine Provider Information Request (RPIR) – P64 Board)
Vision and strategy
The trust had a clear vision for what it wanted to achieve and workable plans to turn it into
action. The vision was developed with involvement from staff, patients and key groups
representing the community.
The trust had a clear vision and set of values, with quality and safety as the top priorities. The
trust’s vision was to maintain and improve the health and wellbeing of the people of Hertfordshire
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and other areas served by the trust. The trust’s values were care, respect, quality, confidence, and
improve. The trust’s vision and values were embedded at board level and informed how the senior
leadership team operated. The board culture was open and honest and demonstrated respect for
patients and those who worked in the trust.
The trust’s organisational objectives were to support people to manage their own health and
wellbeing, to improve outcomes and enhance patient safety, to expand community services
through the delivery of excellence, to use resources efficiently to improve services, and to
empower their workforce to deliver their vision and objectives. In addition, the trust had a ‘wildly
important goal’ to transform and mobilise community service models, in partnership, by October
2019. Staff knew and understood the trust’s vision, values and strategy and how achievement of
these applied to the work of their team. The trust had signed up to support the national 6Cs
strategy, which included care, compassion, competence, communication, courage, and
commitment. The trust supported patients, wherever possible, to remain at home. As part of this,
patients were empowered to participate and take care of their own needs as much as they could.
The trust had communicated its vision and values with front line staff and all staff we spoke with
were aware of these.
Local providers and patients had been involved in developing the strategy. The trust’s overarching
strategy and supporting strategies were fully refreshed in 2015 following presentations by the
medical director of emerging thoughts on the clinical strategy to commissioners. The strategies
were developed in consultation with key staff groups and in consideration of the changing context
in which services were provided. Alignment with the Five Year Forward View (FYFV),
Hertfordshire and West Essex Sustainability Transformation Partnership (STP) and priorities of
commissioners was achieved through review of relevant stakeholder plans and commissioning
intentions and through informal discussion with key stakeholders. Strategy workshops were held
with the board and senior management team, and roadshows led by the chief executive and
executive directors, sought staff views as the strategy was developed. These discussions led to
the development of the trust’s strategy ‘train’ which provided a visual summary of the overarching
strategy.
In 2017 the clinical and quality strategies were combined into a single health and wellbeing
strategy. Delivery of the quality element was driven through the workplans for patient safety,
experience and clinical effectiveness. As part of this, increased emphasis was placed on what
matters most to the people who received services and one of the quality priorities was to
implement patient reported outcome measures across all services by March 2019.
The trust had aligned its strategy to the wider health and social care economy. The strategy
focused on:
Health and wellbeing: working with other organisations to develop local, community approaches to
maintaining health and wellbeing
Self-management: supporting people with health conditions and disabilities to manage their own
care as far as possible
Coordinated care: providing well co-ordinated, personalised, multi-agency care for people with
complex needs.
The trust board had developed positive relationships within the wider health and social care
system and was dedicated to building a system that would be sustainable in the future delivery of
health and social care and the footprint of the Sustainability and Transformation Partnership
(STP). The trust was an active partner in the Hertfordshire and West Essex Sustainability and
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Transformation Partnership, working closely with others to increase their contribution to the health
and wellbeing of the wider population.
The trust worked collaboratively with stakeholders, other local NHS trusts and the third sector to
deliver services to patients. For example, the trust was working with neighbouring acute trusts to
support future service delivery in line with strategic priorities, to reduce its cost base, and to
minimise any burden on the local acute trust.
The trust had worked with its commissioners during the planning round in 2018/19 to target
required efficiencies and to deliver service redesign. This had included work to develop and deliver
a broader core adult community service, to equalise the service offerings across different parts of
the catchment population and to optimise skill mix within both the adult and young people’s teams.
The trust also had to respond to a number of tenders during 2018/19 and recognised that this had
been a significant demand on its resources. This had come at a time when there had been a
number of departures and changes within the trust’s executive team. The trust believed that the
service changes and tendering agenda had, to an extent, added to existing difficulties with
recruitment and retention, and its response to these challenges had meant that the longer term
strategic work had been put on hold.
One of the two local clinical commissioning group (CCG) had taken adult services out to open
market procurement, which could lead to the potential loss of some services. The trust were aware
this could result in financial loss and impact on the trust’s capacity to deliver against strategic
objectives. During our inspection the trust did not demonstrate a clear strategy for if the tender
were to be unsuccessful. After our inspection the trust informed us they had a robust downside
scenario and supporting plan for sustainability should the tender for adult services not be
successful.
The trust had recently appointed a new chief pharmacist (CP) to lead on medicine optimisation
(MO) who told us the pharmacy workforce was under resourced. Whilst there was no standalone
medicines safety officer (MSO), the role had been combined with the chief pharmacist role. The
CP told us that one of the immediate challenges was to recruit appropriate staff to deliver medicine
optimisation service required at the trust.
The main medicine optimisation priorities for the trust were:
• To undertake formal assessments of medicines used in bedded units and improve patient
engagement in the management of their medicines.
• To have pharmacist prescribers in the community and pharmacy technicians to help
administer medicines to patients seen in their own home.
• To bring value and governance to the medicines strategy, formulary adherence and cost
efficiency to the pharmacy service.
• To deliver a medicines management training programme for all patient facing staff.
The trust board received an annual report on infection control which for 2017/18 showed zero
MRSA, 100% of patients were screened for MRSA on admission to the community hospital wards
two cases of Clostridium Difficile apportioned to the trust services against a trajectory of six,
mandatory training compliance exceeded the overall trust target of 90% and staff flu vaccination
uptake was 73.4%. An annual work plan was also presented to the trust board, with themes from
routine audits informing more detailed future audit activity.
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Culture
Managers across the trust promoted a positive culture that supported and valued staff,
created a sense of common purpose based on shared values. Staff felt supported,
respected, and valued and felt proud to work for the organisation.
Staff culture within the trust was positive. Staff we spoke with throughout our core service and
well-led inspection told us they felt positive and proud about working for the trust and their team.
Staff felt empowered to make decisions and to make changes within their service and across the
trust.
Staff reported feeling respected, valued, supported and appreciated. Staff were proud of the trust
as a place to work and spoke highly of the culture. All staff we met were welcoming, friendly, and
helpful. It was evident that staff cared about the services they provided and were proud to work at
the trust. Staff were committed to providing the best possible care for patients and felt there was a
positive working culture and all teams and wards reported good team working. This mutual respect
and support for each other was clear in all areas. Staff agreed there was a culture of openness
and honesty throughout the service. Multidisciplinary teams worked collaboratively and were
focused on improving patient care and service provision.
The trust’s strategy, vision and values underpinned a culture which was patient-centred and
throughout our core service inspection, we saw staff delivering care in this way. Staff described a
no blame culture and how they were actively encouraged to raise concerns and report incidents
without fear of retribution. They also told us they were encouraged to be open and honest in
relation to issues arising. Candour, openness, honesty, transparency and challenges to poor
practice were encouraged by senior leaders.
To react to the recent challenges evident during 2018/19, including the need to respond to service
tenders and the changes within key executive leadership positions, the trust has needed to employ
effective teamwork. The challenges were described as a drain on executive resources and the
trust relied on the non-executive directors (NEDs) to provide additional support, particularly in
relation to the tenders. The risk of this is that when non-executive and executive directors work
closely together in this way it can have an impact on the independence, oversight and scrutiny
aspects of the non-executive role.
The additional workload from the tendering of services and executive level changes meant that
some important financial workstreams had been put on hold, such as the development of service
line management and reporting. However, the interim director of finance said that the pricing and
costing work conducted because of the tendering work, led to a greater level of engagement
amongst the business units and clinical staff, who wanted to see this level of data for their
services. It was therefore recognised by the trust that the development of service line
management and reporting will support a greater understanding of the importance of finances
throughout the organisation.
The trust recognised that some service changes and closures have had an impact on the
workforce, particularly in relation to recruitment and retention. This represents a challenge, in part
also due to the close proximity of the trust to London where many of the workforce could find
alternative employment.
Following Sir Robert Francis’s Freedom to Speak Up (FTSU) review in 2015, NHS England and
NHS Improvement expected all NHS organisations in England to adopt the Freedom to Speak Up:
Raising Concerns policy for the NHS (April 2016), as a minimum standard. The trust had a
Freedom to Speak Up policy (reviewed January 2018) and had appointed a freedom to speak up
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guardian. The FTSU guardian worked with FTSU ambassadors, trust staff and the leadership
teams promoting an open and transparent organisation and to enable a safe means by which staff
could speak up. The freedom to speak up guardian was passionate about enabling staff to raise
concerns and providing a link by which they could be heard. All staff we spoke with throughout our
core service inspection knew who they could raise concerns with at the trust.
Whistle-blowing
From April 2017 to March 2018, the trust reported nine incidents of whistleblowing. The number of
incidents included concerns and issues escalated through the Freedom to Speak up Guardian
(FTSUG). The concerns raised comprised incidents regarding behaviours (including
bullying/harassment), and/or patient safety/quality.
The executive and non-executive FTSU leads reviewed themes and learning and had taken
several actions to further strengthen the arrangements for FTSUG, and to increase staff
awareness and support staff to speak up safely, including:
• Reviewing FTSU policy in January 2018
• The role of FTSU ambassador was developed and eight staff ambassadors identified to
support the work of the guardian
• A new guardian was appointed to work in partnership with the Non-Executive lead
• Promoting raising concerns and the work of the Guardian
Duty of Candour
From November 2014, NHS providers were required to comply with the Duty of Candour
Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The duty of candour is a regulatory duty that relates to openness and transparency and requires
providers of health and social care services to notify patients (or other relevant persons) of certain
notifiable safety incidents and reasonable support to the person.
The trust had embraced the duty of candour regulation and had effective processes in place. The
duty of candour policy was clear, appropriate and reflected the requirements of the regulation and
was supported by a procedural guide that had been developed in December 2017. Incidents
submitted as part of the provider information request provided evidence of duty of candour had
been appropriately applied.
Staff knew the triggers (moderate harm or above) and awareness of the regulation was well-
embedded in areas visited. All patients who had suffered harm (moderate or severe harm)
received an apology within 10 days of the incident being reported. For minimal harm, duty of
candour according to the regulation does not apply, but there was an expectation at a local level of
being open and honest and still give an apology. Duty of candour was followed in all cases of a
serious incidents even when no harm had occurred.
Staff Diversity
The trust provided the following breakdowns of nursing and midwifery staff and qualified allied
health professionals by ethnic group.
Ethnic group Qualified nursing staff (%) Allied Health
Professional (%)
White – British 25.1% 16.9%
White – Irish 1.0% 0.3%
Any other white background 1.3% 1.1%
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Mixed White and Black Caribbean 0.2% 0.0%
Mixed White and Black African 0.0% 0.1%
Mixed White and Asian 0.2% 0.1%
Any other mixed background 0.3% 0.2%
Asian or Asian British – Indian 0.7% 1.0%
Asian or Asian British – Pakistani 0.2% 0.2%
Asian or Asian British – Bangladeshi N/A 0.1%
Any other Asian background 1.0% 0.1%
Black or Black British – Caribbean 0.4% 0.1%
Black or Black British – African 2.0% 0.2%
Any other Black background 0.2% 0.1%
Chinese 0.1% 0.2%
Any other ethnic group 0.4% 0.1%
Not stated 1.4% 0.8%
(Source: Universal Routine Provider Information Request (RPIR) – P6 Staff Diversity)
Workforce race equality standard
The scores presented below are the un-weighted question level score for question Q17b and un-
weighted scores for Key Findings 25, 26, and 21, split between White and Black and Minority
Ethnic (BME) staff, as required for the Workforce Race Equality Standard.
Note that for question 17b, the percentage featured is that of “Yes” responses to the question. Key
Finding and question numbers have changed since 2014.
In order to preserve the anonymity of individual staff, a score is replaced with a dash if the staff
group in question contributed fewer than 11 responses to that score.
Of the four questions above, the following questions showed a statistically significant difference in
score between White and BME staff:
• KF21: Percentage of staff believing that the organisation provides equal opportunities for
career progression or promotion
• Q17b: In the last 12 months have you personally experienced discrimination at work from
manager/ team leader or other colleagues?
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(Source: NHS Staff Survey 2017)
The trust had a NED lead for equality and diversity (E&D), and although it did not have a
standalone E&D strategy, this was overarching in all other trust policies. They shared an E&D
manager with the local acute trust who was very active both within the trust and in the community,
and had some success engaging with seldom-heard groups, especially the traveller community.
The E&D manager reported to the board quarterly and had run board development sessions which
they said were well received.
NHS Staff Survey 2017 – results better than average of community health trusts
The trust had 12 key findings that exceeded the average for similar trusts in the 2017 NHS Staff
Survey:
Key Finding Trust Score National Average
KF1. Staff recommendation of the trust as a place to work or receive treatment
3.83 3.76
KF7. Staff ability to contribute towards improvements at work
72% 71%
KF12. Quality of appraisals 3.34 3.13
KF13. Quality of non-mandatory training, learning or development
4.12 4.08
KF21. Percentage of staff believing the organisation provides equal opportunities for career progression / promotion
90% 88%
KF31. Staff confidence and security in reporting unsafe clinical practice
3.83 3.80
KF5. Recognition and value of staff by managers and the organisation
3.55 3.53
KF6. Percentage of staff reporting good communication between senior management and staff
40% 36%
KF10. Support from immediate managers 3.89 3.86
KF32. Effective use of patient / service user feedback 3.78 3.69
KF23. Percentage of staff experiencing physical violence from staff in the last 12 months
0% 1%
KF26. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months
16% 19%
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NHS Staff Survey 2017 – results worse than average of community health trusts
The trust has five key findings worse than the average for similar trusts in the 2017 NHS Staff
Survey:
Key Finding Trust Score National Average
KF11. Percentage of staff appraised in the last 12 months 85% 91%
KF29. Percentage of staff reporting errors, near misses or
incidents witnessed in the last month 90% 93%
KF16. Percentage of staff working extra hours 75% 71%
KF2. Staff satisfaction with the quality of work and care
they are able to deliver 3.73 3.80
KF24. Percentage of staff reporting most recent
experience of violence 65% 76%
(Source: NHS Staff Survey 2017)
Several members of the board also described an open and honest culture, which they believed
was reflected within the improvement seen within the staff survey results.
The trust used pulse surveys in addition to national surveys to enable a greater drill down on
issues of concern to the staff. It was the trust’s aim to continue to improve the results from these
surveys with recommended place to receive treatment and as a place to work.
Friends and Family test
The Friends and Family Test was launched in April 2013. It asks people who use services whether
they would recommend the services they have used, giving the opportunity to feedback on their
experiences of care and treatment.
From July 2017 to June 2016, the trust scored above the England average for recommending the
trust as a place to receive care, with the exception of March 2018 where this was slightly below
the England average.
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(Source: Friends and Family Test)
Sickness absence rates
From February 2017 to June 2017, the trust’s sickness absence levels were similar to the England
average and from July 2017 to January 2018, these levels were below the England average.
(Source: NHS Digital)
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Guardian of Safe Working Hours
The trust did not have a guardian of safe working hours. The role is a mandated requirement and
was introduced to protect patients and doctors by making sure doctors were not working unsafe
hours. There was lack of oversight of issues relating to junior doctors’ adherence to safe working
hours, as there was no clearly identified person in the guardian of safe working hours role or
reporting to the board.
The trust advised us after our inspection that the junior doctors working at the trusts were on
rotation from the local acute trust and had access to a guardian of safe working hours there. The
new medical director was planning to have discussions with the local trust medical director and the
British Medical Association relating to the guardian to safe working hours role.
Governance
Whilst the trust generally used a systematic approach to continually improve the quality of
its services and safeguarding high standards of care there were some areas that were not
fully effective. These included the arrangements for monitoring the progress of actions
from internal audits and the escalation process for the business units which required a
more detailed scrutiny of their performance.
The trust had structures, systems and processes in place to support the delivery of its strategy.
There were five sub committees, which reported into the board. These included the remuneration
committee, healthcare governance committee, partnership and engagement committee, strategy
and resources committee, and the audit committee. An internal audit was usually commissioned
every three years to review the effectiveness of the committees.
The programme of internal audit work for the year was informed by the trust’s strategic objectives
and the risks identified to the achievement of these. The programme appeared to be
comprehensive and to target a broad range of areas spanning across the corporate objectives. A
review of a sample of internal audit reports provided indicated few ‘high’ level risks were identified
from the reviews undertaken. However, a review of the internal audit progress report (August
2018) identified that there were two actions from the internal audit recommendations made in
2017/18 that had not been implemented by their due date, and one of which was classified as
‘medium’ risk. A further five recommendations had revised implementation dates agreed, following
discussions between internal audit and trust management.
Therefore, we could not be assured that the trust had robust internal arrangements for monitoring
the progress of actions from internal audits to capture and escalate those that are at risk of
missing their implementation dates. This meant the trust was missing the opportunity to take
action to support the delivery of internal audit actions within the agreed timescales, particularly for
and high or medium risks identified.
The governance structure at the trust enabled an embedded risk management approach across all
corporate and operational services, with discussions being reflected at key governance
committees.
Financial and operational performance was reviewed monthly at the business unit performance
review (BUPR) meetings, which were attended by NEDs in rotation. The trust executives that chair
these meetings described a deep dive process, which was conducted with business units where
they may have concerns. The business units remained under an enhanced level of scrutiny until it
was felt that the concerns had been addressed and improvements made. However, other
members of the trust board suggested that the escalation process was not formalised or fully
understood. In addition to this there was no follow up review process in place to confirm and
15
provide assurance that the improvements made from the deep dive and enhanced scrutiny work,
had been embedded. Therefore, we were not assured that the current performance framework
was robust and ensured any improvements were embedded and scrutinised once the business
unit returned to standard monitoring.
The trust had a good structure and governance accountability for medicines management. The
chief pharmacist was managed by the medical director, and attended the trust healthcare
governance committee which fed into the trust board. Therefore, there was no gap in reporting
lines between governance committees, enabling the chief pharmacist to provide medicines expert
opinion at a higher governance level, which would bring value and governance to medicines
optimisation strategy and improve treatment outcomes to patients at the trust.
All aspects of medicines optimisation issues would be discussed at medicines management forum
(MMF) which was chaired by the medical director. Clinical aspects of medicines governance would
then go to the clinical effectiveness group, and incidents/safety aspects would be taken to the
patient safety and experience group. On-call pharmacy services were not always available to ward
staff out of hours. The trust had a verbal service level agreement (SLA) with other trusts to provide
on-call services, although this was not always met, and the chief pharmacist accepted that clearer
accountability and performance monitoring of the (SLA) was required.
The chief pharmacist had approached the trust board to discuss the gaps in medicines
optimisation and their plans to make improvements. The chief pharmacist was seeking funding
from the board to improve pharmacy staffing to enable them to increase their patient facing role
which was needed to improve value, quality and patient centred care to the population, in line with
Carter 2 recommendations. There was also a plan to monitor outsourced pharmacy provision and
to review and implement a formal medicines optimisation policy, as the trust did not have one in
place.
Papers for board meetings and other committees were of a reasonable standard and contained
appropriate information. There was a strong focus on quality with every board meeting starting
with a patient/staff story and quality items first on the agenda. The board welcomed patients and
those close to them at board meetings where they were invited to tell their story of the care they or
their loved one had received at the trust. Board members told us they found this invaluable as it
set the tone for each meeting by focusing on putting patients, their carers and families at the
centre of service delivery. The trust responded to patient stories and used them to share learning
and to improve service delivery.
Prior to our inspection we attended a board meeting. We could see the influence the non-
executive directors (NEDs) had on the overall leadership of the trust. We saw an appropriate level
of challenge from NEDs at board meetings.
Non-executive and executive directors were clear about their areas of responsibility.
Appropriate governance arrangements were in place in relation to safeguarding. The trust had a
clear safeguarding governance structure in place which included a safeguarding executive lead,
named nurses for adults (SGA), children (SGT) and looked after children and care leavers
(LAC/CL) and a named doctor. Safeguarding training/supervision was monitored monthly at the
business unit performance reviews and presented to the board through the Integrated Board
Report. The trust were assured that safeguarding/LAC/CL responsibilities were maintained by
ensuring the following scrutiny was in place:
• Clinical Commissioning Group Section 11 annual audit
• Trust annual audit plan
16
• Hertfordshire Safeguarding Children Board (HSCB) / Hertfordshire Safeguarding Adult
Board (HSAB) annual audit programme
• Monthly safeguarding and LAC dashboards shared with CCG
Audits of staff safeguarding knowledge and awareness of process provided positive assurance. All
risks, action plans, audits, formal case reviews, and activity such as compliance to key
performance indicators (KPIs) were progressed and monitored by the respective safeguarding
forums, HSCB/HSAB Executive and Scrutiny board, or LAC Leadership forum. There were robust
pathways through the trust’s committee governance structure that reported to the executive team,
including reporting pathways from the Safeguarding forum to the Patient Safety Experience Group.
Any identified risks were escalated to the Executive board for discussion and action planning.
LAC activity was shared at the Safeguarding Children (SGC) forum and the CCG LAC Leadership
forum. A quarterly joint Safeguarding and LAC/CL meeting enhanced communication and
imbedded integration across these services.
To provide assurance to the trust and the CCG that staff were keeping vulnerable children and
adults safe, compliance was closely monitored in relation to:
• Adherence to policies and guidance
• Training uptake
• Staff Supervision
• Audit
Staff at all levels of the organisation understood their roles and responsibilities and what to
escalate to a more senior person.
Board Assurance Framework
The board received regular updates in relation to the board assurance framework (BAF)
throughout the year. The board assurance framework identified the risks to delivering key
organisational objectives and the controls in place to mitigate those risks.
The trust provided their board assurance framework, which details five strategic objectives within
each and accompanying risks. A summary of these is below.
• Support the people served to manage their own health and wellbeing
• Improve clinical outcomes and enhance patient safety
• Support the substantial expansion of community services through the delivery of excellent
core services for adults and children
• Use resources efficiently to enhance our ability to improve services
• Develop the organisational capacity to deliver vision and objectives
(Source: Trust Board Assurance Framework – March 2018)
The trust’s BAF and risk registers included financial risks to the organisation. From a review of the
BAF submissions it was not possible to see how assurance was directly linked to each of the
strategic risks, to demonstrate that the current status on assurance had been sufficiently
understood in each case. The BAF extracts provided set out a section titled ‘recent assurances’ for
each strategic risk, which could be marked as either positive, negative, mixed or neutral, in each
case, and there were several areas of potential assurance listed. However, no overall conclusion
was made as to the level of assurance provided, and whether this was adequate, or if not, what
17
was the required course of action to address any gaps in assurance. This meant we could not be
assured that the trust was fully aware of the level of risk to its strategic objectives were contained
within the BAF and had a robust system in place to address these.
Management of risk, issues and performance
The trust had effective systems for identifying risks, planning to eliminate or reduce them,
and coping with both the expected and unexpected.
Finances Overview
Historical data Projections
Financial metrics Previous
Financial Year (2016/17)
Last Financial Year (2017/18)
This Financial Year (2018/19)
Next Financial Year (2019/20)
Income £148.3m £142.5m £136.0m £132.5m
Surplus (deficit) £2.5m £2.1m £2.0m £1.6
Full Costs £145.9m £140.4m £134.0m £130.9m
Budget (or budget
deficit) £1.5m £1.7m £2.0m £1.6m
(Source: Universal Routine Provider Information Request (RPIR) – P59 Finances)
The trust had a strong track record in financial performance and had previously delivered a surplus
in each of its years of operation. The trust had met all financial duties for the previous seven years.
For the financial year ending 31 March 2018, the trust reported a year-end surplus position of
£2,093k, which was £346k ahead of plan and delivered 100% of its cost improvement programme.
At year end, its capital expenditure was £127k below the capital departmental expenditure Limit.
The surplus position included £916k of planned sustainability and transformation fund (STF)
income and an STF incentive bonus was received by the trust of £1,299k for over performing the
agreed control total by £79k. For the current year 2018-2019, the trust was forecasting a year end
surplus position of £1,966k.
Month-end and year-end processes were clear and did not historically result in large and
unwarranted adjustments (internally and through audit). The finance team undertook a
reconciliation between its internal management accounts and the ledgers on an ongoing basis.
Trust corporate risk register
The trust provided a document detailing their two highest profile corporate risks as at May 2018.
Both had a current risk score of 15. Risk targets were not provided.
ID Service Description
Risk score (previous)
Risk level
(current)
Target date for
resolution
526
Human Resources
Insufficient availability of workforce with the right skills to fill trust vacancies and meet future requirements. Leading to difficulties in delivering current services and in adapting services to meet the STP and 5-year forward view. Resulting
15 15 April 2018
18
in potential service delivery/ safe staffing breaches and inability to meet future service demand.
589 Corporate
Herts Valley CCG’s decision to take adult services out to open market procurement is leading to the potential loss of the following services, resulting in financial, reputational loss, and knock-on impact on the organisations capacity to deliver against strategic objectives: Integrated community nursing and therapy services; Community intermediate care beds; Specialist palliative care; Bladder and bowel; Adult speech and language; Lymphoedema; Leg ulcer and tissue viability services; Community Neurological rehabilitation services; Podiatry (excluding diabetes); Nutrition and dietetics.
15 15 Sept. 2018
In addition, the trust provided their eight highest profile operation risks as at May 2018. Each of
these have a current risk score of 15 or higher. Risk targets were not provided.
ID Service Description
Risk score (previous)
Risk level
(current)
Target date for
resolution
567 Skin health
service
The lack of a robust clinical/medical governance structure and the lack of a clinical lead on the dermatology specialist register is leading to the clinical lead, two dermatology doctors, a surgeon and the five GPs with a Special Interest (GPwSIs) are not being adequately supervised clinically, resulting in a lack of assurance that performance targets are met and patients are being provided safe, effective care and jeopardises the continued viability of the service.
16 16 April 2018
577 Nascot lawn
The HV CCG has rescinded the notice given on Nascot Lawn (due to take effect from May 2018) following the outcome of the judicial review to enable consultation with HCC. The risk around ensuring safe, effective service delivery continues to be monitored.
16
16
May 2018
458 Watford
integrated Ongoing shortage of staff as difficulty in recruiting leading to
15 15 May 2018
19
community team
unfilled vacancies, recruitment of bank and agency staff, increase in resignations, long term sickness, resulting in risk to continuity of care, patient’s safety and patient experience.
570 Specialist
palliative care service
Reduction in specialist palliative care clinicians within HCT and local hospices may lead to reduced capacity resulting in number of patients with complex needs not being seen within service specification and potential for increased number of complaints from patients, families and other health care professionals.
15 15 July 2018
590
Integrated community
teams – East and North
Herts
The removal of funds from the contract with ENHCCG across East and North community localities, based on equalisation may lead to a reduction in staffing at all levels resulting in a reduction in activity, not meeting KPIs or Quality metrics, poor patient experience and reputational damage.
15 15 April 2018
602
Hertsmere community adult health
services
On-going nursing vacancies are leading to gaps in experienced staff; potential overspending on bank and agency staff to maintain service continuity; potential gaps in service provision to the Herts Valleys Intake Referral Hub and the ability to deliver CAHS and complex case management contractual obligations, resulting in concerns over patient safety and experience, staff morale and sickness, inability to deliver required contractual response times, and HCT reputational loss.
15 15 Sept. 2018
605 Community Hospitals -
Herts Valleys
A high number of patients whose onward destination from a community hospital bed is delayed (DTOC), is leading to high numbers of patients waiting for admission to a community hospital bed within the Herts Valley locality resulting in patients waiting in a community bed for longer than they should.
15 15 July 2018
608 Community nursing and integrated
Mobilisation and delivery of new Community and Adult Health Services (CAHS) across Herts Valley Integrated Community
15 15 July 2018
20
teams – Herts Valleys
Therapy and Nursing Services to a new service specification, outcomes and contract is leading to an inability to demonstrate delivery of all elements and components of the new CAHS contract. This is resulting in an impact on: current contractual arrangements (impact on performance and activity against original agreed specification); staffing levels and workforce; KPIs/ Outcomes; referral Hub/ CST programme; risk to HCT reputation.
(Source: Universal Routine Provider Information Request – P113 High level risk register)
The trust board had sight of the most significant risks and mitigating actions were clear. All senior
executive directors were aware of the risks within the organisation and in the wider local health
system. The top risks that the team identified were recruitment and retention (staffing and
workforce), and decommissioning of services.
Robust arrangements were in place for identifying, recording and managing risks, issues and
mitigating actions. Staff had access to a risk register and could effectively escalate concerns as
needed. Staff concerns matched those on the risk register.
The chief pharmacist managed the pharmacy risk register, including corporate medicines risks.
The highest risk held in both pharmacy and corporate risk register was lack of pharmacy
resources, which had led to the chief pharmacist seeking approval of more funding for pharmacy
staffing.
Escalation processes were clear and performance was scrutinised at committee and board level.
The trust wide quality report and data pack was sufficient to enable the board to understand the
trust’s performance and challenge areas where improvement was required.
The trust had assurance systems and escalated performance issues appropriately through clear
structures and process. Staff reported incidents appropriately and managers investigated all
incident reports. However, one senior member of staff told us she was concerned that near miss
incidents were not always reported. The incident investigation informed the risk assessments and
the risk register dependent of the risk rating.
There was a clear process for incident reporting. If the level of harm was moderate or above, it
was considered to be a serious incident or never event. All serious incidents had a lead
investigator appointed who would contact the patient/family at the beginning of the investigation.
We reviewed eight serious incident investigations and found all had been completed in a timely
manner and carried out according to the trust policy and procedures. Records and actions plans
were clear and appropriate identified onward learning from each incident.
The pharmacy team conducted quarterly controlled drug (CD) and medicines storage audits, and
quarterly antibiotic and high-risk medicines audits. The results were presented at the medicines
management forum for dissemination. The chief pharmacist accepted that the current audit
programme was reactive, however, there were plans to conduct more proactive audits and
analyse the results and subsequent action plans to improve patient safety and outcomes.
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Senior management committees and the board reviewed performance reports. Leaders regularly
reviewed and improved the processes to manage current and future performance.
Leaders were satisfied that clinical and internal audits were sufficient to provide assurance. Teams
acted on results where needed. There was a yearly audit plan and oversight of every internal audit
was through the audit committee.
Business continuity plans were in place for all services and locations for emergencies and other
unexpected or expected events. The trust was in the process of updating these to make them
simpler and more user friendly. The trust plans, tests, and verifies plans on a regular basis,
providing regular training on the processes and subsequent plans for business continuity.
A hub process had been introduced for organising visits and monitoring referrals. All referrals
come into the local hubs; all localities had a hub, which meant that there was a single point of
access. Referrals were then triaged by a qualified registered nurse or qualified therapist. The visits
were then scheduled in accordance to priority to improve efficiency.
Learning from Deaths
Although a process for reviewing deaths was in place, it was not well established and
shared learning from deaths was not effective.
The trust’s learning from deaths process was not fully established and embedded. The trust had a
mortality review policy in place which was approved in September 2017, and had been promoted
to all staff through ‘Noticeboard’, the trust’s staff newsletter.
A mortality review group (MRG) was also in place and the panel met on a quarterly basis. The
group provided an annual report to the trust board, in addition to quarterly mortality reports
provided and reviewed by the healthcare governance committee and board. The mortality group
was chaired by the associate medical director, who was relatively new to chairing the mortality
group, and a variety of staff attended. There was no representation from a non-executive director.
The notes of the mortality group had limited detail, lacked uniformity and did not always detail any
lessons learnt.
All in-patient deaths were screened using a mortality review trigger tool (MRTT) and reviewed
using the structured judgement review (SJR) method within a month, by a nominated reviewer.
Two SJR templates were used by the trust. One for community inpatient unit deaths and one to
review community deaths. The trust reviewed all deaths in scope using the Royal College of
Physicians (RCP) structured judgement review methodology. The methodology was developed for
acute trusts and had been adapted by Hertfordshire Community Trust to meet the needs of a
community trust. Findings from SJRs helped to identify problems in care that contributed to the
death. In these circumstances, an investigation would be considered under the trust’s ‘Serious
Incident Policy’.
Case reviews considered whether there were problems in the care provided which contributed to
the death. All cases reviewed by the trust to date had not identified that problems in care
contributed to the death, therefore the trust felt investigations were not required. Should such a
death occur and serious incident investigation be required, the serious incident report template
would be used to present investigation findings.
Clinical staff undertaking mortality reviews should have received training on undertaking SJRs.
The previous medical director delivered SJR training in January 2018 after he had received tier
one SJR training. The associate medical director attended tier one SJR training in October 2018.
The head of patient safety attended training delivered by the medical director in January 2018 and
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had since run a workshop to train additional community clinicians in undertaking SJRs. During our
inspection, we found roles of the reviewers varied and included locality managers, lead nurses and
allied health professionals. The new chair stated that they would like to involve more medical staff
in the reviews. All the reviewers had completed SJR training either from a tier one trainer or
delivered by the head of patient safety. However, the standard of reviews was different throughout
the ten that were looked at. Not all SJR’s were fully completed and had details missing, for
example, two looked at did not contain a cause of death.
Learning from deaths was discussed at quarterly mortality meetings to validate data and identify
further action required to make any improvements. The meetings also looked at whether the death
was avoidable or unavoidable and this was scored between one to six. If it was totally unavoidable
they scored it a six or if it was definitely avoidable it scored a one. We reviewed ten SJR’s. Nine
were scored at a six and one was scored at a five. One we reviewed, scored at a six, showed
potential errors in care which could have led to the patient’s death. There was no evidence of a
discussion about this within the mortality meeting minutes and the summary of the discussion said
that the patients care had been good but the documentation had been poor. This was different to
the outcome by the reviewer of the death. There were 47 deaths in the last year. No deaths went
to an investigation. The policy said that if poor care was found, they would repeat the review or do
an investigation. We were not assured that the trust had an effective process for learning from
deaths.
Following the discussion of the death at the mortality meeting, a mortality review finding form was
completed. This was attached to the incident report that was associated with the patient death.
This record did not show the learning from the death or demonstrate that there is any learning.
There were 47 deaths in the last year and they found that two had evidence of avoidability, score
of five. The associate medical director picked up that these were both due to sepsis. This was
raised as a learning for the year with the medical director. They had since allocated a sepsis lead
for the trust.
Families were not contacted to give them an opportunity to raise any concerns about their
relatives’ care. They were not involved in learning from deaths. The policy stated that they were
going to consider involving families. The lead for mortality said that it is something they were
considering at present.
The trust produced a ‘Sharing Lessons in Practice’ newsletter that included action points for the
staff to focus on. Learning from deaths was reported quarterly to the board through the mortality
reports and was included in the trust quality account.
When interviewed, the new medical director said he had confidence in the process the trust had in
place for learning from deaths. However, the lead for mortality was fully aware that the process
needed to improve and be more robust and had arranged a workshop for the week after our
inspection. The agenda was set and included review of the policy, training, improve the quality of
the reviews and them more focussed. They also stated that they had invited a non-executive
director to attend the meeting. The lead had recently attended SJR training and felt that they
would to be able to improve the quality assurance of the process. They were very focussed on
improving the review process and to ensure that the trust was learning from all deaths reviewed.
After our inspection the trust confirmed that the workshop had taken place and in addition to
reviewing current procedures and seeking approaches from other trusts, regular quality assurance
checks from the chair of the panel within a quality improvement framework were planned.
23
Information management
The trust collected, analysed, managed and used information well to support all its
activities, using secure electronic systems with secure safeguards.
The trust used a wide number of information systems across the organisation which captured and
recorded relevant clinical and demographic data about patients along their pathway. Together with
clinical systems, there were also non-clinical systems in place that captured such areas as
incident reporting; this directly contributed to improving the quality of care for patients.
The trust governance framework, including committee and performance reports, meant that the
board could receive timely data as required. Board papers held the necessary information to allow
the board to review risk, performance and quality and make decisions.
Leaders used meeting agendas to address quality and sustainability sufficiently at all levels across
the trust. Staff told us they had access to all necessary information and were encouraged to
challenge its reliability. Team managers had access to a range of information to support them with
their management role. This included information on the performance of the service, staffing and
patient care.
Information technology (IT) systems and telephones were working well and they helped to improve
the quality of care. Staff had access to the IT equipment and systems they needed to do their
work. The trust had recently invested in new systems and upgrades to their IT infrastructure,
including:
• Rolling out of a clinical records system in all services and inpatient wards, allowing staff to
work in a virtually paperless system
• New business intelligence systems to allow teams to analyse performance information in
much greater detail
• Increased range of non-clinical support systems, including an online learning and
development system allowing staff to check their own training records and book onto
courses
Investments into the IT infrastructure with new data centres had increased the trust’s IT resilience
and reliability. The trust were continuing to roll out improved digital and technological platforms to
help teams to communicate more effectively, for example rolling out Skype for Business video
conferencing and introduction of smart phones for front line staff. The new phones will include
apps and functions such as email, staff news app, and the ability for staff to book additional shifts
through the NHS Professional bank site.
The trust submitted notifications to external bodies such as the Care Quality Commission as
required.
Information governance systems were in place including confidentiality of patient records.
Discussions with board members provided a consensus that financial information was viewed as
being fit for purpose and that there were no concerns over data accuracy. The interim director of
finance stated that he has not been requested to change the format or content of his financial
reports since being in post. The recent use of tableau (an analytics platform) and the introduction
of dashboards was viewed as having improved access to data.
Engagement
The trust engaged very well with patients, staff, the public and local organisations to plan
and manage services, and collaborated with partner organisations effectively.
24
The trust had a structured and systematic approach to engaging with patients, those close to them
and their representatives. Patients could meet with members of the trust’s leadership team to give
feedback. To ensure that the voice of patients was heard, all board meetings included a patient
story.
The trust had carried out a series of events which demonstrated public engagement and
community involvement, including:
• Launching Health for Teens website and ChatHealth text messaging service through three
events across the county with secondary schools.
• Interviewed parents, children and young people to develop Patient Centred Outcome
Measure (PCOM) tool
• Focus groups with parents to understand perceptions of health visitors and school nurses,
how they would find out about services and access health information about their child.
• Focus groups with parents to gain views on current occupational therapy service prior to
service redesign
• Public engagement meetings on closure of community beds and commissioning of the new
FIRST service
• Bi-monthly engagement events to provide information and gain public feedback about the
new Health and Wellbeing Centre
• Public events to provide information and obtain feedback on redevelopment plans
• Public events for patients with Healthwatch Hertfordshire around redesign of integrated
care teams in Hertfordshire Valleys area; collated patient stories to gain feedback from
service users and highlight potential impact of redesign
The trust’s ‘High Value Healthcare’ outlined their key priorities in improving patient safety,
improving clinical outcomes and providing excellent patient experience. The patient safety and
experience group (PSEG) reported to and was accountable to the healthcare governance
committee, a formal trust board committee.
The PSEG delivery plan set priority areas and actions required; it was aligned to the trust’s health
and wellbeing strategy, which incorporated the quality strategy, and focused on key areas,
including:
• Promoting/embedding a positive/proactive patient safety culture for implementing safe
patient care
• Developing systems that ensure patient care is safe and compliant, specifically infection
prevention and control, safeguarding adults and children, and medical devices
• Demonstrating gathering, analysing, reporting and sharing patient feedback/experience
through surveys, FFT, compliments, complaints, PALS enquiries
• Demonstrating openness and shared learning from incidents, serious incidents, complaints
• Ensuring safe staffing and effective escalation processes
Communication systems such as the intranet and newsletters were in place to ensure staff,
patients and carers had access to up to date information about the work of the trust and the
services they used. Staff told us the executive and senior management team were visible and
approachable.
25
In the most recent NHS staff survey 2017, 58.4% (1586 employees) responded to the survey,
which was an improvement on the previous year’s response (54%). Despite an extensive period of
organisational change and service de-commissioning, the overall level of staff engagement was a
score of 3.83, which was higher than national average for community trusts. Staff recommendation
of the trust as a place to work or receive treatment was above average, as was staff ability to
contribute towards improvements at work, with staff motivation at the average. In terms of
leadership, staff felt supported, recognised and valued by their managers (above national
average). Staff reported good communication between senior management and staff. The trust
score for quality of appraisals was the top score for all community trusts. Staff survey results for
the effective use of patient/service user feedback was also higher than average.
The trust recognised a weakness was the impact of organisational change and decommissioning
of services on staff morale longer term. Staff satisfaction with the quality of work and care
delivered was lower than 2016. Recent quarterly pulse survey free text comments indicated that
staff were concerned about the uncertainty and the work pressure they were under. Staff we
spoke with told us they felt involved in the tender process and were kept up to date with
information relating to this.
Since the appointment of the new chief pharmacist, there was better engagement with the wider
local health economy, through the chief pharmacist networks and area prescribing committees.
However, the collaborative relationship with trusts providing outsourced clinical services needs to
be strengthened, to ensure a quality review of the service level agreement and monitor
performance framework for the pharmacy services provided.
The trust was actively engaged in collaborative work with external partners, such as involvement
with sustainability and transformation plans (STPs).
Learning, continuous improvement and innovation
There was trust wide commitment to innovation with patient experience and safety at the
heart of improvements.
The trust commissioned an external organisation to review the integrated teams’ delivery of
services. This was undertaken to identify opportunities to improve effectiveness and efficiency in
service delivery through utilising real-time data from practitioners and how they believe things
could be improved. This work led to inclusion of a number of the recommendations incorporated
into the newly designed Community Adult Health Service which went live in November 2017. It
was also used to inform procurement to provide support to teams to drive improved effectiveness
and to develop the culture of local leadership and decision making.
The trust participated in the Lord Carter review of productivity and efficiency in community and
mental health services, and shared transformation work undertaken to date to improve customer
service. This was multi-faceted and included: restructuring administrative functions to a semi-
centralised model based on three contact centres for the county, expanding the use of
technology/mobile working, increasing clinical patient facing time for clinicians and introduction of
e-rostering, reducing bank and agency spend. This was noted in the Carter report May 2018.
The trust was part of the South London Health Innovation Network and information gained from
this network had informed practice to strengthen and support implementation of the duty of
candour regulations.
The trust actively sought to participate in improvement and innovation projects. The trust’s Change
Management Toolkit was developed in 2015/16 to support the delivery of the trust strategy. The
toolkit was available online and used by the transformation team and others involved in delivering
26
change. The strategy and approach to change was communicated to staff through a series of
roadshows.
Opportunities to shared learning, for example, ‘Glimpses of Brilliance’, were available through
social media, the annual 'Leading Lights' award ceremony, quarterly Leaders forum, locality
events, ‘Making a Difference’ workshops facilitated by PMO and NHS Elect masterclasses.
Lessons learned reviews were completed post-change and learning shared.
During 2017, 20 staff from across the STP attended NHSI Quality Service Improvement and
Redesign (QSIR) training and had become accredited practitioners. The trust had individuals
qualified to teach QSIR and a further 50 staff were being trained. A revised approach to
continuous quality improvement, using QSIR was due to be piloted in preparation for a trust-wide
roll-out.
A key component of the trust strategy involved equipping patients with the knowledge, skills, and
information they need to manage their own health and wellbeing. In December 2017, the trust
rolled out a patient-held “My Health Plan” that supported patients to identify their personal goals.
Improvements were planned to reflect best practice learning from stakeholders. To enable staff to
have the right conversations and promote self-care, a three-tier training plan had been
implemented to equip staff with the right skills to support patients to take ownership of their own
health plan. Plans were also in place to make self-management resources available to patients on-
line. Working with NHS Digital, the trust recently undertook a pilot of a MediPi telehealth solution.
The trust was now considering how to use telehealth to support patients with LTCs to self-
manage. The trust's Public Health Nursing (PHN) service will be implementing a range of outcome
measures which will be used to measure the service's contribution to delivering healthy lifestyles.
These include: (1) Hertfordshire County Council's 6 Bees; (2) the outcomes and indicators relevant
to the children and young people in the PHOF; (3) NHS outcomes framework; (4) Ages and
STages 3 (ASQ3) and the Ages, Social, and Emotional Questionnaire (ASQ SE).
The trust had a focus on digital solutions and ways of working to make more efficient use of
resources and to improve working practice. They had introduced the country’s first electronic
consent form.
The trust had completed a three-year transformation project in speech and language therapy to
make best use of a scarce resource and improve care to patients while making the service
sustainable.
The trust was actively participating in clinical research studies, including Healthy Start, Happy
Start – preventing enduring behavioural problems in young children through early psychological
intervention, KASPAR – investigating the effectiveness of a humanoid robot to support social skills
development in children with an autism spectrum disorder.
There were organisational systems to support improvement and innovation work. The trust’s
healthcare assistant insulin initiative had been adopted by the NHSI national nursing team for roll
out across all providers of community services.
A Dragon’s Den panel was started, which included a NED, and was developed into the Innovation
panel, whereby any member of staff could approach with ideas or innovation they had. The panel
was empowered to provide resources and support as well as expertise to make change happen.
Bladder scanning in ICTs/CAHS and a volunteer scheme to deliver crucial prescription medicines
to patients at home who were at end of life were implemented as a result.
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Complaints process overview
The trust was asked to comment on their targets for responding to complaints and current
performance against these targets for the last 12 months.
Question In days Current performance
What is your internal target for responding to complaints? 3 days 100%
What is your target for completing a complaint 25 days 92%
If you have a slightly longer target for complex complaints
please indicate what that is here N/A N/A
Number of complaints resolved without formal process in
the last 12 months? (July 2017 – March 2018) - 154
(Source: Universal Routine Provider Information Request (RPIR) – P51 Complaints Overview)
Number of complaints made to the trust
From April 2017 and March 2018, the trust received 152 complaints. The core service that
received the most complaints was community health services for adults with 82 (54%).
A breakdown of complaints by core service is below.
Core Service Number of
complaints
Percentage of
total
CHS - Adults Community 82 53.9%
CHS - Children, Young People and Families 47 30.9%
CHS - Community Inpatients 22 14.5%
CHS – End of life care 1 0.7%
Total 152
A breakdown of the main themes of complaints is below.
Complaint theme Number of
complaints
Percentage of
total
All aspects of clinical treatment 56 36.8%
Appointments, delay/cancellation (out-patient) 31 20.4%
Communication/information to patients (written and oral) 20 13.2%
Attitude of staff 15 9.9%
Admissions, discharge and transfer arrangements 12 7.9%
Others 11 7.2%
Aids and appliances, equipment, premises (including access) 4 2.6%
Appointments, delay/cancellation (in-patient) 1 0.7%
Patients’ property and expenses 1 0.7%
Failure to follow agreed procedure 1 0.7%
Total 152
(Source: Universal Routine Provider Information Request (RPIR) – P52 Complaint)
Although the trust had a process to capture informal complaints, they were unsure whether all
informal complaints were captured through this process.
Formal complaints would be investigated by the service the complaint related to and an
investigator would be allocated for each formal complaint. However, although informal training was
offered, there was no formal training in place for investigators on how to investigate complaints.
28
The trust had processes in place to ensure the quality of complaint investigations were of a good
standard.
The trust shared learning from complaints through the weekly newsletter, sharing learning in
practice newsletter, team meetings, training events, and development days.
Compliments
From April 2017 to March 2018, the trust received over 12,000 compliments.
No themes have been identified from compliments received, however, the trust’s patient
experience team reported on number of compliments received by service. The top three
compliments by service is reported on in their staff noticeboard to encourage services to record
compliments received, and to evidence continued good work.
A breakdown of compliments received by core service is below:
Community Inpatients:
Location Number of compliments
Danesbury House 142
Hemel Hempstead General Hospital 132
Langley House 97
Potters Bar Community Hospital 87
Queen Victoria Memorial Hospital 61
Holywell 55
Hertfordshire and Essex Hospital 6
Total 580
Community Adults:
There were 4,818 compliments relating to 47 service types in community services for adults.
End of life care:
Service Number of compliments
Specialist palliative care service 26
ICT North & Stort Valley 1
Homefirst North Herts 1
Total 28
The above information does not represent the full 12,000plus compliments. The trust did not
provide any information relating to compliments about community services for children and young
people.
(Source: Universal Routine Provider Information Request (RPIR) – P53 Compliments)
Accreditations
NHS Trusts can participate in a number of accreditation schemes whereby the services they
provide are reviewed and a decision is made whether or not to award the service with an
accreditation. A service will be accredited if they are able to demonstrate that they meet a certain
standard of best practice in the given area. An accreditation usually carries an end date (or review
date) whereby the service will need to be re-assessed in order to continue to be accredited.
The table below shows which of the trust’s services have been awarded an accreditation.
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Accreditation scheme Team/Service accredited
Disability Confident Scheme Trust wide, achieved in 2017
Hertfordshire County Council Purple
Star Promise Scheme
Queensway Clinic, podiatry service, June 2016.
Special Care Dental Service – all services
Health Education England Quality
Framework for Practice Providers Trust wide, confirmed in March 2018
Desmond Diabetes Training
Accreditation Centre Diabetes service
DAFNE (Dose adjustment for normal
eating) Diabetes service
UNICEF Baby friendly initiative stage 3
accreditation Trust wide – July 2017
Accreditation for Psychological
Therapies Services (APPTS) -
(Source: Universal Routine Provider Information Request (RPIR) – P66 Accreditations)
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Community health services
Community health services for adults
Facts and data about this service
Hertfordshire Community NHS Trust (HCT) has organised community services for adults into one
management team (adult’s services business unit) led by the associate director of operations.
This management structure is split into four portfolios each managed by a deputy general
manager.
The Hertfordshire Valleys Community Adult Health Service (CAHS) portfolio consists of the
integrated community teams across Hertfordshire Valley clinical commissioning group (CCG)
geographical area and is split into four localities with each managed by an HCT locality manager.
The managers for this service portfolio had recently, (November 2017), completed a re-
commissioning exercise by the CCG. This consisted of a reduction in funding, the development of
a new delivery model and service specification. In addition, the name of the teams changed
during this time to CAHS. This portfolio also includes the HCT discharge home to assess team.
The East and North integrated community team’s portfolio consists of the community teams
across East and North CCG geographical area and is split into six localities with each managed
by a HCT locality manager. This service is currently undergoing a re-commissioning exercise by
the CCG. This consists of a reduction in funding, the development of a new delivery model and
service specification.
The specialist community services portfolio includes multiple large and small services for
example; podiatry, bladder and bowel and heart failure services. These have multiple different
commissioners (NHSE, Herts Valleys and East and North CCG, acute trusts). Some span the
whole of Hertfordshire and some part of the county only.
(Source: CHS Routine Provider Information Request (RPIR) – Context CHS)
Community health services for adults at this trust has two registered locations. Howard Court is
the registered location for 232 services and St Albans is the registered location for two services:
rapid assessments and leg ulcer services.
(Source: Universal Routine Provider Information Request (RPIR) – P2 Sites tab)
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Is the service safe?
Mandatory training
The service provided mandatory training in key skills to all staff and made sure almost all
completed it and remained up to date.
Staff received mandatory training in safety systems, processes, and practices. Mandatory training
consisted of a range of topics, which included health and safety, information governance, conflict
resolution, equality and diversity and infection prevention and control. Staff received their
mandatory training either online or face-to-face.
The following information was routinely requested within the universal provider information request
spreadsheets, and was completed within a standard template.
The service did not separate their mandatory training data by staff group. Therefore, the data
below includes nursing and midwifery staff, medical and dental staff, allied healthcare
professionals, and healthcare assistants/infrastructure support staff in community inpatient
services.
The trust set a target of 90% for completion of all mandatory training courses except for health and
safety and information governance, which both had a target of 95%.
The breakdown of compliance for mandatory courses for staff in community adult services from
April 2017 to March 2018 is shown below.
Trustwide
Training module name
Number
of staff
trained
Number of
eligible staff
Completio
n (%)
Target
(%)
Target
met
Infection Prevention (Level 1) 278 280 99.3% 90% Yes
Equality and Diversity 1,081 1,115 97.0% 90% Yes
Manual Handling - Object 320 330 97.0% 90% Yes
Information Governance 1,086 1,124 96.6% 95% Yes
Conflict Resolution 849 919 92.4% 90% Yes
NHS |CSTF| Fire Safety 1,030 1,124 91.6% 90% Yes
NHS |CSTF| Resuscitation - Level
2 777 902 86.1% 90%
No
Infection Prevention (Level 2) 566 666 85.0% 90% No
Manual Handling - People 625 769 81.3% 90% No
Health and safety 888 1,119 79.4% 95% No
(Source: Universal Routine Provider Information Request (RPIR) – P40 Training)
For trust wide in community services for adults the 90-95% target was met for six of the ten
mandatory training modules for which staff were eligible. The health and safety module had the
lowest completion rate with 79.4%, compared to the trust target of 95%.
The trust supplied updated mandatory training data as of August 2018. The breakdown by training
module for staff across community adults as of that date is shown in the table below. Please note
that the health and safety training module was not included in the updated data. In addition, some
other training modules had been amalgamated or renamed.
32
Training module name
Number
of staff
trained
Number of
eligible staff
Completion
(%)
Target
(%)
Target
met
Fire 1,010 1,098 92.0% 90% Yes
Conflict Resolution 923 1,033 89.4% 90% No
Equality and Diversity 1,040 1,165 89.3% 90% No
Infection Control Mandatory 926 1,043 88.8% 90% No
Information Governance 1,032 1,165 88.6% 95% No
Resuscitation 865 1,034 83.7% 90% No
Moving and Handling 693 852 81.3% 90% No
Fire Evacuation 51 69 73.9% 90% No
In community adults, as of August 2018 the trust’s training targets were met for one of the eight
mandatory training modules for which staff were eligible.
(Source: DR110, Mandatory training compliance August 2018) Howard Court
Training module name
Number of staff trained
Number of eligible
staff Completio
n (%) Target
(%) Target
met
Infection Prevention (Level 1) 278 280 99.3% 90% Yes
Manual Handling - Object 319 329 97.0% 90% Yes
Equality and Diversity 1,061 1,095 96.9% 90% Yes
Information Governance 1,066 1,104 96.6% 95% Yes
Conflict Resolution 830 900 92.2% 90% Yes
NHS |CSTF| Fire Safety 1,011 1,104 91.6% 90% Yes
NHS |CSTF| Resuscitation - Level 2 759 883 86.0% 90% No
Infection Prevention (Level 2) 551 647 85.2% 90% No
Manual Handling - People 608 750 81.1% 90% No
Health and safety 870 1,099 79.2% 95% No
(Source: Universal Routine Provider Information Request (RPIR) – P40 Training)
For Howard Court in community services for adults, from April 2017 to March 2018 the 90-95%
target was met for six of the ten mandatory training modules for which staff were eligible. The
health and safety module had the lowest completion rate with 79.2%, compared to the trust target
of 95%.
St Albans
Training module name
Number
of staff
trained
Number
of
eligible
staff
Completion
(%)
Target
(%)
Target
met
Conflict Resolution 19 19 100.0% 90% Yes
Equality and Diversity 20 20 100.0% 90% Yes
Information Governance 20 20 100.0% 95% Yes
Manual Handling - Object 1 1 100.0% 90% Yes
NHS |CSTF| Fire Safety 19 20 95.0% 90% Yes
NHS |CSTF| Resuscitation - Level 2 18 19 94.7% 90% Yes
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Health and safety 18 20 90.0% 95% No
Manual Handling - People 17 19 89.5% 90% No
Infection Prevention (Level 2) 15 19 78.9% 90% No
(Source: Universal Routine Provider Information Request (RPIR) – P40 Training)
At St Albans community services for adults, from April 2017 to March 2018 the 90-95% target was
met for six of the nine mandatory training modules for which staff were eligible. Infection
prevention had the lowest completion rate with 78.9%, compared to the trust target of 90%.
Data provided demonstrated that the service achieved compliance with the trust target percentage
for six out of the 10 mandatory training modules. For the remaining four modules, compliance with
mandatory training was between 79% and 86%.
(Source: DR110, Mandatory training compliance August 2018)
During the last inspection in February 2015 staff told us they had to travel considerable distances
for training and had problems getting protected time to attend training. During this inspection, staff
told us that accessibility of training had improved and training records seen, showed improved
compliance.
Staff received reminder emails, with their managers copied in, from the learning and development
department when they were due any mandatory training updates. Managers discussed any
training issues during staff appraisals and one to one meetings. Staff stated it was their own
responsibility to book onto training courses. Minutes of meetings that we saw, showed that
mandatory training was discussed at both team meetings and managers’ meetings.
Safeguarding
Staff understood how to protect patients from abuse and worked well with other agencies
to do so. Staff had training on how to recognise and report abuse and they knew how to
apply it. Staff had the appropriate level of safeguarding training for the services they
delivered.
There was a safeguarding adults’ policy in place, which was in date, outlined what safeguarding
was, its importance, and provided definitions to the different types of abuse. The policy also
covered staff responsibilities about raising and reporting safeguarding concerns. It was accessible
to all staff via their intranet and staff knew where they could find this.
We saw information on staff boards offering advice and guidance on recognising and responding
to abuse. Staff were aware of the trust safeguarding lead and this information was displayed on
notice boards within departments. Teams had safeguarding champions who supported staff with
training and referrals.
Grade 3 and above pressure ulcers were not routinely referred to the local safeguarding team. A
tissue viability nurse told us they referred any grade 3 ulcers to the local safeguarding team if
there were additional safeguarding circumstances. This was in line with the trust policy.
Safeguarding Training completion
The service did not separate their mandatory training data by staff group. Therefore, the data
below includes nursing and midwifery staff, medical and dental staff, allied healthcare
professionals and healthcare assistants/infrastructure support staff in community inpatient
services.
34
Up to date mandatory training data seen following our inspection showed that, trust wide, the 90%
target was met for all safeguarding training modules.
Prevent training is a government directive to support vulnerable individuals. Prevent is the duty in
the Counter -Terrorism and Security Act 2015 on specified authorities, in the exercise of their
functions, to have due regard to the need to prevent people from being drawn into terrorism. It is
mandatory for all trust staff to complete prevent training. The trust set a target of 90% compliance;
Howard Court were 92.3% complaint and St Albans were 75% complaint.
From April 2017 to March 2018 the breakdown of compliance for safeguarding training for all staff
in community services for adults is shown below.
Trust wide
Training module name
Number
of staff
trained
Number
of eligible
staff
Completio
n (%)
Target
(%)
Target
met
Safeguarding Adults (Level 1) 195 195 100% 90% Yes
Safeguarding Adults (Level 2) 906 929 97.5% 90% Yes
Safeguarding Children (Level 1) 191 196 97.4% 90% Yes
Safeguarding Children (Level 2) 905 929 97.4% 90% Yes
NHS |CSTF| Preventing
Radicalisation - Levels 3, 4 & 5
(Prevent Awareness) 781 824 94.8% 90% Yes
NHS |CSTF| Preventing
Radicalisation - Levels 1 & 2 (Basic
Prevent Awareness) 196 213 92.0% 90%
Yes
Safeguarding Children (Level 3) 5 6 83.3% 90% No
In community services for adults the 90% target was met for six of the seven safeguarding training
modules for which staff were eligible. Level 3 safeguarding children module did not meet the target
with 83.3%.
The trust supplied updated safeguarding training data as of August 2018. The breakdown by
training module for staff across community adults as of that date is shown in the table below.
Please note that the different levels of safeguarding adults and preventing radicalisation training
had been replaced by a single module for each of these two training subjects by August 2018.
Name of course
Number of
staff
trained
Number of
eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Safeguarding Children (Level 3) 32 32 100% 90% Yes
Safeguarding Adults 1,121 1,169 95.9% 90% Yes
Safeguarding Children (Level 2) 970 1,019 95.2% 90% Yes
Safeguarding Children (Level 1) 140 152 92.1% 90% Yes
Preventing radicalisation 1,025 1,123 91.3% 90% Yes
SAFA Champions 15 31 48.4% 95% No
In community adult services, as of August 2018 the trust’s training targets were met for five of the
six safeguarding training modules for which staff were eligible. SAFA champions did not meet the
target with 48.4% completion rate, compared to 95% trust target.
35
(Source: DR110, Mandatory training compliance August 2018)
Howard Court
Training module name
Number
of staff
trained
Number
of eligible
staff
Completio
n (%)
Target
(%)
Target
met
Safeguarding Adults (Level 1) 194 194 100% 90% Yes
Safeguarding Adults (Level 2) 887 910 97.5% 90% Yes
Safeguarding Children (Level 1) 190 195 97.4% 90% Yes
Safeguarding Children (Level 2) 886 910 97.4% 90% Yes
NHS |CSTF| Preventing
Radicalisation - Levels 3, 4 & 5
(Prevent Awareness) 766 808 94.8% 90%
Yes
NHS |CSTF| Preventing
Radicalisation - Levels 1 & 2 (Basic
Prevent Awareness) 193 209 92.3% 90%
Yes
Safeguarding Children (Level 3) 5 6 83.3% 90% No
At Howard Court in community services for adults, the 90% target was met for five of the seven
safeguarding training modules for which staff were eligible. Safeguarding adults (level 3) did not
meet the target with 83.3% completion rate.
St Albans
Training module name
Number of staff trained
Number of eligible
staff Completio
n (%) Target
(%) Target
met
Safeguarding Adults (Level 1) 1 1 100% 90% Yes
Safeguarding Adults (Level 2) 19 19 100% 90% Yes
Safeguarding Children (Level 1) 1 1 100% 90% Yes
Safeguarding Children (Level 2) 19 19 100% 90% Yes
NHS |CSTF| Preventing Radicalisation - Levels 3, 4 & 5 (Prevent Awareness) 15 16 93.8% 90%
Yes
NHS |CSTF| Preventing Radicalisation - Levels 1 & 2 (Basic Prevent Awareness) 3 4 75.0% 90%
No
At St Albans in community services for adults the 90% target was met for five of the six
safeguarding training modules for which staff were eligible Preventing radicalisation – levels 1 and
2 (Basic prevent awareness) training module did not meet the target with 75% completion rate.
(Source: Universal Routine Provider Information Request (RPIR) – P38 Training)
Safeguarding referrals A safeguarding referral is a request from a member of the public or a professional to the local
authority or the police to intervene to support or protect a child or vulnerable adult from abuse.
Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and
institutional.
36
Each authority had their own guidelines as to how to investigate and progress a safeguarding
referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will
work to ensure the safety of the person and an assessment of the concerns will also be conducted
to determine whether an external referral to children’s services, adult services or the police should
take place.
Referrals were provided on a trust wide level so we were unable to break this down to core
service.
From 1 April 2017 to 31 March 2018 there were 382 safeguarding referrals for adults made by
HCT staff. During the same period the trust made 390 safeguarding referrals for children.
(Source: Universal Routine Provider Information Request (RPIR) – P11 Safeguarding)
Safeguarding referral forms were accessible online via the patient’s record on the trust’s electronic
record keeping system. Staff knew how to complete a referral and an incident report in line with
policy. The system was a database used by all clinicians across the trust detailing all patients’
episodes of contact with the health service.
Staff discussed safeguarding issues, lessons learnt and action points during handover meetings.
Staff told us the actions they would take if they suspected a safeguarding incident; this was in line
with policy. Staff gave examples of what they would consider to be a safeguarding incident, such
as patterned bruising. Staff felt that they worked well as a team to safeguard patients. For
example, a patient with a grade 3 pressure ulcer thought to have been the result of neglect in care,
was the subject of a multi-agency meeting to discuss their management plan and actions required
to safeguard them.
Cleanliness, infection control and hygiene
The service controlled infection risk well most of the time. Staff generally kept themselves,
equipment and the premises clean. They mostly used control measures to prevent the
spread of infection.
Most staff adhered to infection prevention and control measures. Arms were bare below the
elbows and nursing staff wore wearing personal protective equipment (PPE) when carrying out
clinical tasks. This was also shown in the locality audit results for February to June 2018 where
100% of staff were bare below the elbow. We observed staff on home visits, in the rapid
assessment unit and in the leg ulcer clinic using gloves and aprons. They washed their hands or
used hand gel between patients and created a clean area for dressings. However, we saw one
physiotherapist wearing a stoned ring whilst performing a clinical task.
Hand sanitiser dispensers and hand washing facilities were available in all clinical areas. We
observed most staff completing hand hygiene before, between and after patient contact. This was
in line with National Institute for Health and Care Excellence (NICE) guidance for infection
prevention and control, Quality Standard 61 (April 2014). The guidance states that healthcare
workers should decontaminate their hands immediately before and after every episode of direct
contact care.
During an observation of the leg ulcer clinic and a home visit we saw staff delivered clinical care
using aseptic (sterile) techniques.
We saw elbow operated, or sensor operated ‘no touch’ clinical hand wash sinks in clinical
environments. These met health building note standards. Health building notes give best practice
guidance on the design and planning of new healthcare buildings and on the adaptation or
extension of existing facilities. Most clinic rooms had hand wash sinks, paper towels, liquid soap,
37
and pedal bins available, with posters displaying effective handwashing techniques. We found that
at St Alban’s City Hospital, during the speech and language therapy clinic, the speech and
language therapist was in a room without a sink or hand gel dispenser. We also found that in the
gymnasium within the physiotherapy department at Queen Elizabeth II Hospital (QEII) the sink
was broken, this meant that staff were unable to wash their hands before and after patient contact.
However, there were hand gel dispensers on the wall, which facilitated decontamination of hands.
Most of the areas we visited appeared visibly clean. In the physiotherapy clinics at both Lister
Hospital and QEII Hospital, we observed staff cleaning the examination couch and equipment in-
between patient use. Staff used specialist cleaning wipes to reduce the risk of cross
contamination.
There was limited use of ‘I am clean’ stickers in clinic areas to indicate that equipment had been
cleaned after patient use. Staff said that they did not routinely use these stickers. We could not,
therefore, be assured that all equipment had been cleaned after each patient use. However,
following inspection, the trust informed us that their cleaning and disinfection policy only required
high risk items, such as commodes, to be cleaned after each patient use.
We saw that cleaning schedules were not always completed when they were in place. For
example, at Potters Bar Community Hospital, we saw that in two out of the three rooms, checklists
were completed on eight occasions during 2018. A third room had the checklist completed on
three occasions during 2018. Data sent by the service showed poor completion rates across
several locations of service delivery. The manager of Cheshunt Community Hospital had provided
an action plan for improving this within their service.
There were clear processes for the management and disposal of clinical waste. In clinics, clinical
and non-clinical waste were segregated into foot operated colour-coded bins. We saw that sharps
bins in clinics were mostly secured to the wall. They were signed, dated, and not overfilled.
However, we saw a partially filled sharps bin in the clinical room at Potters Bar Community
Hospital, which was not secured to the wall and was balancing on a chair.
The trust had a target of 90% for mandatory training. Infection prevention and control mandatory
training compliance was 99.3% trust wide for level 1 and for level 2 it was 85.0%.
Data seen showed that hand hygiene dip test results were mostly 100% across the localities
between February to June 2018. Two localities had compliance of 97% and 94% due to missed
hand hygiene following contact with the patient surroundings.
In the musculoskeletal (MSK) clinic and leg ulcer clinic, there were disposable curtains around
each cubicle area. These curtains were in date and were replaced regularly as required.
Environment and equipment
The service generally had suitable premises but did not always have equipment that was
regularly maintained. When we found out of date equipment during our inspection, we
raised this with managers, who took action to address this. Following our inspection, we
saw that there were large amounts of equipment on the service equipment maintenance
logs that were out of date for annual testing. We were not assured that the service had
effective processes for ensuring that all equipment was maintained in line with policy.
We visited several buildings and saw that most were purpose-built. However, not all buildings
were fit for purpose. Some services were delivered in older buildings, which were not always
suitable for their intended use. For example, at St Albans City Hospital, the clinic room being used
was carpeted and had no sink. This meant that the staff using it were unable to comply with the
38
trust’s infection control policy. After our inspection we were told that these services had moved to
a new unit on 1 October 2018 and all the environmental issues were resolved fully.
We found that the environment in the Nevells Health Centre was in a poor state of repair and
needed updating. For example, the doors to the clinic rooms in the physiotherapy department
were not soundproofed. This meant that conversations could be heard easily through the door.
Clinic storage rooms were clean, tidy, and well organised. We observed equipment was stored
appropriately in clinics; however, access to some storage rooms was not always restricted to staff
only. Clinic storage rooms in Potters Bar Community Hospital and QEII physiotherapy gymnasium
had been left unlocked. There was a risk that unauthorised people could therefore have had
access to medical consumables and presented a tamper risk for essential equipment.
Medical devices were managed by the trust’s medical devices team. A list of all medical devices
was maintained. We found that not all equipment and consumables were in date. For example, at
the hand therapy clinic at Lister Hospital, there were items found that expired in 2011, 2014, 2016
and 2017 and the splint pan expired in June 2018. The splint pan is used to allow custom shaping
hand splints for patients. In QEII Hospital, the ultrasound unit and the shockwave unit were due for
testing in January 2018. This was raised with senior staff at the time of the inspection. Staff stated
that these items would be removed from use immediately and they would arrange for equipment to
be tested where required. The service confirmed that all items were removed immediately and
staff have been reminded to routinely check use by dates prior to use.
The service gave us a copy of their medical devices maintenance logs. This showed that 1,378
items of equipment out of 5,638 were overdue for a service. We saw that 13 of these were high-
risk items, such as syringe drivers (battery-powered pumps that deliver medication at a constant
rate through a very fine needle under the skin). All items on the log were rated on a risk level from
low to high. Managers told us that the risk rating formed a basis for prioritisation of their annual
schedule. The overdue equipment maintenance was not included on the service risk register. The
service stated that some items of equipment were now serviced in-house, in order to improve the
quality and responsiveness of the service. However, due to the large numbers of equipment that
were not compliant with annual testing requirements, we were not assured that all equipment was
well maintained.
The treatment room and clinical area at Potters Bar Community Hospital were visibly clean and
tidy. However, cleaning schedules checks were rarely recorded daily. We also found some out of
date items such as cannulas, paediatric emergency oxygen masks and blood taking equipment.
Staff received training to use specialist equipment. For example, community nurses used syringe
drivers to deliver doses of drugs to patients in their own homes.
During the last inspection, in February 2015, we were informed that equipment was not always
readily available at weekends including commodes, mattresses and walking frames. During this
inspection, staff said this had improved and equipment was readily available. Stock was
replenished from a central warehouse and was maintained weekly by technical instructors. Staff
stated that they did not have any issues obtaining the equipment.
Staff ordered mobility equipment and pressure-relieving equipment through an online portal for
community equipment service. Staff stated that they had good access to equipment and it was
usually available quickly. If any equipment was needed urgently it was always delivered within 24
hours.
We saw bariatric equipment in clinics and staff stated that they could order for patient’s homes if
needed.
39
There were emergency call bells in most consulting rooms and clinic areas. However, the rapid
assessment unit at St Albans City Hospital had no emergency call bells, therefore, patients were
given a hand bell to use. The manager of the service told us that they were due to move premises
on 1 October 2018 to a unit where emergency call bells were installed.
There was not a robust process in place for daily checking of the items on the resuscitation trolley
at Potters Bar Community Hospital. The checklist was basic and did not include a full list of the
items on the trolley, checks of the sealed tamper proof tag number, or clear responsibilities for
checking the trolley daily. The checklist was completed 14 days in August 2018 and nine days out
of 18 in September 2018. We saw that the emergency medicines kept on the trolley were stored in
a box with a sealed tag which was tamper evident. However, these medicines were kept on top of
the trolley, not locked away and the sealed numbered tag was not checked daily. We were
therefore not assured that these medicines had not been tampered with. We raised this
immediately with senior staff who locked the medicines away in the resuscitation trolley and
informed us that they would do a full check of the trolley and all its contents immediately.
The resuscitation trolley at St Alban’s City Hospital was stored in a room behind a door which was
difficult to access. The checklist for this was completed daily during September, August and July
2018 and all items on the trolley were in date. However, it contained the cardiopulmonary
resuscitation policy which was out of date. The service confirmed that following the move to the
new unit, the resuscitation trolley was stored in a centralised location.
Minutes seen showed that medical device alerts had been discussed and actions were taken
where needed.
Assessing and responding to patient risk
Whilst systems and procedures were mostly in place to assess, monitor and manage risks
to patients, not all patients had up to date risk assessments recorded.
Patients in all services were assessed with a range of holistic assessment tools which were in line
with national practice. Staff completed risk assessments as part of the electronic patient record.
This included malnutrition universal screening tool (MUST), Waterlow (to assess the risk of skin
damage) and falls. We reviewed 19 patient records and found that care plans were completed.
However only 15 had up to date risk assessments. We found two Waterlow risk assessments that
had not been updated since March 2018 and one since April 2018. This was in line with the
service’s own dip test audit results from February to July 2018. Discussions in some locality team
meetings also highlighted that Waterlow and MUST risk assessments were not always completed.
Action plans were not seen within the locality meetings for increasing compliance or re-audit. The
policy stated that Waterlow risk assessments must be reassessed no less frequently than a
monthly basis. Staff told us that if a patient was high risk, the risk assessments would be updated
weekly. Following our inspection, the service provided an action plan. This included reviewing care
plan completion and increasing the dip testing of the notes to provide assurance that all records
were completed. The service leads also stated that the locality managers would review the data
quality reports which identified patients who were outstanding risk assessments and ensure gaps
in the recording were resolved.
The service had been using Waterlow risk assessments to evaluate a patient’s risk to developing a
pressure ulcer. The service was piloting the ‘Purpose T’ risk assessment which was an evidence
based holistic tool and included a more detailed skin evaluation. As this was still in the pilot phase
its efficiency had not been fully tested.
40
At St Albans City Hospital in the rapid assessment unit, no documentation templates including
Waterlow, MUST, or pain had been completed. All patients had pre-populated care plans in place
and staff only completed risk assessments if a problem had been identified. We spoke with staff
who stated a policy for the implementation of these assessments was under development. The
manager stated that an action plan was being implemented to improve compliance. This included
regular auditing and data quality reports. This was planned to commence following the move of the
unit on 1 October 2018. After our inspection, the service advised us they had introduced new
processes including the use of a designated assessment bay, training of the team manager to
access reports on the electronic record keeping system in order to monitor the team’s
effectiveness and commenced dip testing of the records. The locality manager also met with the
local team to reinforce expectations around the use of risk assessments.
Staff were aware of how to manage deteriorating patients. Nursing staff offered patients advice on
the phone or arranged for an urgent visit. If staff remained concerned about a patient’s condition,
they contacted the patient’s GP or emergency services. There were no specific tools to monitor
deteriorating patients, such as community early warning scores. We saw that if a patient’s vital
signs of, for example, pulse, blood pressure and respirations were outside of the normal range,
once inputted onto the electronic system, it changed from black to red. There was no agreed
action plan for the nurse to follow when discovering an out of range result. We did see in the rapid
assessment unit that national early warning scores (NEWS) were being used. We observed staff
monitoring a patient through using the NEWS chart for deterioration of their condition.
Most patient referrals were processed through a central hub. A triage system was in place to direct
referrals to the most appropriate service. This was led by administrators who recorded referrals on
the trust’s record keeping system, noted their urgency and then passed them on to the appropriate
clinician. Staff used their clinical judgement to triage referrals and identified patients based on a
fixed criterion and then prioritised their urgency. This meant that patients were directed to the right
service first time. Patients who were deemed to require prioritising were seen by the nursing or
therapy teams on the same day, to prevent hospital admission. Routine patients were seen within
72 hours or one week depending on their clinical need. We observed a staff member appropriately
triaging referral emails and calls that were made to one of the referral hubs.
Some services had separate systems for referrals. For example, the musculoskeletal (MSK)
physiotherapy service categorised patients into acute, sub-acute and chronic. Any referrals then
identified as urgent and complex were allocated to senior staff for assessment within two weeks.
In the patient records we saw that where patients had been identified as being at high risk of skin
pressure damage or falls, care plans were put in place. These listed actions to mitigate and
minimise these risks. Actions included ordering pressure relieving equipment and regularly
reviewing dressings. The service’s record keeping system prompted staff to act on risk
assessments. For example, if a patient scored two or more for falls risk assessment, the system
would prompt the staff member to make an online referral to the therapy team.
All new pressure ulcers that were categorised at grade two, three and four were reported as an
incident. The report was sent to the tissue viability team lead to review and decide if further
investigation was needed. Community teams had a weekly handover where all members of the
multidisciplinary team discussed all new pressure ulcers reported in the previous week. The
community teams had tissue viability link nurses who also worked closely with the tissue viability
team. They were readily available for advice and support to community nursing staff. One tissue
viability link nurse stated that they tried to see all new pressure ulcers within their team.
41
There were systems in place to protect lone workers, including a trust wide lone worker policy.
Staff were issued with mobile phones which had the ability to track their locations by GPS. All
managers had their team’s whereabouts and staff were required to update the system as they
progressed throughout the day. There was a panic button for help through the record keeping
system if staff felt in danger whilst with a patient. If there was any increased risk perceived, staff
would visit in pairs, for example when staff were working after dark or in isolated locations.
Staffing
The service did not always have enough staff with the right qualifications, skills, training
and experience to keep people safe from avoidable harm and abuse and to provide the
right care and treatment. There were high vacancy levels for nursing staff and a
dependence on bank and agency staff to cover shifts. However, managers were aware of
the issues and had put strategies in place to try and address this situation.
During the last inspection, there were shortages of nursing staff and therapists. Staff were worried
about understaffing and the impact that this had on the service. In the follow up inspection in April
2016, it was found that staffing levels had improved and that the service had introduced new
measures to attract and retain staff and the vacancies had decreased from 13% to 9%. This risk
had remained open on the risk register since the previous inspection. Data provided showed there
was an overall vacancy rate of 12% which was above the target of 10%. The vacancy rate was
19% for registered nurses. The service stated that they had ongoing recruitment campaigns, for
example, advertising, open days, an introduction of flexible working and specialist interest roles.
Recruitment was identified by managers as being an issue due to the trust’s location, as it was
close to London where salaries there, included London weighting allowance. There was high
turnover and high vacancies, particularly in Lower Lea Valley and Stevenage integrated
community teams, and Watford CAHS. This had an impact on patient care at times, which led to
appointments being deferred. There was an escalation policy that had a clear process when
deferral was required. Only low risk patients were deferred. However, from July to September
2018, 456 clinical visits were deferred which resulted in nine incidents. Seven of these incidents
were relating to insulin administration and two were due to poor communication between the
teams. Managers stated that these were all identified within 24 hours of the missed visits and did
not cause severe harm to the patients. It was not clear what level of harm the patients sustained.
Most nursing staff and managers we spoke with identified staffing levels as a concern. Managers
held a daily pressure point call where they reviewed staffing levels across all services and moved
staff to cover staffing shortages.
We were informed that the community nursing teams were considering introducing auto
scheduling of their caseloads. This system allocated patients to each nurse according to their
priority. This was assessed by allocating patients based on minutes of care needed and
determined by the care plans on the patient’s record. The new system allocated a maximum
number of minutes per staff and allowed for lunch breaks and administration time. Staff stated that
when this was trialled, they were much happier with the allocation of their caseload and felt that it
was fair.
The managers used a spreadsheet to create an operational pressures escalation levels (OPEL)
status for staffing. The OPEL framework was an NHS England tool which produced a RAG rating
level of escalation. RAG rating uses a red, amber green traffic light system to indicate high to low
risk. There were four levels of escalation, categorised as green, amber, red and black, where
black indicated the most severe level of alert. The report split the trust into two areas,
Hertfordshire Valley Community (HVC) and East and North Hertfordshire Community (ENHC). The
42
HVC status report showed that 14 out of 21 days were red (OPEL three) and one day was black
(OPEL four). This meant that their staffing levels were at 60-80% of optimum for at least half of the
month. This meant that visits that had been deemed low priority, were cancelled. The data ENHC
showed that 14 out of 27 days were green (OPEL one) and 13 days were amber (OPEL two). This
demonstrated that their staffing levels were consistently above 80% with the majority over 90% for
the month of September 2018.
There were a few teams such as Danesbury community neurology team and the tissue viability
team that were fully staffed, however managers stated that they still felt short staffed due to an
increase in demand.
The service had adopted several initiatives to maintain safe staffing levels. Band three healthcare
assistants (HCAs) had undergone extra training to enhance their skills. Competencies had been
introduced to enable them to undertake some nursing tasks, for example, administering insulin to
clinically stable diabetic patients, within their homes. HCAs completed a comprehensive teaching
and assessment programme prior to administering insulin alone. This involved mentoring, an
insulin workbook and competency sign off. Staff we spoke with stated that this had reduced the
pressure on the district nursing team at key times such as 8am to 10am and 4pm to 6pm. This
meant that they could concentrate on seeing urgent patients during these times.
Nursing managers told us that there was high use of bank and agency staff to cover unfilled shifts.
We were told that there was an induction process in place for new agency staff. We saw
completed forms whilst on inspection. Managers reported that most agency staff used were
regular returners who knew the services well. When a visit was completed by an agency nurse, a
permanent member of the team would do the following visit. Therapy services managers told us
that they did not generally use bank and agency staff.
Managers stated that they had issues with staff retention, especially in MSK physiotherapy where
staff often left to work elsewhere. The diabetes team however had retained all staff for more than a
year and were at full establishment. We were told that the staff were happy.
Planned v Actual Establishment
Year 1 section:
Details of staffing levels within community services for adults by staff group as at March 2017 are
below.
Community adults total:
Staff group Planned
staff WTE
Actual Staff
WTE Staffing rate (%)
NHS infrastructure support 188.0 182.3 97.0%
Other Qualified Scientific, Therapeutic & Technical staff (Other qualified ST&T)
16.9 19.1 Over-established by
13.4%
Public Health & Community Health Services
2.6 0.6 21.8%
Qualified Allied Health Professionals (Qualified AHPs)
363.3 320.0 88.1%
Qualified ambulance service staff 5.0 6.4 Over-established by
28.3%
43
Qualified nursing & health visiting staff (Qualified nurses)
478.6 389.0 81.3%
Support to doctors and nursing staff 133.8 127.1 95.0%
Support to ST&T staff 81.6 79.7 97.7%
Total 1,269.6 1,124.2 88.5%
Year 2 section:
Details of staffing levels within community services for adults by staff group as at March 2018 are
below.
Community adults
Staff group
Planned
staff
WTE
Actual Staff
WTE Staffing rate (%)
NHS infrastructure support 169.5 152.3 89.9%
Other Qualified Scientific, Therapeutic &
Technical staff (Other qualified ST&T) 17.0 18.0
Over-established by
5.8%
Public Health & Community Health
Services 1.8 0.4 22.7%
Qualified Allied Health Professionals
(Qualified AHPs) 321.9 285.7 88.8%
Qualified ambulance service staff 6.0 9.0
Over-established by
49.5%
Qualified nursing & health visiting staff
(Qualified nurses) 439.1 330.7 75.3%
Support to doctors and nursing staff 129.4 138.9
Over-established by
7.3%
Support to ST&T staff 86.5 80.5 93.1%
Total 1,171.1 1,015.5 86.7%
(Source: Universal Routine Provider Information Request (RPIR) – P16 Total Staffing)
Vacancies
The trust target was 10% for vacancy rates. From March 2017 to April 2018, the trust reported an
overall vacancy rate of 12% in community services for adults. This did not meet their target.
Across the trust overall, vacancy rates for nursing staff were 19% and for allied health
professionals were 10%.
A breakdown of vacancy rates by staff group in community services for adults at trust level is
below:
Community adults total
Staff group Vacancy rate
Public Health and Community Health Services 72.4%
44
Qualified Nursing and Health Visiting Staff 19.2%
Qualified Allied Health Professionals 9.7%
NHS Infrastructure Support Staff 8.8%
Support to doctors and nursing staff 5.2%
Support to Scientific, Therapeutic and Technical Staff 4.7%
Other Qualified Scientific, Therapeutic, Technician Staff -1.4%
Qualified ambulance service staff -98.0%
Total 11.8%
(Source: Universal Routine Provider Information Request (RPIR) – P17 Vacancy)
Turnover
The trust target was 12% for turnover rates. From April 2017 to March 2018 the trust reported an
overall turnover rate of 15.8% in community services for adults. This did not meet their target.
Across the trust overall turnover rates for nursing staff were 19.8% and for allied health
professionals were 10.9%.
A breakdown of turnover rates by staff group in community services for adults at trust level is
below:
Community adults total
Staff group Turnover rate
Qualified Ambulance Service Staff 56.6%
Qualified Nursing and Health Visiting Staff 19.8%
NHS Infrastructure Support Staff 16.2%
Support to Doctors and Nursing Staff 15.7%
Support to Scientific, Therapeutic and Technical Staff 12.6%
Other Qualified Scientific, Therapeutic, Technician Staff 12.3%
Qualified Allied Health Professionals 10.9%
Public Health and Community Health Services 0.0%
Total 15.8%
(Source: Universal Routine Provider Information Request (RPIR) – P18 Turnover)
Sickness
The trust’s target was 3.6% for sickness rates. From April 2017 to March 2018, the trust reported
an overall sickness rate of 4% in community services for adults. This did not meet their target.
Across the trust overall sickness rates for nursing staff were 5% and for allied health
professionals were 2.2%.
A breakdown of sickness rates by staff group in community services for adults at trust level is
below:
45
Community adults total
Staff group Sickness rate
Support to Doctors and Nursing Staff 5.4%
Qualified Nursing and Health Visiting Staff 5.0%
Qualified Ambulance Service Staff 4.9%
Support to Scientific, Therapeutic and Technical Staff 4.6%
NHS Infrastructure Support Staff 3.2%
Qualified Allied Health Professionals 2.2%
Other Qualified Scientific, Therapeutic, Technician Staff 1.0%
Public Health and Community Health Services 0.0%
Total 4.0%
(Source: Universal Routine Provider Information Request (RPIR) – P19 Sickness)
Nursing – Bank and agency qualified nurses
From April 2017 to March 2018 the trust reported bank and agency usage for qualified nurses in
community services for adults as below:
Type of shift Total number of shifts
Shifts available 9,630
Filled by bank 2,537
Filled by agency 5,383
Shifts not filled 1,710
Nursing - Bank and agency nursing assistants
From April 2017 to March 2018 the trust reported bank and agency usage for nursing assistants in community services for adults as below:
Type of shift Total number of shifts
Shifts available 6,410
Filled by bank 704
Filled by agency 5,080
Shifts not filled 626
(Source: Universal Routine Provider Information Request (RPIR) – P20 Nursing Bank Agency)
Medical locums
From April 2017 to March 2018 the trust reported agency usage for consultants and registrars in community services for adults as below:
46
Staff group Shifts available Not filled
Consultant 1 1
Registrar 6 6
Total 7 7
The trust stated that they did not have a medical bank due to low usage; however, one was being
set up via National Health Service Professional (NHSP) in 2018.
(Source: Universal Routine Provider Information Request (RPIR) – P21 Medical Locum Agency)
Suspensions and supervisions
During the reporting period from April 2017 to March 2018, community services for adults reported
that there had been a suspension of a member of staff within one of the inpatient units.
(Source: Universal Routine Provider Information Request (RPIR) – P23 Suspensions or
Supervised)
Quality of records
Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-
date and available to all staff providing care.
We saw that all services used electronic patient records. These were accessible through password
protected systems to authorised staff. Staff could view and share patient information to deliver
safe care and treatment in a timely and accessible way. Staff allocated tasks to their colleagues
through the system; for example, a physiotherapist tasking the occupational therapist to see a
patient, so that they received a system alert. Staff had laptop devices to access and updated
records whilst in patients’ homes. We were informed that connectivity was limited at times,
especially in remote locations. There was an alternative system that staff used, where templates
were downloaded in advance and then were completed with the patient present. These
automatically updated on the electronic record keeping system when connectivity was restored.
Paper light folders were kept in the patients’ homes which contained basic information. The folder
contained contact information for both in working hours and out of hours, if the patient felt they
required swift attention. We also saw information, in the folder, about how to make a complaint.
There were comprehensive assessment processes in place in the records that we reviewed. Staff
used a range of pre-determined assessment tools to ensure that there was both a consistent
approach and that a holistic assessment of patient’s needs was completed. Following assessment,
care plans were agreed with patients. We saw that patients with the mental capacity to do so,
were asked for their consent to the agreed care plans. We saw that all notes entries were
contemporaneous and up to date. They were dated, timed and electronically initialled by staff
completing the entry, which is in line with national guidance.
The nurse who specialised in treating leg ulcers, stated that their productivity had improved since
gaining access to the electronic system which contained the laboratory results. This was a system
used by GPs to obtain sample results such as wound swab results. This meant that the specialist
leg ulcer nurses were able to access their own results and act on them immediately, as the
majority were nurse prescribers. This meant patients had quicker access to antibiotics if needed.
Staff informed us that the quality of care records were audited. All services had submitted data for
May 2018. There was variable compliance with the audit standards. The data showed that some
areas had a compliance of 61% whereas others were higher, at 89%. The combined compliance
47
was 80.41%. We asked the service what actions they had taken to improve the record keeping
standards. The minutes of the clinical effectiveness group in August showed that the clinical
record keeping audit report was discussed. Each team received an individual audit report to share
with their teams. There was no evidence of these results being discussed in locality team meeting
minutes or any action plans made to improve practice.
The service had a business continuity plan for if access to the electronic record system had been
lost. This detailed using an alternative site for access if possible. One manager stated that each
Monday the total visit list for the week was loaded onto a secure USB stick which was locked away
securely. This was ‘wiped’ and replaced each Monday morning. This process was not seen within
the business continuity plan.
Medicines
Although medicines were prescribed, given, recorded and generally stored in accordance
with best practice, there was lack of knowledge surrounding some significant policies and
key audits were not undertaken.
Medicines were not generally stored or transported by staff in the community health services, with
the exception of adrenaline. Most handling of medication happened in patient’s own homes or care
homes. If a patient ran out of medication staff would request it from their GP, or request that
community pharmacy set up a delivery system. Additionally, all staff carried adrenalin ampules or
automatic injection devices containing adrenaline for allergic emergencies. Staff did not transport
oxygen or other medical gases in their vehicles.
The service had advanced nurse practitioners (ANP) and some specialist nurses who were non-
medical prescribers. Non-medical prescribers are health professionals who have undergone
additional training and are qualified to prescribe some medication. This meant that patients did not
have to wait to see their GP to have changes to existing prescriptions or new medication
prescribed. ANPs prescribe medication if it had already been prescribed by the GP and a repeat
prescription was required. If a new medication was prescribed, the ANP informed the patient’s GP
through the electronic patient record system or email before prescribing.
Most medications used by the community health services were prescribed by GPs. Prescription
pads were all reconciled according to which staff member they were allocated to. They were
signed out to staff and it was their responsibility to keep the pad secure.
Patient group directions (PGDs) provide a legal framework that allows some registered health
professionals to supply and administer specified medicines to a pre-defined group of patients,
without them having to see a doctor. We saw PGDs in place for specified medicines for specialist
physiotherapists. This ensured the service complied with the National Institute for Health and Care
Excellence (NICE) guidance when prescribing medication for individual patients. We saw
completed PGDs in the MSK department at QEII Hospital, but staff at the pulmonary rehabilitation
service were unable to produce a signed PGD for frequently used medicines such as salbutamol
(an inhaler used to treat shortness of breath in, for example, acute asthma attacks). We were not
assured that the unit had signed PGDs in line with guidance.
In the MSK physiotherapy service, there was a policy for completion of injection therapy for pain
relieving and anti-inflammatory medicines, which were part of a PGD. The PGD consisted of
written instructions which enabled suitably qualified therapists to administer certain medicines to
patients in planned circumstances. The PGDs had appropriate detail and description and were
signed off by an authorising doctor. The PGDs were due for renewal in November 2018.
48
Care plans and journal entries in patients’ records detailed their allergy status and information
about insulin management, such as time and site of administration of dose. Staff did not
administer time specific medicines unless there was a two-hour window which allowed for any
delays. For example, they administered low molecular weight heparin and used syringe drivers as
there was a two-hour window. All details of these were included in patient’s care plans. Care
agencies usually dealt with time specific medicines.
Healthcare assistants (HCAs) and band four staff, had been trained to administer insulin to stable
diabetics. These patients were selected against a strict criterion and were monitored monthly by
the community nurses and diabetic nurses. They reviewed the management plan and ensured that
the patients were still suitable to be seen by HCAs. The June 2018 audit showed that 100% of
patients were seen weekly by a registered nurse in addition to the unregistered staff. All the staff
had attended diabetes training at the local university. They were assigned a registered nurse as a
mentor who signed them off when competent. We saw two sets of completed competencies. The
policy for this was due for renewal in April 2018 and was being reviewed at the time of our
inspection. Since this initiative, there had been no insulin related incidents reported and managers
were considering extending the patient criteria for band 4 staff as they had completed further
training. The efficiency of this project was monitored by regular dip tests of the patient electronic
notes and discussions at monthly meetings. The project had been presented by the project lead
and HCAs at the Leeds ‘Leading Change and Adding Value’ conference and the service had been
informed that there were plans to publish it.
All medication that we checked was in date within a locked cupboard or fridge. However, fridge
temperatures were not always completed daily. In addition, the minimum and maximum
temperature was not monitored in line with the policy. At Stevenage integrated community team,
they were found to be monitored daily, but at Potters Bar Community Hospital they were
completed 16 times in July, 14 times in August and eight times out of 18 in September. This was
raised immediately with staff on site who told us that Hertfordshire Community Trust nurses were
not always on site. Additionally, there was lack of guidance with regards to who was responsible
for these checks when they were not on site. They stated that they would pass this onto the
manager and ensure a plan was put into place.
QEII physiotherapy department stored medication within their clinical room. The temperature of
this room was monitored on a weekly basis. The policy did not state a frequency of requirement for
checking the room temperature. However, the approved checklist within the policy stated that the
monitoring should be completed daily. It was checked five times in July, four times in August and
six times in September. The temperature was consistently recorded at above 25 degrees which
was above the recommended temperature for storing medicines. Staff had discussed the elevated
temperatures with the pharmacy department who said that no escalation was required. Following
the inspection, we were sent a memorandum which had been sent to the staff on the 9 August
2018 regarding the storage of medication in elevated temperatures. There were clear guidelines
on actions to be taken. We were not assured that staff were aware of how to store medicines
safely in line with their manufacturer guidelines and trust policy.
In locality team meetings, drug alerts were discussed and any actions required as a result.
The service did not complete any medication chart audits within the community setting, this was
due to lack of capacity within the team. The chief pharmacist stated that they monitored any errors
through the incident reporting system. This was recognised as a gap in their service and had been
added to the trust risk register.
49
Safety performance
Safety Thermometer
The Safety Thermometer was used to record the prevalence of patient harms and to provide
immediate information and analysis for frontline teams to monitor their performance in delivering
harm free care. Measurement at the frontline is intended to focus attention on patient harms and
their elimination.
Data collection takes place one day each month – a suggested date for data collection was given
but the wards were able to change this. Data was submitted within 10 days of suggested data
collection date.
Community Settings
Data from the Patient Safety Thermometer showed that the trust reported 178 new pressure
ulcers, 89 falls with harm and 81 new urinary tract infections in patients with a catheter from July
2017 to July 2018 within community services for adults. However, it should be noted that pressure
ulcers may have been acquired prior to the patient being referred for care to HCT.
0
5
10
15
20
25
30
Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18 Mar18 Apr18 May18 Jun18 Jul18
Pressure Ulcers - New
0
2
4
6
8
10
12
14
Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18 Mar18 Apr18 May18 Jun18 Jul18
Falls with Harm
50
(Source: NHS Safety Thermometer)
There was an increase in the number of cases of harm free care from July 2017 to July 2018 in
new pressure ulcers and the prevalence of urinary tract infections in patients with catheters.
However, there was a slight decrease in the number of cases of harm free care for patient falls.
Senior managers told us that safety thermometer data was collected and submitted by community
nursing teams monthly. However, we were informed that in Quarter 1, the results did not correlate
with the number of patient contacts on the day of the survey. Senior managers found that staff
were not always aware of the criteria. Managers were discussing this within their teams to improve
compliance. A podcast had also been recorded, outlining the purpose of the safety thermometer
and how to report effectively. Results and lessons learned were shared at monthly senior nurse
meetings. We saw that action plans were created by the locality leads and reviewed monthly at the
meetings. There was also evidence of safety thermometer results being discussed at speciality
meetings, for example, such as the pressure ulcer forum.
Incident reporting, learning and improvement
The service managed patient safety incidents in line with best practice. Staff recognised
incidents and reported them appropriately. Managers investigated incidents and
sometimes shared lessons learned with the whole team and the wider service, although
this was variable. When things went wrong, staff apologised, but not all staff were aware of
their duties with regards to their duty to give patients honest information and suitable
support.
Staff understood their responsibilities in raising safety concerns and reporting them as incidents.
All staff had access to the electronic reporting system. Staff described what they would report as
an incident and the process for doing this. Staff told us that they received an email
acknowledgement when they submitted an incident and managers discussed the incident with
them before completing an investigation. Service and locality leads were responsible for
completing incident investigations. The community trust had monthly meetings to discuss
complaints, litigation, incidents, concerns from the PALS team, and safeguarding - CLIPSS. These
detailed any incidents that had occurred. It contained top three lessons learnt and team actions
and this was sent to senior managers for review. There was a varying level of detail within these
reports, across the different teams, within the service.
The service had a variety of methods to share lessons learned from a review of incidents, such as
team training, team meetings, emails, and handovers. Learning from incidents was discussed at
0
2
4
6
8
10
12
14
16
Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18 Mar18 Apr18 May18 Jun18 Jul18
Catheter & New UTI
51
weekly or monthly team meetings. There was variable quality of meeting minutes across the
service and the majority lacked detail regarding specific incidents and lessons learned. Some
services had made changes for example, an occupational therapist told us that they had an
increase in incidents surrounding poor referrals that had lacked clarity of diagnosis. They had met
with the clinical lead and developed a training programme for the junior doctors to provide them
with guidelines for hand therapy. They said that this had led to an improvement in the clarity of the
referrals.
Staff described the principle and application of duty of candour, Regulation 20 of the Health and
Social Care Act 2008, which relates to openness and transparency. It requires providers of health
and social care services to notify patients (or other relevant person) of ‘certain notifiable safety
incidents’ and provide reasonable support to that person. There were duty of candour posters
seen in waiting rooms and on staff notice boards. Some staff we spoke with had a good
understanding of the principles of being open and honest when something went wrong, however
not all were aware of the duty of candour.
There was a serious incident panel that reviewed all serious incidents and whether action plans
had been completed.
Never events
Never events are serious patient safety incidents that should not happen if healthcare providers
follow national guidance on how to prevent them. Each never event type has the potential to cause
serious patient harm or death but neither need have happened for an incident to be a never event.
From August 2017 to July 2018, the trust reported no never events in community services for
adults.
(Source: Strategic Executive Information System (STEIS))
Serious Incidents
Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).
These include ‘never events’ (serious patient safety incidents that are wholly preventable).
In accordance with the Serious Incident Framework 2015, the trust reported 12 serious incidents
(SIs) in community services for adults, which met the reporting criteria, set by NHS England from
August 2017 to July 2018.
Of these, the most common types of incident reported were:
• Pressure ulcer meeting SI criteria with three (25% of total incidents).
• Abuse/alleged abuse of adult patient by staff meeting SI criteria with three (25% of total
incidents).
• Sub-optimal care of the deteriorating patient meeting SI criteria with three (25% of total
incidents).
• Slips/trips/falls incident meeting SI criteria with one (8.3% of total incidents).
• Treatment delay meeting SI criteria with one (8.3% of total incidents).
• Confidential information leak/information governance breach meeting SI criteria with one
(8.3% of total incidents).
52
(Source: Strategic Executive Information System (STEIS))
Serious Incidents (SIRI) – Trust data
From April 2017 to March 2018, trust staff within community services for adults reported seven
serious incidents. There were three pressure ulcers reported as ‘other’ and four of the seven
incidents involved pressure ulcers.
Of these, none involved the unexpected death of a patient.
The most common types of serious incidents were abuse/alleged abuse of adult patient by staff,
(three incidents;) treatment delay, (one incident) and one incident of sub-optimal care of the
deteriorating patient.
The number of the most severe incidents recorded by the trust incident reporting system is
comparable with that reported to Strategic Executive Information System (STEIS).
(Source: Universal Routine Provider Information Request (RPIR) – P29 Serious Incidents)
Prevention of Future Death Reports (Remove before publication)
The trust had no deaths requiring Coroner's Inquest in the last 12 months for community services
for adults.
(Source: Universal Routine Provider Information Request (RPIR) – P86 Prevention of future death
reports)
53
Is the service effective?
Evidence-based care and treatment
The service generally provided care and treatment based on national guidance and
evidence of its effectiveness, although some polices were beyond their date for review.
Managers checked to make sure staff followed guidance.
We found that staff in the community health services used a variety of techniques and resources
to ensure that care and treatment was delivered in line with legislation, standards and evidence-
based guidance to achieve effective outcomes. Staff followed best practise guidelines from
professional registration bodies such as the Nursing and Midwifery Council (NMC) and the Health
and Care Professions Council (HCPC). Staff were able to access guidelines and standards on the
trust intranet which was available in all office bases.
We saw that there were local policies produced based on national best practise guidelines such as
the local pressure ulcer policy and the urinary catheterisation management policy. These policies
should be reviewed every three years in line with trust guidelines. However, we noted that not all
the policies staff showed us were in date, for example the urinary catheterisation management
policy we saw was last reviewed in May 2014 and the resuscitation policy we saw was last
reviewed in November 2011. However, following inspection, the trust stated that the resuscitation
policy was last reviewed and issued in May 2016. Staff in the service were unable to show us this
up to date policy at the time of inspection.
We saw that most staff used nationally recognised assessment tools to holistically assess patients
physical, mental health and social needs. Most services used core assessment and care planning
tools, which listed which assessments should be used. However, in the community treatment unit
(previously known as the rapid assessment unit) we noted that no assessment templates were
completed within the patient’s electronic records. The templates were part of the electronic record
system but were not routinely completed by staff. These templates included tools for recording of
past medical history, pain, medication, allergies and risk assessments, for example, Waterlow
scoring and the malnutrition universal screening tool (MUST). However, they were blank in all
records we reviewed. When we asked about this, staff told us that there was no requirement to
complete these but that there was a policy under development for implementation of this process.
In other services, for example, nursing and therapy, nationally recognised tools, were used
including the Waterlow scoring tool for pressure area risks, the elderly mobility scale, and the
Montreal cognitive assessment (a screening tool for mild cognitive impairment.) We saw that
where risks were identified following assessment, action plans were in place in the form of care
plan documents. Care plans, for example for catheter care, were based on NICE guidelines and
the Royal Marsden clinical nursing recommendations (a nationally recognised manual of evidence
based clinical nursing procedures).
Staff in the community neurology team told us that they used a range of national guidance to
influence their practise and deliver evidence-based care. These included the Royal College of
Physicians stroke guidelines, the NICE guidelines for stroke rehabilitation, the National Stroke
Strategy standards, and vocational rehabilitation standards within the National Service Framework
for long term conditions. Therapy leads in the community neurology service told us how they had
developed a new group exercise programme for patients in the early stages of Parkinson’s
disease based on current evidence and emerging research. The community neurology team told
us that they held journal clubs as part of their monthly in-service training programme; at these
54
sessions they reviewed and discussed journal articles to ensure they were following best and
current practise.
The tissue viability team told us that standardised wound assessments and tissue viability
pathways of care were being developed based on NICE guidelines, and the National and
European Pressure Ulcer Advisory panels guidelines. Best practise statements for all staff to
follow had been developed following attendance at a tissue viability forum. The service lead
explained that there was a tool for pressure ulcer categorisation on all staff laptops which had
been developed by the NHS England Midlands and East clinical network.
Staff in the integrated care team explained how they had used the NICE guidelines for falls to
develop a standardised approach to assessments and a more multidisciplinary approach to falls
management.
In a physiotherapy clinic at Lister Hospital staff who worked with patients following amputation
surgery told us how they followed NICE guidelines for provision of compression stump socks
within 10 days of amputation surgery.
Service leads in several services explained that they received a monthly email with a summary of
new NICE guidance published, which they reviewed to identify any relevant guidance which
needed actions to implement in service delivery.
The diabetes team used a nationally recognised structured education programme to support
patients with type 2 diabetes. The DESMOND (diabetes education and self-management for
ongoing and newly diagnosed) programme was developed by NHS staff following research and
pilot studies.
Pain relief
Pain was assessed as part of the core assessment templates used on the trust’s electronic record
keeping system by most services. In one of the integrated care teams, for example, we saw that
pain assessment was part of the core assessment templates, the wound care template and end of
life care template. This pain assessment included a review of the cause of pain, medications for
pain, and visual analogue pain scoring scales. There was an Abbey pain scale score option to
assist in assessing pain for patients with learning disabilities or living with dementia. However, in
the community treatment unit, we saw that the pain assessment templates were not routinely used
by staff.
During our observations of care in the physiotherapy service, we saw that staff were sensitive to
patients in pain, and checked throughout their intervention how their pain was affected.
In the podiatry clinic we observed that the staff member asked the patient about their pain levels
throughout their assessment of a foot wound.
Staff used a variety of methods to address pain including repositioning patients, provision of
pressure relieving equipment, exercises and advice, and adjustment of pain relieving medication
through liaison with GPs or nurse prescribers.
Patient outcomes
The service monitored the effectiveness of care and treatment and used the findings to
improve them. They compared local results with those of other services to learn from them.
Audits – changes to working practices
55
The trust participated in 23 clinical audits in relation to this core service as part of their Clinical
Audit Programme.
Audit name Area covered Key Successes Key actions
National Parkinson's
Audit NCAPOP
Quality Account
Audit 2017/18
Neurological
Service
100% cases submitted -
minimum of 10
responses for
Speech and
Language Therapy,
Occupational
Therapy and
Physiotherapy.
Full report still to be
issued, so cannot
yet demonstrate
where practice has
been changed.
Report yet to be
presented.
National Sentinel
Stroke National
Audit Programme
(SSNAP) NCAPOP
Quality Account
Audit 2017/18
Community
Hospitals and
all Integrated
Community
Teams
Ongoing data collection
from 1 November
2013 - data
submitted for 737 in
2017/18.
As part of the
Sentinel Stroke
National Audit
Programme
(SSNAP) our Acute
Therapy Services
(Occupational
Therapy and
Physiotherapy) at
the Lister Hospital
and the Adult
Speech and
Language Therapy
teams at Lister and
Watford General
have significantly
improved their
performance moving
from a C rating to ‘A’
rating over the last
16 months.
Achieving the rating
of ‘A’ puts the
Service in the top
No key actions.
56
23% out of 215
stroke services
across the country.
SSNAP audit results
[Q3 2017] (released
to the public in
March) show that
Danesbury have
maintained their `A`
rating and Holywell
have achieved their
first `A` rating.
National COPD
Rehabilitation Audit
NCAPOP Quality
Account Audit
2017/18
Pulmonary
Rehabilitation
Service
Data submitted for 118
eligible patients’.
Organisational
questionnaire
completed.
Full report is to be
presented to Clinical
Effectiveness Group
in August 2018, so
cannot yet
demonstrate where
practice has
changed.
Report yet to be
presented.
Sight Impaired Audit
(CVI) - WHDESP
(46)
Diabetic
Retinopathy
Services
Submitted annually to West Herts Diabetic Eye
Screening Programme (DESP) board meeting
with NHS England.
National Diabetes Adult
(NDA) Audit
NCAPOP Quality
Account Audit
2017/18 (3)
Adult Diabetes
Community
Service
Data was submitted for
3648 patients.
• Fewer people with
Type 1 than with
Type 2 and other
diabetes receive
their annual checks.
• The last four years
have seen
improvements in the
combined 3
treatment target
achievement in both
Type 1 and Type 2
and other diabetes.
• Timely offers of
structured education
have improved over
the last three years
• Our Diabetes Service
will continue to offer
monthly Saturday
DESMOND
Education Clinics to
increase participation
in structured
diabetes education
(especially for
patients under 40).
• Diabetes Service to
work with GP's and
Practise Nurses to
increase their
awareness of the
need for retinal
screening and to
provide clarity
around referral
57
• Timely offers of
structured education
have improved over
the last three years
• The apparently low
rates of attendance
may be due to
incomplete recording
of attendance data in
GP electronic
records.
Good compliance
was seen in
monitoring key
aspects of Diabetes
care, in accordance
with NICE Quality
Standard QS6 -
Diabetes in Adults.
responsibilities and
routes for patients.
• Seek new
approaches to
improving
management for
those overall doing
worst. Design and
test new approaches
to providing regular
review and
optimising treatment
for people with
diabetes aged
younger than 65.
• Type 2 diabetes
care providers
should work with
people who have a
Severe Mental
Illness (SMI) to
increase care
process completion.
National Audit of
Intermediate Care -
NAIC NCAPOP
Quality Account
Audit 2017/18 (4)
Bed Based IC,
home based
IC and re-
enablement
services
Intermediate Care
Teams/Community
inpatient units: 65
questionnaires
submitted
Community ICT
Teams: 52
questionnaires
submitted
• Dependency levels
recorded were 31%
for homebased, 35%
for bed-based and
36% for re-ablement
services.
• The dependency
levels of people on
admission, and the
improvements made
during their stay,
were similar to the
2015 results for
home and re-
ablement services.
• Over 96% of
It is suggested that the
audit content is
reviewed in the light
of the NICE
Guidelines issued in
2017: NICE
guideline, NG74
Intermediate care
including re-
ablement.
• Share results at the
Operational Senior
Management Team
(OSMT)/Operational
Services at HCT to
identify whether
there is any learning
to be shared
(feedback at CEG
meeting in October
2018 once this work
stream has been
undertaken).
• Work with
Operational Teams
58
service users replied
‘yes – definitely’ to
the
question ‘I was
aware of what we
were trying to
achieve’.
• Over 91% of
people felt they had
been treated with
dignity and respect.
Evidenced that we
are treating people
with respect and
kindness.
to improve the
Average Length of
Stay in hospital.
Work has been done
with the CCGs, in
particular Herts
Valley to address
this and improve
practices.
• Work with the
Acute Trusts and the
local CCGs to
improve the winter
pressure planning
and ensure
admission criteria
are being followed.
National NDFA
Diabetes Foot Care
Audit part of NDA
2016/17
NICE GUIDANCE
NCAPOP Quality
Account Audit for
2017/18 (10)
Podiatry • Podiatry SystmOne
templates now
incorporate a wound
care classification as
recommended by
NICE in NG19.
• Patients who ‘self-
present’ have the
highest healing rates
but they also have
less severe ulcers.
• To increase
participation rates in
this audit by July
2018.
• Reviewed the
referral pathway.
• By July 2018, work
with commissioners
to improve access to
Multi-Disciplinary
Footcare Team.
• Amended
SystmOne podiatry
template and
incorporated a
wound care
classification as
recommended by
NICE Guideline
NG19.
• Podiatry Service
referral form
reviewed and
updated.
• All Podiatrists
completed at least 2
NDFA forms as part
of their objectives to
increase audit
numbers.
• Review current
59
pathway for foot care
and work with our
commissioners and
other providers to
develop a Multi-
Disciplinary foot care
clinic to ensure
compliance with
NICE guidance for
preventing and
managing foot
problems in adults
with diabetes by
allowing 24 hours
access to the
specialist multi-
disciplinary team.
June 2018 update:
Recruitment to extra
posts has been
carried out and staff
are now in place and
finalising the clinics.
The funding is
available until March
2019.
National NDFA
Diabetes Foot Care
Audit part of
National Diabetes
Audit (NDA)
2017/18.
NICE GUIDANCE
NCAPOP Quality
Account Audit for
2017/18 (10)
Podiatry • People are alive and
ulcer-free at 24
weeks in only two
thirds of cases of a
diabetic foot ulcer.
• At the 12 week
outcome, 60% of the
population with less
severe ulcers were
alive and now ulcer-
free.
• At the 24 weeks
outcome, 74% of the
population with less
severe ulcers were
alive and now ulcer-
free.
• Across all ulcers at
the 24 weeks
outcome, only 3% of
the population had a
new ulceration after
• All people with diabetic
foot ulcers should be
referred promptly for
early specialist
assessment,
according to the
NICE guidance
NG19.
• Providers should
endeavour to record
all new instances of
diabetic foot ulcers,
and to complete
outcome data for all
patients registered in
the audit.
• Reviewed the
Podiatry Service
referral form and
current pathway for
foot care and have
worked with
60
being ulcer-free.
Increased reporting
of diabetic ulcers,
more follow-up and
treatment, therefore
better diabetic care.
commissioners and
other providers to
develop a multi-
disciplinary foot care
clinic to ensure
compliance with
NICE Guidance for
preventing and
managing foot
problems in adults
with diabetes by
allowing 24 hour
access to the
specialist multi-
disciplinary team.
Referrals to the
Podiatry Service for
Non-Acute Nail
Surgery (19)
Podiatry • 302/380 patients had
the A3 (Non-acute
Nail Surgery)
invitation letter sent
to them.
• 131 people ( 44%)
have chosen to not
respond to the invite
and have therefore
been discharged
• 161 people (55%)
have responded to
the invite and have
been seen at an
assessment
appointment
• Of the 161 people
who came for an
assessment
appointment for Nail
surgery, 65% went
on to have nail
surgery.
• Clear benefit in the
outcomes of the
patients, there is
clarity in the
invitation letter that
is sent initially to
patients laying out
clearly what service
can be offered so
that there can be no
• It was decided to
continue with the
system of placing the
patients triaged to
the A3 group (Non-
acute Nail Surgery)
on the separate
waiting list.
• Send out the
specific A3 invitation
letter to the patients,
relevant to their
group.
61
misunderstanding as
to what their
treatment plan will
offer.
For the Podiatry
service the benefits
have been that
resources are used
effectively, seeing
fewer assessments
booked and those
patients are able to
follow the correct
clinical pathway to
achieve the best
outcome.
Audit of the Community
Clinic Caseload
(26)
Adult Diabetes
Community
Service
• A total of 232 patients
were identified from
the search. When
the patient records
were reviewed, it
was found that 32 of
these patients
already had CCC
appointments
allocated, so these
were excluded,
leaving a total of 200
patients eligible for
the audit.
• 80% of patients
were seen within the
last 6 months.
Implemented a
cashing up process
for all clinicians (i.e.
ensuring all patients
have an onward
action at the end of
clinics)
• Audit repeated in 6
months to ensure
above process
embedded
• All actions have
been implemented
as a result of the
audit, including
implementing a
cashing up process
for all clinicians.
Reviewed the
process for patients
phoning up to cancel
appointments, and
trained staff on the
cashing up process
and issued
flowcharts.
Infection Control (IPC)
(40)
Environment/Safety
Audit - includes
Sharps Safety (I)
Hand Hygiene (ii)
MRSA Screening
(iii) Urinary Catheter
Bed Bases
monthly
audits:
Integrated
Community
Teams
quarterly
audits: Health
All audits reported at the Infection Prevention and
Control Forum.
62
Care (1) Insertion
and (2) Continuing
Care (iv) Peripheral
Vascular Catheter
(v) Enteral Feeding
(vi) Commode (vii)
a) Hand Hygiene
Urinary catheter
care insertion and
continuing care.
Vascular devices b)
Hand Hygiene
Environment/safety
audit (and specific
dental service
audits).
Visitors, MIU
(HEH) RAU
(SACH)
Dental
service.
Diabetes Audit on 9
Care Processes
(66)
Adult Diabetes
Community
Service
100% of results (56/56)
have:
•
Discussed/reviewed
the results of the 9
Care Processes with
the patient
• Evidenced the
results of the 9 Care
Processes in the
patient discharge
letter
100% was achieved
in 4/9 Core
Processes:
• Smoking Status
• Albumin: creatinine
ratio
• Serum creatinine
measurement
• Foot examination
Over 90% was
achieved in 4/9 Core
Process:
• BMI
• Cholesterol
measurement
• Blood Pressure
• HbA1c
Measurement
• Continued to embed
the 9 care processes
within the service
and ensure ongoing
monitoring of this.
• Reported on the
audit findings to East
and North Herts
Clinical
Commissioning
Group (CCG).
• Shared
results/findings with
the Community
Diabetes Specialist
Service.
• Diabetes Service
are working with GPs
and practice nurses
to increase their
awareness of the
need for annual
retinal screening and
to provide clarity
around referral
responsibilities and
routes for patients.
• Increase structured
diabetes education
programme
(DESMOND) offered
to patients in West
63
Hertfordshire, and
although diabetes
patient education is
not commissioned in
East and North
Hertfordshire, HCT’s
Diabetes Specialist
Nurses are providing
education to practice
nurses, community
nurses and GPs.
• The new Integrated
Diabetes Service has
now aligned services
in the acute (WHHT),
community (HCT)
and mental health
(HPFT) Trusts to
provide a seamless
pathway for patients.
Consultants,
diabetes specialist
nurses, dietitians,
podiatrists,
Improving Access to
Psychological
Therapies (IAPT)
and Rapid
Assessment,
Interface and
Discharge (RAID)
services now provide
a holistic service that
will meet the needs
of the population in
Herts Valley.
• Participate in the
next round of the
National Diabetes
Audit (2018/19).
Diabetes Service
DESMOND Audit
(74)
Adult Diabetes
Community
Service
• 74% of patients are
extremely likely to
recommend this
Service to friends
and family if they
needed similar
treatment.
• 94% of patients felt
• Regular CCG
meetings undertaken
with the local CCGs
to improve the
achievement of NICE
recommended
treatment targets.
• Improve
64
they were treated
with dignity and
respect.
• 88% of patients felt
the information was
given to them in a
way they could
understand.
• 81% of patients
were clear about
what would happen
next.
Overall, patients
were well-informed
about their
treatment.
collaboration
between West
Hertfordshire
Hospitals Trust
(WHHT) and HCT
Diabetes Service to
develop an
integrated model for
the delivery of care
across acute and
community sectors
(Action complete).
• Practice education
training for nurses
increased to benefit
patient care and
further improve
patient clinical
outcomes. Started in
one locality – now
rolled out to three
localities and
planning to expand
this further.
• Diabetes Specialist
Nursing (DSN) Team
have now trained
Health Care
Assistants (HCAs)
for administering
insulin. Patient
feedback as part of
the HCA project:
Single collated list -
WHDESP (92)
Diabetic
Retinopathy
Services
Submitted annually to West Herts DESP
programme board meeting with NHS England.
Slit Lamp
Biomicroscopy -
WHDESP (93)
Diabetic
Retinopathy
Services
Submitted annually to West Herts DESP
programme board meeting with NHS England.
Plus Size Patients
Management Audit
(46)
East & North &
Herts Valleys
(Adult bed
bases, ICTs
and clinic-
based
services - Leg
Ulcer,
• 90% (18/20) of staff
were aware of the
Management of
Plus-Size Patients
policy
• 70% (14/20) were
aware of the risk
assessment tools for
• Re-launch of the Plus-
Size Patients policy
following review with
a requirement for
managers to ensure
that staff are aware
of the content of the
policy, specifically
65
Podiatry,
Diabetes,
Bladder &
Bowel
Plus-Size patients.
• 95% of staff were
aware of how to
report an incident
related to the moving
and handling of a
patient.
• 90% (18/20) staff
would know how to
report moving and
handling equipment
if it is not fit for
purpose.
• In response to the
question, ‘Are you
aware of how to
access moving and
handling and other
specific equipment
for plus-size
patients?’, 18
responded positively
(90%).
Over 90% of staff
were aware of how
to manage and
handle plus-size
patients effectively,
in accordance with
HCT's Management
of Plus-Size Patients
policy (2015).
relating to the risk
assessments, patient
pathway and
processes to be
taken when
accepting plus-size
patients on referral.
• There was an
apparent lack of
awareness of which
Trust Director is the
nominated
responsible person
for Risk and Health
and Safety. This was
addressed through
the re-launch of the
policy and training.
• All staff who
provide care for plus-
size patients should
be aware of how to
order appropriate
equipment; this is
addressed through
raising awareness of
the policy and
through manual
handling training
sessions.
(Source: Universal Routine Provider Information Request (RPIR) – P37 Audits)
During the inspection we found that there was a clear approach to monitoring, auditing and
benchmarking the quality of services or the outcomes for patients receiving care and treatment in
community health services. We saw that services participated in a range of local and national
audits and that there were action plans in place to address any issues of reduced compliance with
standards. Service leads told us that audit findings were regularly discussed at team meetings,
such as results of the safety thermometer, catheter care, hand hygiene and record keeping audits.
For example, locality managers in the integrated care team told us that record keeping audits were
completed annually and that themes identified were recorded on a tracker which was added to
team meeting agendas for discussion. There were quality leads for each team who collated and
analysed audit data and informed locality leads of any areas of concern. There was a process for
the locality leads to share this information with the team leaders, who would cascade any
information for sharing to the rest of the team. We saw that the locality leads created performance
matrices and action plans from this data, which was reviewed at monthly managers meetings. For
example, we saw that record keeping audit results showed a theme of the use of abbreviations
66
and a failure to consistently document a patient’s allergy status, and that there was an action plan
to address this. The plan included raising the issues at staff team meetings, targeted staff training
and a review of compliance.
Outcome measures were routinely used in most multidisciplinary teams; staff told us they used a
range of outcome measures as appropriate to each patient group. These included balance and
mobility measures, quality of life measures and cognitive assessment tools. Staff we spoke with
told us that the before and after data for these outcome measures was reviewed for individual
patients. However, staff reported that there was not a process in place to routinely collect, analyse
and report on specific outcome measures, as a whole service. The lead for allied health
professionals told us that the patient specific functional scale (PSFS) was used across all
therapies. This was a self-reported, patient-specific outcome measure, designed to assess
functional change. Although there was reporting of completion rates of this measure, the lead told
us that the process for reporting on the impact demonstrated by any change observed, was still
under development. All therapy teams used goal setting as a method of identifying patient’s
outcomes.
The tissue viability lead told us that they audited wound care by reviewing pain scores and
infection rates documented in patient records. This data was analysed and shared at team
meetings where actions were discussed, such as the provision of additional training. The team
were in the process of rolling out a new pressure risk assessment tool called PURPOSE–T
(pressure ulcer risk primary or secondary evaluation tool). This was a holistic assessment tool
which was evidence based and had been piloted with positive staff feedback. Staff were being
trained in its use and a template for completion on the electronic records system was being
developed. The tissue viability team were completing an audit on whether delivery of care was in
line with care plans such as use of recommended wound dressings and antibiotics. The results of
this had led to the development of treatment decision tool posters designed to guide staff in best
practice.
In the leg ulcer clinic, healing rates were used as an outcome measure, through an assessment
tool on the electronic record keeping system. The service reported that rates of leg ulcers healing
within 12 weeks was at 68%. There was an informal process of raising awareness and teaching in
place to improve this, but no documented action plan.
There were a range of key performance indicators used across community health services which
were reported to commissioners of services. These included, for example, screening for anxiety
and depression, patient uptake of self-management programmes, and prevention of admission
data. Senior staff were involved in collating and reporting this data and told us that it was shared
with staff at team meetings. There were some Commissioning for Quality and Innovation (CQUIN)
goals in place. CQUINs are national goals which make a proportion of healthcare providers'
income conditional on demonstrating improvements in quality and innovation in specified areas of
patient care. Services used data from the CQUINs to monitor and evidence that patient’s needs
were being met.
The community neurology service was seeking funding for a research trial of the Parkinson’s
exercise programme which they had developed. The programme called STABLE- staying active
with big limb exercises, had been developed by therapists working within the service. Staff
explained that they wanted to complete a randomised controlled trial of the STABLE programme
as a quality improvement initiative to demonstrate its effectiveness.
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Competent staff
The service made sure staff were competent for their roles. Managers appraised staffs’
work performance and held supervision meetings with them to provide support and
monitor the effectiveness of the service.
Clinical Supervision
The service provided the following information about their clinical supervision process:
Supervision was delivered in line with the clinical supervision framework policy; supervision
happened in groups, action learning sets; individual supervision and informal support to enable
staff to reflect on their practice. There was no formal prescription of either frequency or percentage
compliance.
Supervision was managed and monitored by services with variation in the robustness of
processes and recording. Data from 2017 identified gaps where supervision did not happen or was
incorrectly recorded.
Further work was being undertaken in the trust to enable improved access to supervision,
including development of formal groups within services by locality quality leads and more robust
monitoring systems.
(Source: CHS Routine Provider Information Request (RPIR) – CHS4 Clinical Supervision)
Staff we spoke with all told us that they had regular supervision. Staff described a variety of
supervision methods, including one to one meetings, peer support, and group supervision. There
was also opportunity for clinical supervision in the form of observation of staff practise or joint
working on visits. Team leads monitored supervision processes and ensured that all staff had
access to supervision. Physiotherapy staff described a peer supervision where groups of staff met
to discuss complex patients and share knowledge in order to deliver effective treatment. In the
integrated care team there was a reflective supervision group which staff attended weekly to
discuss any cases that they may have found emotionally stressful. There were action learning sets
in place for senior therapists to share knowledge through sharing of experiences and peer support
groups for technical instructors in the service.
There were clinical quality leads in post in the integrated care teams who supported nursing staff
and health care assistants. They told us that their role was to provide clinical leadership and
effectiveness such as competency based provision of care, for example for catheter care and
wound care.
There were clinical nurse specialists in post for example tissue viability, leg ulcer and diabetes
services who were available to support, advise and train staff in other teams. For example, the
diabetes nurse specialists met regularly with district nurses and delivered education sessions to
the team. Forums for practice nurses for staff who worked at GP practices were held every six to
eight weeks, in order to provide updates on best practice. We were told that there was a pressure
ulcer link nurse who worked in the integrated care team who provided updates to staff at weekly
handover meetings and sent email updates on any new guidance for practise. In addition, there
were champions roles within teams for specialist areas such as safeguarding and dementia.
These staff were given extra training to enable them to develop specialist knowledge and be a
resource for the whole team.
There were competency assessment frameworks in place for staff for specific tasks within their job
role. These were assessed by senior staff and signed off once completed. In some services, such
as physiotherapy, there was an annual review of competencies for staff. For example, competence
68
in delivering emergency respiratory physiotherapy as part of the on call respiratory physiotherapy
rota, was assessed by the senior member of staff by observing individuals practise for half a day.
There were competencies in place in nursing teams for interventions such as delivery of insulin
therapy. All registered nurses completed mandatory update training for insulin therapy annually.
There was a programme in place for training health care assistants to deliver insulin therapy. This
involved completion of a workbook, specific training sessions and observations of care to
demonstrate competency in the role. There were criteria for to enable health care assistants to
administer insulin to suitable patients, which included a standard operating procedure to follow.
This meant that assistant staff were given opportunity for personal development and could acquire
the rights skills and knowledge for safe and effective patient care.
Appraisal rates
From April 2017 and March 2018, 93.2% of all staff within adult community services had received
an appraisal compared to the trust target of 90%.
(Source: Universal Routine Provider Information Request (RPIR) – P39 Appraisals)
Data showed that compliance rates for staff receiving annual appraisals were above the trust
target. Appraisals had been completed annually with all staff we spoke with, and some staff
described a six-monthly review of objectives set during the appraisal process. Staff told us that
appraisals were used to identify goals for learning and further development.
Staff told us that there were different types of additional training opportunities for ongoing learning
and development. This included in house training, attendance at external courses, opportunities
for master’s degree qualifications and development of extended scope skills such as nurse
prescribing. Examples of in house training available were top to toe clinical skills training for
nurses and therapists, updates on inhaler techniques and auscultation skills and therapy journal
clubs. In the community neurology service, during our inspection, there was a guest speaker from
an orthotics company who was attending to deliver a training session to staff. Staff in the
physiotherapy service told us that they attended in-service training sessions every six weeks. In
the community adult’s health service staff told us that in-service training sessions were held after
team meetings every few weeks.
External training opportunities included community nursing qualifications, associate practitioner
qualifications for health care assistants, specialist palliative care courses, a Pilates course and
injection therapy training for physiotherapists. Several staff reported that they had had funding
provided for such training as it was identified in their appraisal as a training need. One technical
instructor we spoke with told us they had completed a level three national vocational qualification
whilst in post, which had been funded by the service. A health care assistant told us that they were
currently completing a foundation degree in health and social care through a local university,
which had been funded through the service. An occupational therapist told us that they were
completing an advanced clinical practise course through a local university which was being funded
through the service. One therapist was attending a multiple sclerosis annual conference but told
us the service had been unable to fund this. A further two therapists also reported that they had
not been able to access funding for external courses for the past two years. Service leads we
spoke with acknowledged that funding for external courses could be challenging. They explained
that they planned to bring in external speakers to run local workshops which could be attended by
more staff at a reduced cost to the trust.
The tissue viability lead told us that a joint role had been developed to work across the tissue
viability and community nursing teams. This role meant that specialist knowledge could be
developed by the staff member and shared widely in the community nursing team. The role acted
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as a specialist resource within the nursing team to educate staff and increase their knowledge.
The staff member in the role told us that it had provided a good learning opportunity for them to
develop additional skills and experience.
There were rotational physiotherapy posts within the trust which meant that staff were able to work
across a range of different clinical areas to develop a breadth of knowledge and skills.
A new staff member in post in the physiotherapy service described their induction process and told
us it involved specific training and opportunities to shadow experienced staff, in order that they
could develop knowledge, skills and competence.
Staff told us that there were support systems in place for staff undergoing the revalidation process.
There was opportunity for support by community matrons and line managers as well as a peer
group support for nurses. For allied health professionals (AHPs) the leads kept a log of all staff
who had been called to provide reregistration evidence to the health and care professions council.
They asked these staff to share their learning from the process and to be available for peer
support for other staff.
There were allied health professional forums held quarterly which were open to all AHPs.
Managers told us that the agendas for these forums were developed collectively with staff.
Multidisciplinary working and coordinated care pathways
Staff in different clinical roles worked together as a team to benefit patients. Doctors,
nurses and other healthcare professionals supported each other to provide good care.
Staff worked with referrers and other care providers, such as the local hospital and GP
surgeries to ensure patients were seen by the most appropriate service. There were
effective communication systems and clear referral processes in place.
During the inspection, we saw positive examples of multidisciplinary working throughout the
services. We saw that multidisciplinary teams worked together in shared open offices which staff
told us facilitated better communication and good team working. Integrated care teams referred
patients to other specialist teams when necessary, such as lymphoedema, diabetes, speech and
language therapy, dietetics and podiatry services. Staff explained how they requested other
members of the multidisciplinary team to assess patients by sending messages, or ‘tasks,’ through
the electronic records keeping system. Staff told us how they worked jointly with staff in the
respiratory and diabetes services to manage more complex patients on the caseload. The
specialist services offered training and support for staff in the integrated care team.
Staff reported that they had good working relationships with other teams and that there was easy
access to referral on to services or requests for advice.
The electronic records system was used by the majority of services and some GPs, which meant
that staff could see which other teams were involved in patient’s care and could see the other
team’s care record entries. This facilitated joined up and holistic care delivery.
Within teams such as the integrated care team, we were told that there were daily and weekly
handovers for sharing information about the caseload. In addition, there was a monthly meeting
with each of the GP practices in the team’s geographical patch. This comprised a group of staff,
including a nurse, therapist, pharmacist, and representatives from social care and mental health
services, met with the GP to jointly review any patients with complex needs. Staff told us that each
practice had a named therapist and community matron who would represent the integrated care
team at these meetings.
70
There was a referrals hub and a triage system where clinicians considered referrals to ensure they
were appropriate and to prioritise their urgency. Referrals could be made to the hub by nurses,
GPs and other health professionals. For some services, patients were able to self-refer, if they
were previously known to the service.
For specialist services such as the community neurology team, there was a need to have a
confirmed diagnosis of a neurological disease in order to access the service. In the integrated care
teams, referrals were received by email through a referrals hub and forwarded to nursing and
therapy staff who were on a rota to triage all new referrals to the service. There was a document to
support the triage process which identified suitable conditions that could be seen and any
exclusion criteria. Staff told us that they used their experience to allocate patients into different
categories, depending on the urgency of their condition. These categories were urgent (meaning
they should be seen on the same day), one week and four weeks. Managers told us that staff kept
protected time slots in their diaries on the electronic system to ensure that patients identified as
urgent, could be offered a same day appointment. This level of urgency aimed to avoid
unnecessary hospital admission through the delivery of rapid response care in the community.
Referrals to services were handled effectively with clear criteria and a multi-agency approach to
ensure people got the right care swiftly. For example, in the physiotherapy service, referrals were
received by email and triaged by senior clinical staff in order to review the appropriateness of the
referral and prioritise its urgency. There were criteria for three different categories of urgency:
• Priority one patients were those who were post-surgery or whose symptoms were so
severe they were off work or unable to sleep; these patients could be seen within two
weeks of referral.
• Priority two patients were those who were sub-acute and were still able to function despite
their symptoms; these patients were seen within six weeks of referral.
• Priority three patients were those with more chronic symptoms which were longer term and
stable problems; these patients were offered an appointment within 14 weeks of referral.
In the speech and language therapy, the service lead told us that referrals were triaged by a senior
therapist in each locality to identify the urgency of each referral.
In the community neurology team at Danesbury, staff told us that there was a holistic approach to
care and that they had introduced a joint assessment process for all new patients. Occupational
therapists and physiotherapists in the team worked together to complete the core assessment and
set joint patient goals. For patients with Parkinson’s disease and multiple sclerosis, the service
offered monthly ‘one stop shop’ appointments, where patients could be seen by the therapists and
specialist nurses at the same appointment.
In the musculoskeletal (MSK) triage service, patients with orthopaedic problems were referred by
GPs or consultants for triage and reviewed by extended scope practitioner (ESP) physiotherapists.
ESPs could determine treatment options including referral to orthopaedic consultants for possible
surgery. The MSK triage staff were able to request images such as x-rays and could offer injection
therapy for pain and inflammation and advice on exercises for strengthening. This meant that
some patients’ needs could be met through this service and avoid unnecessary referral to an
orthopaedic consultant.
Some teams, for example, integrated care included nursing and therapy staff. The community
neurology team also had psychology support and specialist nursing roles to support patients with
multiple sclerosis and Parkinson’s disease. The community neurology service employed a clinical
navigator for patients with rare or rapidly progressing neurological diseases. This enabled patients
71
referred to the service to be assessed at home quickly and referred on to different team members
and other support services as required. The clinical navigator linked in with local hospices, support
groups and charities, and social care services through monthly case conferences, where patients’
needs were reviewed and discussed to ensure they were being met.
We saw that there were multidisciplinary clinics for diabetes and podiatry, where patients would
see different types of staff at the same appointment. This reduced the need for unnecessary
appointments and enabled staff to work together to provide holistic patient care. Staff told us that a
diabetes consultant and diabetes specialist nurse visited each GP practice within the team’s
geographical patch to provide specialist education and review the clinical governance of
community diabetes care. There was a community pharmacist who worked alongside the diabetes
specialist nurses to review patient’s medications and provide education to the team.
In the hand therapy clinic, we saw that occupational therapists, physiotherapists and doctors
worked together to provide pathways of care. The team were in daily contact to ensure a
coordinated approach to patient care.
Health promotion
The service had an embedded approach to promoting self-management with patients. Staff had
received training in delivering a self-management programme to patients. Teams were prompted
to encourage patients to attend self-management programmes and reported on the number of
patients who took up the opportunity to attend. The community neurology team described how
they were considering incorporating the programme as a part of one to one therapy, or as an
online activity in order to increase uptake.
The lymphoedema service promoted self-management of the condition through the use of
compression hosiery, which patients could apply independently, rather than attending a clinic to
have their limb bandaged by a nurse.
We saw that most locations we visited had notice boards displaying a comprehensive range of
information on health matters. For example, we saw information on diabetes education
programmes, support groups for respiratory conditions, long term health conditions information
leaflets, and posters from local charities advising patients how to stay safe and warm during
winter.
The service offered a diabetes education programme known as DESMOND which delivered self-
management education modules, toolkits and care pathways for people with, or at risk of
developing, type 2 diabetes.
We saw a range of ‘myth busting’ posters in the physiotherapy clinic waiting area which
encouraged patients to self-manage conditions such as back and neck pain and arthritis. The
service had developed links with local gymnasiums to support patients to attend and take
responsibility for improving their own health.
Staff in the pulmonary rehabilitation service told us that they participated in public awareness days
called ‘healthfests’ and provided a stall at these events for information and advice about lung
diseases.
Staff told us that their core assessment templates included assessments of smoking, alcohol
intake and diet. There was a smoking cessation programme available which all staff could access
to refer patients on to.
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Some teams had key performance measures in place to screen patients for anxiety and
depression and refer on to additional mental health support services if wellbeing concerns were
identified.
The patient specific functional scale was used with all patients in the service. The scale was used
to encourage patients to identify their own goals for achievement which empowered them to
manage their own health and wellbeing.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the
Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health
and those who lacked the capacity to make decisions about their care.
There was a consent policy in place which community services adhered to. The policy was in date
and provided information on gaining, and recording consent for provision of care and treatment.
We observed that consent was recorded in the patient records that we reviewed.
The templates where risk assessments were recorded, had a section to indicate that patients were
in agreement with their care plans. There was a tick box on the electronic records system which
enabled staff to indicate at each visit, that patients had consented to delivery of the care plan.
During our observations of care, we heard staff asking patients if they were happy for treatments
to be carried out. Staff told us that it was usual practise to ask patients for verbal consent to
treatment prior to every intervention. We asked staff how they would ensure consent from patients
who were not able to verbally or otherwise, indicate their agreement to treatment. The integrated
care team explained that there was a learning disabilities team who could be contacted for advice
and support with patients who may need support in making decisions about their care. Staff in the
tissue viability service described how they would consider best interests decision making for
patients who lacked capacity, and told us that they would involve relatives in order to do this. We
saw that there was a capacity assessment template within the electronic records keeping system
which could be used if a patient’s capacity to consent to treatment was unclear. Staff in the service
were able to access community psychiatric nurse support from a neighbouring trust when
undertaking complex mental capacity assessments.
Staff in the community neurology team told us that they used pictures and cards with patients who
had communication difficulties in order to facilitate conversations about consent.
In the physiotherapy service, there was a consent policy for more invasive procedures, such as
acupuncture and injection therapy. In addition, there were acupuncture guidelines and an injection
therapy standard operating procedure, which documented consent requirements for these
treatments. Staff told us that there were forms completed by patients to indicate consent to these
treatments. The forms prompted staff to explain the intervention to patients, exclude any
contraindications to treatment and to discuss any risks of the procedure with patients. We saw
evidence of the use of these forms during our inspection. There were audits of compliance with
completion of consent forms. We asked to see results of these audits and saw that from June
2018 to September 2018 there was 100% compliance with the audit standards.
Mental Capacity Act and Deprivation of Liberty training completion
From April 2017 to March 2018 the trust reported that Mental Capacity Act (MCA) – level two had
been completed by 97.7% of staff within community services for adults, compared to a trust target
of 90%. This demonstrated that the service had exceeded compliance with the trust target for staff
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completion of mental capacity act training. All staff we spoke with during our inspection reported
that they had completed mental capacity act training.
The trust supplied updated MCA training data as of August 2018. By that date the trust had a
single level of MCA training. This had been completed by 94.6% of staff across community adults
as of that date, compared to the trust target of 90%.
The trust did not provide any data prior to inspection, for deprivation of liberty safeguard (DoLS)
training. However, following inspection, some data for DoLS training compliance was provided for
a limited number of community health services for adults. For the services for which data was
provided, this showed 95% of staff had completed it, which was in line with the trust target.
(Source: DR110, Mandatory training compliance August 2018)
Deprivation of Liberty Safeguards
From April 2017 to March 2018 the trust reported that no Deprivation of Liberty Safeguard (DoLS)
applications were made to the Local Authority for community services for adults.
(Source: Universal Routine Provider Information Request (RPIR) – P13 DoLS)
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Is the service caring?
Compassionate care
Staff cared for patients with compassion. Feedback from patients confirmed that staff
treated them well and with kindness.
All patients we spoke with were complementary of the care they had received. Patients and their
relatives told us staff were extremely friendly and helpful. Patients we spoke with used phrases
such as ‘fantastic care’ and ‘excellent service’ to describe their experience. One patient told us
that the staff in the podiatry clinic helped her ‘leave with a smile’ after her visit. The main
concerns patients raised with us were around high car parking charges and some long waits in
clinics, which did not run on time.
We saw thank you cards and letters displayed in many clinical areas which all provided positive
feedback from patients.
During our observations of care, we saw that patients were treated with respect and compassion.
We saw that staff were professional and polite and always introduced themselves by name to the
patients. Staff showed empathy with patients and took time to interact in a considerate and
sensitive manner. Staff took time to explain the service and offered opportunities for patients to
ask questions. Staff respected patients’ social, cultural, and religious needs.
We observed therapists and nurses using an encouraging attitude with patients, for example
praising their efforts with exercises or giving reassurance about their progress with treatments.
We saw a therapist treating a patient following amputation surgery and that the therapist was kind
and reassuring. We observed the therapist bend down to wheelchair height when they spoke with
the patient which demonstrated respect and compassion.
Staff respected patients’ privacy and dignity by ensuring seating in reception areas was far
enough away from the reception desk to maintain confidentiality. However, there was not a
privacy line at every reception for patients to stand behind whilst waiting for other patients to be
dealt with.
In one of the physiotherapy clinics we visited, we saw that cubicle areas had curtains which staff
drew during treatment sessions to maintain patient’s privacy. However, we noted that
conversations could be heard in the corridor, through the curtains which meant that a patient’s
privacy and dignity could be compromised. However, in other clinic areas there were individual
consultation rooms which were more soundproof and could be locked as an additional privacy
measure.
The NHS Friends and Family Test (FFT) is a satisfaction survey that measures patients’
satisfaction they have received. FFT data provided by the service showed from July 2018 to
September 2018 that an average of 98.6% of respondents would recommend the service.
Emotional support
Staff provided emotional support to patients to minimise their distress.
Staff throughout the different services understood the need for emotional support. We spoke with
patients and relatives who all felt that their emotional wellbeing was cared for. Staff had a good
awareness of patients with complex needs and those patients who may require additional support
during their visit to outpatient clinics, or within their home environment.
Patients we spoke with told us they knew who to contact if they had any concerns about their
care. Each patient seen in their own home had a nursing folder which contained information
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about the service they were receiving, which included contact details for the team during working
hours and for out of hours advice and support. We accompanied staff on some home visits and
saw staff took the time to get to know the patients and tailored their care to meet their individual
needs.
During clinic appointments we saw that staff spent time talking about a patient’s condition with
them and provided information and advice about their general health and wellbeing.
Initial assessments in most teams included a screening tool for anxiety and depression which
meant that staff could identify this need and refer patients on for additional assessment or
support as required.
The clinical navigator in the community neurology service was able to signpost patients to local
charities and voluntary organisations who could offer support and advice to patients with complex
or long-term conditions. This included a range of disease specific groups to support carers’
needs. We saw that notice boards in clinics had information on support groups for patients and
carers, for example for lung disease.
Understanding and involvement of patients and those close to them
Staff involved patients and those close to them in decisions about their care and
treatment.
Patients and relatives, we spoke with said they felt involved in their care. They had been given
the opportunity to speak with the staff looking after them and to ask any questions. All patients
we spoke with told us they were provided with a good, clear explanation about their condition. We
saw that patients using physiotherapy services were provided with written information about their
condition. Any recommended home exercises were printed as a personalised exercise
programme from a computer programme which provided patients with a diagrammatic
representation and written description of the recommended exercises.
We observed interactions between therapy staff and patients where exercises were explained
and demonstrated to patients to ensure they fully understood them.
We saw that staff discussed treatment plans with patients so that they were involved in their care
planning. We saw that therapy staff used a goal setting approach with patients and facilitated
conversations around realistic goal setting. Goals were documented in patient’s care plans once
they had been agreed. This approach encouraged patients to be involved in their care, feel
listened to and respected, and to make shared decisions about their treatment.
We observed that staff took time to listen to patients and adapted treatment approaches
considering patient feedback. For example, we saw a physiotherapist change a patient’s exercise
programme as they reported it was too strenuous. Another patient was offered attendance at a
back-pain class rather than one to one therapy as it was agreed they would find this more
motivating.
In the speech therapy clinic, we saw a staff member discuss a patient’s concerns with them at
length and ask questions which demonstrated they understood the impact of the symptoms on
that patient’s wellbeing.
We noted that staff used different methods to support communication in patients with any barriers
such as neurological impairment, or language spoken. We observed a physiotherapist speaking
slowly, using simple language and taking time to clearly explain a treatment to a patient who did
not speak much English. This meant that staff could be sure that patients understood their care
and treatment and could be involved in shared decisions about their care.
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Is the service responsive?
Planning and delivering services which meet people’s needs
The service planned and provided services in a way that met the needs of local people.
The service worked closely with commissioners, stakeholders and other providers to plan and
deliver integrated health and social care in a way that met the needs of local people. Adult
community services began a transformation process in November 2017, developed to meet the
health needs of the population across the county. There was an ongoing programme of work
underway to deliver integrated care through locality based multidisciplinary services.
Community nursing services worked alongside therapists in patch-based teams, where each
team was responsible for specified GP practices within the area and could meet the needs of the
local population. Services were provided across the whole county, although the East and North
Hertfordshire area was commissioned separately to the West of Hertfordshire area, meaning
there was some inconsistency in how services were delivered. There were a number of
integrated care or community adult health services teams across the county which operated as
geographical sub-teams to deliver patient needs led care. This ensured the right staff member
with the right skills was available to support patient care, wherever the patient lived within the
county. Staff in integrated teams visited patients at home to deliver both urgent and planned care.
Patients were prioritised which enabled patients being discharged from hospital or at risk of an
avoidable hospital admission, to be seen urgently. Rapid assessment, treatment and support was
available on the same day to ensure patients received appropriate care and rehabilitation in the
community. These services worked closely with acute hospital wards, GPs and social care to
provide responsive, personalised care. The multi-disciplinary team model was planned to ensure
patients received care tailored to their needs. The trust worked in partnership with local
commissioning bodies to review the demand and capacity of these services to ensure they met
the needs of the local population.
In addition, there were a range of clinic services available for specialities such as podiatry,
diabetes, and leg ulcers. These clinics were held in a variety of locations across the county to
facilitate ease of travel and attendance. This meant there was equity of service provision across
geographical patch based teams.
For speech and language therapy services and community neurology, patients could be seen at
home, in residential or nursing homes, or in a clinic, dependant on what environment was most
suitable to meet their needs. These types of specialist services were able to meet the needs of
patients with complex, long term needs, such as Parkinson’s disease, multiple sclerosis and
stroke.
Staff told us that the local equipment service was accessible, well stocked and responsive and
was able to deliver items of equipment such as hospital beds and hoists without delay when
required.
Staff told us that interpreting services were widely available to support the care of patients whose
first language was not English. The service could provide support over the telephone or could
arrange to do face to face visits to support staff during clinic appointments or home visits.
Meeting the needs of people in vulnerable circumstances
The service took account of patients’ individual needs.
Staff in all areas tailored their services in response to the complex needs of vulnerable patients,
for example, those living with dementia or neurological conditions. Staff in specialist services,
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such as the community neurology service, had additional training to understand the impact of
neurological conditions. They demonstrated knowledge of impairments that patients living with
neurological conditions may experience and used treatment approaches based on this to meet
individual patient’s needs. For example, staff explained how they used communication cards and
pictures to facilitate communication in order to understand patients’ needs.
Staff in the integrated care team told us about a dementia café they could refer patients and
carers to for support. The café was held at a local supermarket and was led by the community
psychiatric nursing team. Staff also reported that there was a mental health service who could be
contacted for advice and support, and who could perform joint home visits with staff, for patients
with complex needs.
We were told that there was a learning disabilities specialist team who were available to offer
support and advice to staff in other teams to support the needs of vulnerable individuals. For
example, staff told us about a purple book that the learning disabilities team could provide to
records patients preferences and individual care needs. This meant that all staff visiting the
patient could be aware of their specific needs. In addition, staff told us how they worked with
carers to ensure patient needs were identified and met.
In clinics we saw information posters entitled ‘information your way’ which advised patients that
information could be provided in different formats on request, for example, braille, large print,
easy read or different languages.
We saw that there was a facility on the electronic patient record system to alert staff to additional
requirements a patient may have, for example if they had a disability or communication support
needs.
We noted that the clinics we visited were accessible to patients with a physical disability, as
patient lifts were available and that there was ramped access to the health centres. However, not
all areas had automatic doors which could impede access for wheelchair users.
We noted that in the clinic rooms we visited, they were equipped with chairs and examination
beds suitable for patients of extreme excess body weight (obesity).
Access to the right care at the right time
Patients could access the service when they needed it. Waiting times from referral to
treatment and arrangements to admit, treat and discharge patients were in line with good
practice.
Referrals – IN RPIR
The trust has identified the below services in the table as measured on ‘referral to initial
assessment’.
The trust met the referral to assessment target in all of the 21 targets listed.
The trust did not provide separate details of the assessment to treatment times but commented
for all services that onset of treatment occurs at initial assessment.
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Name of in-patient ward
or unit
Days from referral to initial assessment Comments,
clarification National / Local
Target Actual (median)
Adult Bladder & Bowel
Care 126 (18 weeks) 49
Onset of treatment
occurs at initial
assessment
Adult Occupational
Therapy Service E&N
(Acute Therapies)
126 (18 weeks) 0
Onset of treatment
occurs at initial
assessment
Adult Physiotherapy
Service E&N (Acute
Therapies)
126 (18 weeks) 0
Onset of treatment
occurs at initial
assessment
Adult Speech & Language
Therapy 126 (18 weeks) 5
Onset of treatment
occurs at initial
assessment
Community Cardiology 126 (18 weeks) 5
Onset of treatment
occurs at initial
assessment
Community Respiratory
Service 126 (18 weeks) 8
Onset of treatment
occurs at initial
assessment
Diabetes 126 (18 weeks) 72
Onset of treatment
occurs at initial
assessment
Heart Failure Service 126 (18 weeks) 1
Onset of treatment
occurs at initial
assessment
ICROPS 126 (18 weeks) 66
Onset of treatment
occurs at initial
assessment
Leg Ulcer Service 126 (18 weeks) 19
Onset of treatment
occurs at initial
assessment
Lymphoedema Services 126 (18 weeks) 10
Onset of treatment
occurs at initial
assessment
MSK Physio & OT West 126 (18 weeks) 26
Onset of treatment
occurs at initial
assessment
MSK Physio E&N 126 (18 weeks) 43
Onset of treatment
occurs at initial
assessment
79
MSK Triage E&N 126 (18 weeks) 89
Onset of treatment
occurs at initial
assessment
Neuro Rehab - Community 126 (18 weeks) 68
Onset of treatment
occurs at initial
assessment
Nutrition & Dietetics 126 (18 weeks) 14
Onset of treatment
occurs at initial
assessment
Pain Management &
Chronic Fatigue 126 (18 weeks) 50
Onset of treatment
occurs at initial
assessment
Podiatry MSK Low Risk 126 (18 weeks) 69
Onset of treatment
occurs at initial
assessment
Podiatry Service 126 (18 weeks) 63
Onset of treatment
occurs at initial
assessment
Pulmonary Rehab 126 (18 weeks) 29
Onset of treatment
occurs at initial
assessment
Skin Health Service 126 (18 weeks) 95
Onset of treatment
occurs at initial
assessment
(Source: CHS Routine Provider Information Request – CHS10 Referrals)
Data showed that for all services for which information was provided, there was compliance with
national targets for referral to assessment and referral to treatment times. Patients we spoke with
during our inspection told us they had been offered clinic appointments quickly, for example in
the podiatry, dietetics, and rheumatology services. However, during our inspection, staff in some
services told us that there were long waits for patients to be seen. For example, the tissue
viability service did not have target wait times to see patients as it was not a commissioned
service, however, they reported wait times of up to six weeks for initial assessments. Staff told us
that they had received verbal complaints from patients about the wait time for an appointment. A
nurse in the team explained that the team was very small and capacity was limited. However, the
introduction of dual nurse roles across community nursing and tissue viability was designed to
increase capacity and reduce waits for patients. Therapy staff in the community neurology service
told us that patients who were deemed to be a lower priority, were waiting between 18 and 25
weeks for a therapy assessment. However, there was a prioritisation system through the triage
process in order to identify patients with more urgent needs. Priority patients received a joint
physiotherapy and occupational therapy assessment which meant they had a holistic assessment
without delay, which avoided unnecessary repetition of work. Priority patients were those with an
acute relapse of their condition or those being discharged from residential beds who needed
continued rehabilitation in their own homes. In the physiotherapy clinic at Kingsway, staff told us
that priority three patients, who should have been seen within 14 weeks, were waiting around five
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months for a first appointment at the time of our inspection.
There was a single point of access or referrals hub for community adult services which processed
referrals and signposted them on to the appropriate service in line with service criteria. This
avoided any unnecessary delays in referrals reaching the right service. Clinical staff within
services then triaged referrals and prioritised them. Several services had triage systems in place
which meant that patients with urgent needs were able to be have their care and treatment
prioritised. For example, in the integrated care and community adult health services, patients
could be seen the same day if necessary. These were patients who were at risk of an
unnecessary hospital admission, if responsive care could not be provided in the community. In
the physiotherapy service, those patients with the most severe symptoms were categorised as
urgent and offered appointments within two weeks. Staff in these teams allocated staff to a daily
triage rota to ensure that referrals could be assessed for urgency without delay. Managers in
services that offered rapid response, told us that a system of protecting slots in staff diaries for
new urgent patient assessments, enabled them to be responsive to their care and treatment
needs.
Service leads in community adult health services explained that a daily conference call took place
with each locality team lead to identify any areas of high clinical demand. This call was used to
allocate staff across localities to ensure that caseloads could be safely managed and patients’
care needs could be met across the county.
We saw that in some clinics there was a sign at reception advising patients to contact staff if they
had been waiting beyond their appointment time. Although some clinics such as physiotherapy
and speech and language therapy, usually ran to time, we noted that some clinics had long wait
times beyond appointment times for patients to be seen. In the leg ulcer clinic that we visited,
patients we spoke with told us they had been waiting for up to one hour after their appointment
time. In the ophthalmic clinic waiting times were displayed, however the wait times were dated for
two days prior to the clinic date. The waits on that day had been up to three hours beyond
appointment times.
We asked the service for numbers of cancelled clinics within community adult services between
June 2018 and August 2018. They reported that a total of 2700 clinic rotas had been cancelled
during this time period. They commented that a large number of these clinics had been cancelled
due to a change of time due to appointments being booked in advance. They said that in some
cases another clinic was added to deal with demand, which meant that the original clinic would
show as a cancelled clinic. The service said that these numbers did not represent a failure to
perform agreed clinics and that their systems did not allow for the reason for cancellation to be
recorded.
The service collected numbers of occasions when appointments were not attended. From July
2018 to September 2018 the service reported that an average of 2.6% appointments were ‘did
not attend’ (DNA) appointments. The highest rate of DNAs was in the musculoskeletal
physiotherapy service (23%) and the lowest rate of DNAs was in the integrated community team
(0.05%). We asked the service for any information relating to standard operating procedures or
policies for management of DNAs in clinics but they did not provide any. We spoke with staff in
the physiotherapy service who told us that if patients did not attend appointments they did not
routinely contact them. However, if a patient made contact within two weeks of their appointment
date, a further appointment would be offered to them. If the patient did not get in touch following a
missed appointment, they would be discharged back to the GP and would need a re-referral to
the service in order to access the service.
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In the leg ulcer clinic and speech and language therapy service, staff reported that if patients did
not attend (DNA) for an appointment, they would record this on the electronic record keeping
system and contact the patient to offer them another appointment. If patients missed two
consecutive appointments they would be discharged back to the care of their GP.
In the integrated care services, patients were offered initial appointments by telephone and were
also sent a letter if they could not be contacted by telephone. If the service had not received
contact from the patient within two weeks of sending a letter, they were discharged from the
caseload and referred back to their GP.
The lymphoedema clinic reported that they received high rates of DNAs due to the nature of the
caseload; all patients had a diagnosis of cancer and as a result often had symptoms or side
effects of treatment which meant they could not attend appointments. Staff told us they were
introducing a text message reminder service to try and reduce the rate of DNAs. This system was
already in place in some services such as physiotherapy clinics.
Most clinics were delivered between the hours of 9am to 5pm, Monday to Friday, although the
lead for speech and language therapy told us that they offered evening and early morning
appointments to improve access for patients. Some services were available seven days a week,
such as the community adult health and integrated care team services. Since these services
offered a rapid response option, nursing staff worked on a rota to cover the service every day
from 8am to 10pm. Out of these hours, there was an evening and night nursing service available
for emergencies such as blocked catheters. Although the therapists worked over seven days,
they did not provide a full therapy service at weekends, as a trial of this had resulted in increased
waiting lists. Therapists did complete triage of new referrals and urgent new assessments during
the weekend.
Another way in which services worked to ensure people had timely access to treatments, was by
the use of staff skill mixing. For example, health care assistant staff had been trained to deliver
insulin therapy to stable diabetic patients. This initiative had been introduced to help relieve the
pressure on community nursing caseloads, so that qualified staff time could be released to
perform other nursing care. This meant that the length of time patients had to wait to be seen was
minimised.
The use of technology supported timely access to care and treatment, for example, the ability of
nursing staff in the leg ulcer clinic to access laboratory results through a shared electronic
system. The system was used by GPs to obtain results such as wound swab results. Since the
leg ulcer nurses were able to access these results directly, it meant that they could act on them
immediately. As the majority of staff were nurse prescribers this meant that patients had quicker
access to antibiotics if needed. One of the nursing staff stated that the access to the electronic
system containing laboratory results had improved the team’s productivity.
Learning from complaints and concerns
The service treated concerns and complaints seriously, investigated them and learned
lessons from the results, which were shared with all staff.
Complaints
From April 2017 to March 2018 there were 80 complaints about community services for adults.
The trust took an average of 25 days to investigate and close complaints. This is in line with their
complaints policy, which states complaints should be dealt with within 25 working days.
A summary of complaints within community services for adults by subject is below:
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Community Adults Total
Subject Number of complaints
All aspects of clinical treatment 31
Appointments, delay/cancellation (out-patient) 17
Admissions, discharge and transfer arrangements 9
Communication/information to patients (written and oral) 7
Attitude of staff 7
Others 6
Aids and appliances, equipment, premises (including access) 2
Appointments, delay/cancellation (in-patient) 1
Total 80
(Source: Universal Routine Provider Information Request (RPIR) – P52 Complaints)
The service had a clear process and policy in place for dealing with complaints, staff we spoke to
were aware of the complaints procedure. We saw information about how to raise a complaint was
available throughout community health services for adults, in the form of leaflets and posters. The
hospital website had a section detailing how to make a complaint. Complaints could be made in
person, by telephone, and in writing by letter or email. All patient held treatment folders kept by
patients in their homes contained information on how to make a complaint if they were unhappy
with the service they had received.
We saw that complaints were taken seriously and were investigated at a local level in the first
instance. Verbal complaints would be escalated to service leads who aimed to achieve a
resolution with complainants through a discussion about their concerns, in the first instance.
Managers told us that if patients weren’t happy with their response, they were supported to
escalate their complaint through the patient liaison and advice service (PALS).
Managers told us that they would discuss any complaints with staff at handovers and team
meetings. Staff told us that feedback about complaints and any learning was shared at team
meetings.
Locality leads told us that for their monthly meetings with the deputy general manager for the
business unit, they produced a CLIPPS (complaints, litigation, incidents, PALS, serious incidents
and safeguarding) report. This meant that complaints for all services across the business unit
were logged and discussed at a senior level, including the outcome and any identified learning.
Managers told us that they fed back any shared learning at service team meetings; we saw
minutes of these meetings which confirmed this.
We heard an example of how learning from a complaint had resulted in a change in the hand
therapy clinic. A patient had complained that the phones weren’t always answered if they tried to
call to make a change to their appointment. As a result, a voicemail system had been set up so
that patients could leave messages. There was a process in place for administrative staff to
check for messages regularly and pass them on to relevant staff.
Staff in the integrated care team told us about a complaint about the ordering of unsuitable
equipment for a patient over a weekend. They described how therapy leads had investigated the
complaint and discussed it with the staff members involved. As a result, some additional training
had been provided to the team and a written response was provided to the complainant.
Compliments
From April 2017 to March 2018, the trust received over 12,000 compliments; however, they did
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not provide the data by core service so we are unable to identify how many compliments were
received for community services for adults.
(Source: Universal Routine Provider Information Request (RPIR) – P53 Compliments)
Is the service well-led?
Leadership
The service had managers at all levels with the right skills and abilities to run a service
providing high-quality sustainable care.
There was a clear leadership structure within community health services where individual leaders
had identified responsibilities and reporting structures across the business unit.
Community health services sat in the business unit of adult services, which was sub-divided into
inpatient beds, community and specialist services. Within community services in the business
unit, we saw that services were divided into two areas, one for East and North Hertfordshire and
one for Hertfordshire Valley. This was in line with local commissioning arrangements as services
in the east and north of the county were commissioned by a different commissioning body to
those in the west (Hertfordshire Valley). Both areas had a deputy general manager, reporting to
the associate director of operations, who had oversight of the operational issues across both
areas. Each deputy manager was responsible for several locality managers who managed
integrated care or community adult health multidisciplinary teams, which were patch based. Each
team was aligned to a hub of GP practices for service delivery. The locality managers reported
directly up to the deputy general managers. The specialist services subdivision included clinics,
for example, diabetes and podiatry services, the community neurology service and
musculoskeletal physiotherapy services. We saw that there was a similar management structure
in these services with a deputy general manager across all specialist services. There were
mechanisms in place for the deputy general managers to report information up to senior leaders
in the executive team and to cascade information down to individual teams through the locality
leads. Each locality lead oversaw the therapy and nursing teams in their patch. There were
service leads, and clinical leads within each locality, who had overall responsibility for the day to
day delivery of the clinical services provided.
There was a lead allied health professional (AHP) in post and two clinical quality leads for
physiotherapy and occupational therapy. These posts sat in the quality directorate and provided
support to AHPs across the county. They reported to the director of nursing and quality. These
staff described a networked role responsibility which looked at consistency of practise across the
county and had input into service transformation such as the development of the integrated care
teams.
Integrated care teams had been developed in November 2017 as part of a service redesign and
were set up to deliver planned care, case management and same day response, in order to meet
the needs of the local population. The transformation had been commissioner led and was
necessary to address financial constraints within the local clinical commissioning groups (CCGs).
CCGs are clinically-led statutory NHS bodies responsible for the planning and commissioning of
health care services for their local area, including deciding what services are needed for diverse
local populations, and ensuring that they are provided. Locality leads were responsible for
facilitating integrated working between therapy and nursing services. Leads told us that there had
been a need to deliver services differently in the new integrated care model, in order for quality
services to be delivered sustainably. An example of this was the upskilling of health care
assistant staff to do additional tasks such as deliver insulin therapy, following completion of
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competency based training.
We saw that processes were in place for locality leads to work together across the business unit
and allocate resources flexibly to the area of greatest need. There was a daily conference call in
east and north Hertfordshire and Hertfordshire Valleys between the locality managers which
reviewed staffing levels and caseloads in each team. Staff were allocated to a neighbouring team
in order to facilitate sustainable service delivery.
Staff told us that their local leaders were very visible and approachable and took time to
communicate with them and listen to their concerns.
We heard that representatives of the executive team had attended training sessions delivered by
staff in the tissue viability service. Some staff told us that they had seen senior managers doing
walkarounds in their department which made them visible and approachable. Staff told us how
the senior executive team communicated with them weekly by email and sent video clip
messages out to all staff. We were shown an intranet page which had photographs of all the
executive team with their names and role, to help staff know who they were. One of the deputy
general managers told us that they were aware that staff had struggled with the recent
transformation of services, and recognised that they felt ‘done to’ and not listened to. In an
attempt for staff to feel more engaged, they had set up lunchtime sessions where lunch was
provided alongside a short presentation to update staff on any developments within the trust. At
these events staff were encouraged to identify what was going well and what they would like to
change, in order to make them feel listened to and engaged in change.
All staff we spoke with told us that they were well supported by their line managers and they were
able to meet with them regularly.
Managers told us about various leadership development opportunities within the service. All band
five and six staff worked to competency frameworks and within these were some leadership
competencies. For band seven and eight staff, there was a focus on leadership competencies as
a core part of their development. We were told that a year long ‘foundations in leadership’ course
was delivered internally which 20 staff could attend one day a month to develop leadership
knowledge and skills in preparation for senior posts. There were also masters courses in public
sector leadership and business administration available through local universities, for which
funding could be applied for through the NHS leadership academy.
Vision and strategy
The service delivered care based on the trust’s vision for what it wanted to achieve. The
vision was the focus of each service’s work and was embedded within the business unit.
There were workable plans to turn it into action, developed with involvement from staff,
patients, and key groups representing the local community.
There was a clear trust vision and set of five values which underpinned the work staff did every
day. Most staff were aware of the vision and values. We saw that the trust vision was displayed
as a screensaver on computers. We noted that the vision and values were on display on public
noticeboards in some of the locations that we visited. Staff we spoke with were unclear how the
vision and values had been developed and did not report having had an opportunity to contribute
to their development.
The trust vision was ‘to maintain and improve the health and wellbeing of the people of
Hertfordshire and other areas served by the trust’. As part of developing their strategy, the trust
had identified five top objectives to achieve the vision. These were aligned to the trust values
which managers told us were crucial to the way staff worked. The trust values were ‘care,
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respect, quality, confidence and improve’. All staff in the service received an annual appraisal
which incorporated the trust values when reviewing performance and identifying learning
objectives.
We asked one of the deputy general managers of integrated care services, if there was a local
strategy or set of objectives related to the trust vision and strategy. They told us that there were
not any local objectives but that the trust vision was embedded in the business unit and was the
focus of their work.
Culture
Managers across the service promoted a positive culture that supported and valued staff,
creating a sense of common purpose based on shared values.
All staff we spoke with in community health services said they felt respected and valued by their
managers and colleagues. Staff reported feeling positive about their job roles and feeling proud
to work in the service. Staff morale was high, and individuals described an ethos of working
together as a team to benefit patients. Managers told us they were proud of the staff in their
teams and that there was a culture of ‘growing’ and developing staff. Several managers talked of
teams being ‘great’, ‘fantastic’, ‘lovely’ and ‘committed’. They told us that staff worked together
well and supported each other and commented that staff retention was high.
We heard from one of the locality leads that they had recognised the need to offer staff more
flexible working arrangements in order to recruit and retain staff. They described being supportive
of staff working long days, twilight shifts or weekend working only, in an effort to manage
childcare or other caring commitments.
One staff member who had been off sick due to a long-term condition told us that their manager
had been particularly supportive of their return to work. They described how their role had been
adapted and that their manager had been ‘brilliant’.
One of the diabetes team managers told us that there were two away days held annually to help
with team building and promotion of a positive working culture.
Staff told us they felt safe at work and described lone working processes which had been
established to reduce lone working risks in accordance with the trust lone working policy. In some
teams that saw patients outside of core working hours, they explained that it was standard
practise to visit all new patients in pairs. Staff described tracking processes and buddy systems
within teams which ensured that all staff were accounted for as safe at the end of their working
day. Staff carried mobile phones which could be used to alert other staff if someone felt unsafe
and needed assistance. One team told us they had set up a closed social media group for team
members in order to facilitate tracking and staff safety. The electronic records keeping system on
staff laptops had a panic button facility which could be pressed by staff who felt at risk. This
feature alerted all staff users of the system that someone needed urgent assistance by sending
out a message to all staff through the system.
Staff told us that felt confident to raise concerns with managers and that they would be listened to
and taken seriously. They explained the process for raising and escalating concerns and talked
about the whistleblowing policy. Some staff we spoke with were aware that the organisation had
a freedom to speak up guardian, and could signpost us to finding further information about the
role on the intranet. We saw posters advertising the freedom to speak up guardian role on some
staff noticeboards during our inspection.
Staff at all levels had opportunities for personal and career development. Staff felt supported to
develop and managers told us they supported people to develop.
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Registered nurses and therapists had support to complete requirements for their revalidation or
reregistration.
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Governance
The service generally used a systematic approach to continually improve the quality of its
services and safeguarding high standards of care by creating an environment in which
excellence in clinical care would flourish. However, there was not an effective approach
for regularly reviewing trust policies or for monitoring compliance with equipment testing
requirements.
There was a structured approach to governance within community adult services. There were
systems and processes in place to ensure regular review and accountability of service delivery.
There were mechanisms for cascading information upwards to the senior management team and
downwards to clinicians and other staff on the frontline. The deputy general managers told us
that they attended meetings with their associate director of operations, and other members of the
executive team, monthly, to review performance reports provided by the organisations business
unit. The deputy general manager then met together with the locality leads on a monthly basis for
a governance meeting to review operational performance. These meetings followed a set agenda
and used the business unit performance reports to review risks, staffing, finance, performance
and outstanding actions. Each locality lead produced a CLIPSS (Complaints, Litigation, Incidents,
PALS, Serious incidents and Safeguarding) report for this meeting which was reviewed and
discussed. Locality leads then met with team leads for each service and reviewed an action log
which served as the meeting agenda. Individual teams met together with their team or service
lead regularly and followed a set agenda for the meetings, which were minuted and shared with
all staff. We saw that the agenda included service updates, operational issues, staffing, risks,
training and a review of the locality CLIPSS reports.
Managers had access to governance systems that enabled them to monitor the quality of care
provided. This included the provider’s electronic incident reporting system and electronic staff
record system (which provided oversight of training and appraisal compliance, and staffing
levels). Service leads used these systems to develop an overview of any recurring themes or
issues that was shared at monthly team meetings. Clinical policies and guidelines were available
for all staff via the intranet. Staff showed they knew how to access relevant policies. However,
during our inspection we saw that two of the policies we reviewed were overdue for review.
These were the resuscitation and management of urinary catheters policies. We asked the
service if there were more up to date versions of these policies and were told that both policies
were under review. They told us that staff were reminded on the trust’s intranet site that all
policies remain applicable for implementation, including those that had an overdue review date.
They also told us that there was a programme of follow-up for all policies including those that
were due and overdue for review. However, since the resuscitation policy was seven years
overdue for review and the management of urinary catheters policy was four years overdue, this
meant that we could not be assured that there was an effective system for regularly reviewing
policies.
During our inspection we found several items of equipment that were overdue for annual testing.
Additionally, information requested following inspection showed that there were large amounts of
equipment on the maintenance log that were overdue for testing. Staff in community adult
services told us that all medical devices were managed by the medical devices team. They told
us that this team had an asset list of all medical devices which was maintained and recorded and
used to schedule and record all maintenance activity performed. However, data provided by the
service did not evidence that this system was effective. The service stated that it had been
recognised there was a need to improve maintenance compliance and ensure that all services
had accurate and timely reporting on the maintenance compliance of medical devices within their
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area. They reported that there was a project underway to provide live reporting of this information
to services and to include summary reports of equipment compliance in all monthly business unit
performance reports. At the time of inspection, we did not find that managers had processes in
place for oversight of equipment maintenance compliance.
All staff had a clear understanding of their roles and understood what they were accountable for
and to whom. Staff were supported in their daily role and were clear of expectations to report
incidents and concerns.
Management of risk, issues and performance
The service had effective systems for identifying risks, planning to eliminate or reduce
them, and coping with both the expected and unexpected.
We saw that the service had systems in place for identifying, recording and managing risks.
Service leads and locality leads were able to tell us what their current risks were and we saw that
these were documented on a local risk registers. Leads reported that the biggest risks were
staffing levels, although there were mitigating actions in place to address this and reduce the
impact on services as far as possible. Local risk registers used a risk assessment framework to
score risks. Identified risks were scored on a five by five matrix for likelihood and severity of the
risk, where the maximum score was 25. These risk scores, were then ‘RAG’ rated to indicate the
severity; RAG rating uses a red, amber green traffic light system to indicate the severity of the
risk score. Serious risks were those scoring 15 to 25, high risks scored eight to 12, moderate
scored four to six risks and low risks one to three. On the community adult service risk registers
we saw that there were three high risks identified, which were around staffing, delayed transfers
of care, and the lack of a skin service clinical specialist lead. Each of these risks had a
description of the risk and likely impact, assurances in place, action to mitigate the risk, and gaps
in assurance, and a target risk level to be achieved with target dates. We were told that the risk
register was reviewed at locality lead meetings and progress against achievement of reduced risk
scores was discussed and documented.
We observed staff in a leg ulcer clinic having to carry out treatments with some level of manual
handling risk due to the environment and equipment constraints of the service. However, we saw
that managers had risk assessed the tasks staff carried out, which documented the level of risk
and mitigating actions to reduce the risk.
Managers told us that there was a serious incident panel responsible for reviewing all serious
incident investigations and monitoring completion of recommended action plans. The panel had
oversight of any themes and learning from serious incidents which could be shared with staff
through locality and service lead meetings.
There were processes for regularly reviewing performance within community adult services.
Locality managers met monthly with the deputy general managers and reviewed service action
logs, staffing, performance and CLIPSS (complaints, litigation, incidents, PALS, serious incidents
and safeguarding) reports. Performance issues were discussed and escalated to the executive’s
team business performance meeting through the deputy general managers. Each service had a
set of key performance indicators to achieve in line with their service contract, for example on
compliance with waiting times or treatment outcomes
Each service completed monthly audits include a ‘dip test’ of records and a snapshot of safety
thermometer data for each caseload one day a month. Results were collated by locality leads
and any themes identified for discussion and sharing. There was an outcome measure used
across all services in the business unit, which measured patient’s functional outcomes. The data
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from this measure was reported and reviewed by each service as an additional method of
monitoring service performance.
There was a winter pressures management plan in place which was based on processes already
in place to review, prioritise and plan consistent delivery of services across the county. We heard
that there was a daily or weekly conference call set up to review caseloads and staffing levels
based on the operational pressures escalation level (OPEL) status declared for each service.
Systems were in place to allocate resources to the areas of greatest need by using the workforce
flexibly. This meant that older people and people in vulnerable circumstances would continue to
receive care at a safe level.
Managers told us that there was always a senior manager on call for the trust who could be
contacted at weekends or evenings for staff to escalate any concerns or potential risks. The
executive on call would be contacted in the event of any major incident.
Information management
The service collected, analysed, managed and used information to support all its
activities, using secure electronic systems with security safeguards.
Information was collected by services as key performance indicators (KPIs) to provide evidence
to commissioning bodies that services were compliant with targets. This information was collated
through electronic care record systems. Performance measures were in place and were routinely
reported and monitored.
We saw that business unit performance reports were compiled for each service, which were used
to share information at monthly operational performance meetings. The reports were used to
identify any service quality issues alongside the CLIPSS report data. Data for the reports was
reported directly from the electronic records system which meant that the data was valid, reliable
and relevant and was easily accessible. Action logs were in place to ensure that any quality
issues were monitored and regularly reviewed.
Information technology systems were used to process referrals and to manage caseloads and
waiting lists. These systems held patient information which could be accessed by clinical staff
across different services through a password protected process. This ensured secure sharing of
patient identifiable data in line with data security standards.
We saw that services participated in a range of national audits, such as the sentinel stroke
national audit programme (SSNAP) and the national diabetes audit, and submitted data to
external bodies in line with requirements.
Engagement
The service engaged with patients, staff and the public to plan and manage appropriate
services, and collaborated with partner organisations effectively.
Services regularly collected friends and family test (FFT) data from patients. We saw FFT
comment cards available at several clinic locations, which patients were encouraged to complete.
We saw ‘tell us what you think’ posters displayed in clinic rooms, to encourage patients to provide
feedback on services.
One of the deputy general managers reported that the last staff satisfaction survey had
highlighted that staff were struggling with recent changes implemented in services as they did not
feel listened to or able to contribute to decisions. This had been recognised and there were now
lunchtime sessions held for staff in each locality with the deputy general manager. These
sessions gave staff an opportunity to hear locality and trust updates and to tell managers about
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what was going well, what they were finding difficult and a chance to share ideas. There was an
output from these sessions to recognise the discussions, in the form of, ‘you said, we did’
posters. Examples were given of changes made as a result of these sessions, including the
introduction of patient satisfaction surveys built into the telephone system for the referral hub, and
the review of safe working systems during nursing twilight shifts. There was a clear agenda from
managers to use these sessions to demonstrate to staff that they were being listened to and to
make them feel engaged in change.
Allied health professional leads explained how they had worked closely with therapy staff during
the transformation of adult services to ensure that staff were engaged and involved in the
changes.
Staff in the tissue viability service told us that they were encouraged to be part of service
improvements and gave an example of how a triage process was being implemented based on
an idea from one of the team.
Therapy staff in the integrated care team told us that they were being supported to develop a falls
clinic and falls class by their manager, following making the suggestion in order to reduce waiting
lists.
Therapy staff in the community neurology service told us that managers were supportive of
service improvements and described how a member of the team had implemented a change in
the type of splinting materials used in the service. The staff member had identified the resource
implications, which they presented to managers who agreed to finance the new equipment
required. Managers were also supportive of additional staff training in order to facilitate
implementation of the change.
We heard that patients were involved in making decisions about their treatment through a joint
goal setting process led by staff. During our inspection we saw that therapists routinely asked
patients what they wanted to achieve and had discussions to agree and set patient centred goals.
We heard about local development boards within the trust which were aimed at engaging patients
in the development of services and to gather service user feedback on any changes
implemented. The boards included representatives from Hertfordshire community NHS trust,
GPs, social care, other local organisations and patient representatives. We were told that he
meetings were held monthly in each locality.
Staff in the community neurology service told us how patients had been involved with staff in the
development of a case of need for a respiratory pathway. Patients had met with staff to evidence
the need for a local pathway, which was being submitted to commissioning bodies.
There was a patient experience group within the trust which met with members of the trust board
in order to seek views, share feedback and shape services.
The community neurology service explained how they invited patients who had previously used
the service to work with them in delivering self-management programmes. Patients were asked to
share their experiences and provide peer support to others. The service had also involved
patients in feedback on the Parkinson’s diseases exercise programme (STABLE) which the team
had developed. They used questionnaires and focus groups to gather feedback which they used
to influence development of the programme. The service hoped to receive funding to complete a
research study of the STABLE programme and had involved two patients in the process, naming
them as research associates on the bid.
Physiotherapists in the musculoskeletal triage service told us how they worked closely with
orthopaedic consultants from the acute trust in order to review complex referrals and ensure they
91
were seen by the most appropriate service. The service told us they were building links with local
gymnasiums so they could advise patients on where they could go to continue self-management
of their condition after therapy sessions had been completed.
The integrated care team met with GP practices in each locality monthly which provided an
opportunity to develop positive and collaborative working relationships across service providers
to deliver patient needs led services. The team invited representatives from social care and the
voluntary sector to case conference meetings which enabled services to work together to identify
and support patient’s needs in the community. The neurological navigator described how they
worked collaboratively with consultants, social care, palliative care services and local charities to
provide information and support to service users.
The trust had an annual staff awards ceremony, where staff were recognised who demonstrated
achievement of the trust values.
Learning, continuous improvement and innovation
The service was committed to improving services by learning from when things went well
and when they went wrong, promoting training, research and innovation.
We heard about a range of service improvements and innovations within community adult
services. For example, in the tissue viability service we were told how the lead was implementing
the use of a new pressure risk holistic assessment tool called PURPOSE -T. This had followed a
pilot of the use of the tool which had received positive feedback. Staff were receiving training and
templates for documenting use of the tool were being developed with the aim of it being fully
implemented in November 2018.
In the diabetes service there had been innovative work to ensure the delivery of the DESMOND
(diabetes education and self-management for ongoing and newly diagnosed) programme was
widely accessible to patients. Increased numbers of programmes were being delivered, including
some on Saturdays to improve access to patients who worked. In addition, a special DESMOND
group for patients with a learning disability, and their carers had been implemented. The diabetes
service held virtual clinics to provide advice and support to GPs about diabetes management.
The clinics reviewed patient’s care records and made recommendations to GPs, which avoided
the need for additional face to face appointments for patients. The service had reviewed the skill
mix required for different tasks within the nursing service and had established a process for
health care assistants to deliver insulin to stable diabetic patients. This released registered nurse
time to deliver more complex care and enabled health care assistants to develop new skills within
their role. The process was competency based and had criteria and standard operating
procedures for staff to follow. The innovation was unique and had been submitted as a
nomination for the trust’s annual leading light awards. These awards had been developed to
celebrate, recognise and reward individual staff or teams going the extra mile for their patients.
There was a culture of improvement and innovation within services. Several staff members had
been supported to complete additional training such as acupuncture and injection therapy
training. Some staff had completed additional training for them to hold nurse prescriber roles
within teams. A number of support staff had completed associate practitioner training
programmes at local universities. There were a number of qualified clinicians who had completed
Master’s level modules at university through the support of the trust.
The community neurology service had developed an exercise programme for Parkinson’s
disease patients which had been nominated for a Parkinson’s UK, Parkinson’s excellence
network award. The service was seeking research funding to do a randomised controlled trial of
92
the programme.
Managers told us that there was a process for learning from reviews such as mortality reviews.
They explained that in the event of an unexpected death, a senior clinician reviewed the care
records and then the information was presented at a mortality review panel led by the director of
nursing. Any learning identified was then shared with teams through the deputy general
managers and locality managers.
93
Community inpatients services
This evidence appendix provides the supporting evidence that enabled us to come to our
judgements of the quality of service provided by this trust. It is based on a combination of
information provided to us by the trust, nationally available data, what we found when we
inspected, and information given to us from patients, the public and other organisations. For a
summary of our inspection findings, see the inspection report for this trust.
Hertfordshire Community NHS Trust provides NHS healthcare services to a population of 1.2
million people in Hertfordshire and West Essex. The trust provides community-based services for
adults and older people, children and a range of ambulatory and specialist care services. They
serve the communities of Broxbourne, Dacorum, East Hertfordshire, Hertsmere, North
Hertfordshire, St Albans, Stevenage, Three Rivers, Watford and Welwyn/Hatfield.
Hertfordshire Community NHS Trust (HCT) manages eight inpatient units situated in five
locations. The inpatient units are geographically spread across Hertfordshire and are
commissioned by three different organisations.
The locations the community inpatient units are based are:
• Bishops Stortford – Hertfordshire and Essex inpatient unit
• Hemel Hempstead – St Peters and Simpson inpatient units
• Potters Bar – Potters Bar community hospital inpatient unit
• Watford – Langley house which includes Holywell and Midway inpatient units
• Welwyn Garden City – Queen Victoria Memorial and Danesbury inpatient unit
The trust provides 185 intermediate care rehabilitation beds and additionally, stroke and
neurological rehabilitation beds. They also deliver a patient pathway under ‘Pathway 3’. Pathway
3 is for patients being discharged home for assessments, and is used for more complex patients,
and particularly for continuing health care assessments which require a multi-agency approach
and involve social care providers. This pathway is organised through Simpson inpatient unit.
Patients in the region are allocated beds via the county community bed bureau, which is a central
access hub for all community hospital bed based units.
We carried out this unannounced inspection 18 – 21 September and 27 September 2018. We
inspected the Hertfordshire and Essex inpatient unit; St Peters and Simpson inpatient units;
Holywell and Midway inpatient units and Danesbury inpatient unit. At Potters Bar, we looked at
medicines management only.
During the inspection, we spoke with 25 staff of various grades including service leads, matrons,
therapy managers, ward sisters, nurses, student nurses, therapists, doctors and housekeeping
staff. We spoke with eight patients and three relatives, observed care and treatment and looked
at 10 patients’ medical and nursing records and 24 patients’ prescription charts. We also looked
at 18 do not attempt cardio pulmonary resuscitation records.
The service was last inspected in April 2016 and at that inspection the community inpatient
service was rated good for safe, effective, caring, responsive and well led. During this inspection,
we looked at the changes and considered any progress that had been made within the
community inpatient services.
94
Facts and data about this service
Information about the sites which offer community inpatient services at this trust, is shown in the
table below. The table only includes the sites to be inspected.
Location site name Team/ward/satellite name Number of inpatient beds
Danesbury Home Adult neurological centre inpatient
unit 1
Hemel Hempstead
General Hospital Simpson ward 21
Hemel Hempstead
General Hospital St Peters ward 20
Hertfordshire and
Essex Hospital Inpatient unit 28
Langley House Holywell neurological rehabilitation
inpatient unit 16
Langley House Langley house inpatient unit
(Midway) 32
Potters Bar Community
Hospital Inpatient unit 29
Queen Victoria
Memorial Hospital Intermediate care inpatient unit 22
Sopwell and Langton wards at St Albans City Hospital, which closed in April and July 2017
respectively, are excluded from the table above and most other data sets in this report where a
site-level breakdown is available.
The trust reported that two clinics are held each month at Danesbury Home. No clinics are held at
the other community inpatient locations.
(Source: Routine Provider Information Request (RPIR) Universal P2 – Sites)
95
Is the service safe?
Mandatory training
While the service provided mandatory training in key skills to staff not all medical staff had
completed all the required mandatory training. Nursing staff across the inpatient units had
completed most of their mandatory training.
The service had a mandatory training programme for all staff. This included topics such as
infection prevention and control, moving and handling, fire evacuation, conflict resolution, and
information governance. The mandatory training programme was tailored to the skill requirement
of staff and was dependent upon their role. For example, clinical staff received training in manual
handling of patients, which non-clinical staff were not required to undertake.
The trust set a target of 90% for completion of mandatory training, except for health and safety
and information governance training, where the target was 95%. During our inspection in April
2016, we saw that most of the inpatient units were at, or close to their mandatory training target,
except the Hertfordshire and Essex hospital where compliance was 78% overall.
Most of the inpatient wards had achieved 90% compliance overall, except Potters Bar where
overall compliance was 85%. Information provided by the service after our inspection showed
there were individual topics at some units where the trust target was not met. For example, at
Potters Bar, resuscitation level two was 52% and conflict resolution was 78%, fire safety at Hemel
Hempstead Hospital was 76% and manual handling people 75%, at Hertfordshire and Essex
hospital.
We were not provided with updated figures for resuscitation level three. Resuscitation level three
was a requirement for all registered nurses, however at Potters Bar only 83% of nurses had this
training. Throughout the service, the overall compliance rate for resuscitation level three was 84%.
The overall compliance for health and safety training was 73%.
Medical staff training targets were not met for three out of six mandatory topics. Compliance to
resuscitation level three training was 77% and equality and diversity training was 33%.
Managers told us their mandatory training figures were higher now than when the information was
provided to us in March, although they could not show us this during our inspection. A senior
manager also told us there was a delay in uploading the training data into the electronic system
and that their learning and development team were aware of this delay and were trying to rectify it.
Some training was provided using e-learning courses, and some training was through face-to-face
sessions. Staff could access e-learning courses at work or at home. If staff completed training at
home in their own time, they were reimbursed for it.
A breakdown of compliance for mandatory courses as of March 2018 for medical/dental and
nursing staff in community inpatient services is shown below:
Mandatory Training completion
The trust set a target of 90% for completion of all mandatory training courses except for health and
safety and information governance, which both had a target of 95%.
Trust wide
The breakdown of compliance for mandatory courses for staff in community health inpatient
services from April 2017 to March 2018 is shown below.
96
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Manual handling - object 27 28 96.4% 90% Yes
Equality and diversity 293 305 96.1% 90% Yes
Conflict resolution 247 269 91.8% 90% Yes
Information governance 282 308 91.6% 95% No
Infection prevention (level 2) 254 279 91.0% 90% Yes
Fire safety 313 353 88.7% 90% No
Manual handling - people 243 275 88.4% 90% No
Resuscitation - level 2 214 253 84.6% 90% No
Resuscitation - level 3 111 133 83.5% 90% No
Health and safety 226 308 73.4% 95% No
In community health inpatient services, the trust’s training targets were met for four of the 10
mandatory training modules for which staff were eligible.
The trust supplied updated mandatory training data as of August 2018. The breakdown by training
module for staff across community inpatients as of that date is shown in the table below. Please
note that the health and safety training module was not included in the updated data. In addition,
some other training modules had been amalgamated or renamed.
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Fire 55 56 98.2% 90% Yes
Infection Control Mandatory 240 268 89.6% 90% No
Information Governance 267 298 89.6% 95% No
Equality and Diversity 266 298 89.3% 90% No
Conflict Resolution 236 271 87.1% 90% No
Fire Evacuation 248 286 86.7% 90% No
Resuscitation 212 265 80.0% 90% No
Moving and Handling 207 259 79.9% 90% No
In community health inpatient services, as of August 2018 the trust’s training targets were met for
one of the eight mandatory training modules for which staff were eligible.
(Source: DR110, Mandatory training compliance August 2018)
Mandatory training completion by module – qualified nursing staff – trust wide
The breakdown of compliance for mandatory courses for qualified nursing staff in community
health inpatient services from April 2017 to March 2018 is shown below.
Name of course
Number of
staff
trained
Number of
eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Manual handling - object 3 3 100% 90% Yes
Resuscitation - level 2 31 32 96.9% 90% Yes
97
Equality and diversity 115 119 96.6% 90% Yes
Infection prevention (level 2) 111 120 92.5% 90% Yes
Conflict resolution 104 113 92.0% 90% Yes
Manual handling - people 106 116 91.4% 90% Yes
Information governance 109 120 90.8% 95% No
Fire safety 121 135 89.6% 90% No
Resuscitation - level 3 72 81 88.9% 90% No
In community health inpatient services, the trust’s training targets were met for six of the nine
mandatory training modules for which qualified nursing staff were eligible. Resuscitation – level 3
had the lowest completion rate with 88.9%, compared to the 90% trust target.
The trust supplied updated mandatory training data as of August 2018. The breakdown by training
module for qualified nursing staff across community inpatients as of that date is shown in the table
below. Please note that the health and safety training module was not included in the updated
data. In addition, some other training modules had been amalgamated or renamed.
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Fire 16 17 94.1% 90% Yes
Infection Control Mandatory 91 98 92.9% 90% Yes
Information Governance 89 98 90.8% 95% No
Fire Evacuation 85 94 90.4% 90% Yes
Equality and Diversity 86 98 87.8% 90% No
Conflict Resolution 85 98 86.7% 90% No
Resuscitation 76 94 80.9% 90% No
Moving and Handling 74 94 78.7% 90% No
In community health inpatient services, as of August 2018 the trust’s training targets were met for
three of the eight mandatory training modules for which qualified nursing staff were eligible.
Mandatory training completion by module – qualified nursing staff – Danesbury Home
community inpatient services
A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for
qualified nursing staff in community health inpatient services at Danesbury Home is shown below:
Name of course
Number of
staff
trained
Number of
eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Conflict resolution 15 15 100% 90% Yes
Equality and diversity 15 15 100% 90% Yes
Infection prevention (level 2) 15 15 100% 90% Yes
Fire safety 29 30 96.7% 90% Yes
Resuscitation - level 2 16 17 94.1% 90% Yes
Manual handling - people 14 15 93.3% 90% Yes
Information governance 13 15 86.7% 95% No
98
At Danesbury Home community inpatient services, the trust’s training targets were met for six of
the seven mandatory training modules for which qualified nursing staff were eligible. Information
governance was the only module where the training target had not been met.
Mandatory training completion by module – qualified nursing staff - Hemel Hempstead
General Hospital community inpatient services
A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for
qualified nursing staff in community health inpatient services at Hemel Hempstead General
Hospital is shown below:
Name of course Number of
staff trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Manual handling - people 24 25 96.0% 90% Yes
Equality and diversity 23 25 92.0% 90% Yes
Infection prevention (level 2) 23 25 92.0% 90% Yes
Resuscitation - level 3 23 25 92.0% 90% Yes
Conflict resolution 21 25 84.0% 90% No
Information governance 21 25 84.0% 95% No
Fire safety 19 25 76.0% 90% No
At Hemel Hempstead General Hospital community health inpatient services, the trust’s training
targets were met for four of the seven mandatory training modules for which qualified nursing staff
were eligible. Fire safety training module had the lowest completion rate with 76.0%, compared to
the 90% trust target.
Mandatory training completion by module – qualified nursing staff - Hertfordshire and
Essex Hospital community inpatient services
A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for
qualified nursing staff in community health inpatient services at Hertfordshire and Essex Hospital
is shown below:
Name of course Number of
staff trained
Number of
eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Conflict resolution 12 12 100.0% 90% Yes
Equality and diversity 14 14 100.0% 90% Yes
Information governance 15 15 100.0% 95% Yes
Manual handling - people 14 15 93.3% 90% Yes
Resuscitation - level 3 9 10 90.0% 90% Yes
Infection prevention (level 2) 13 15 86.7% 90% No
Fire safety 13 15 86.7% 90% No
At Hertfordshire and Essex Hospital community health inpatient services the trust’s training targets
were met for five of the seven mandatory training modules for which qualified nursing staff were
eligible.
Mandatory training completion by module – qualified nursing staff – Langley House
community inpatient services
A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for
qualified nursing staff in community health inpatient services at Langley House is shown below:
99
Name of course Number of
staff trained
Number
of eligible
staff
Completion
rate
Trust
target
Met
Yes / No
Manual handling - people 15 15 100.0% 90% Yes
Equality and diversity 15 15 100.0% 90% Yes
Fire safety 13 15 86.7% 90% No
Resuscitation - level 3 13 15 86.7% 90% No
Infection prevention (level 2) 13 15 86.7% 90% No
Information governance 13 15 86.7% 95% No
Conflict resolution 11 13 84.6% 90% No
At Langley House community inpatient services, the trust’s training targets were met for two of the
seven mandatory training modules for which qualified nursing staff were eligible.
Mandatory training completion by module – qualified nursing staff – Potters Bar
Community Hospital community inpatient services
A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for
qualified nursing staff in community health inpatient services at Potters Bar Community Hospital is
shown below:
Name of course
Number
of staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Fire safety 18 18 100% 90% Yes
Equality and diversity 17 18 94.4% 90% Yes
Infection prevention (level 2) 17 18 94.4% 90% Yes
Information governance 17 18 94.4% 95% No
Conflict resolution 16 18 88.9% 90% No
Resuscitation - level 3 15 18 83.3% 90% No
Manual handling - people 14 18 77.8% 90% No
At Potters Bar Community Hospital community health inpatient services, the trust’s training targets
were met for three of the seven mandatory training modules for which qualified nursing staff were
eligible.
Mandatory training completion by module – qualified nursing staff – Queen Victoria
Memorial Hospital community inpatient services
A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for
qualified nursing staff in community health inpatient services at Queen Victoria Memorial Hospital
is shown below:
Name of course
Number
of staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Equality and diversity 13 13 100.0% 90% Yes
Information governance 13 13 100.0% 95% Yes
Manual handling - people 13 13 100.0% 90% Yes
Fire safety 13 13 100.0% 90% Yes
Conflict resolution 12 13 92.3% 90% Yes
Resuscitation - level 3 12 13 92.3% 90% Yes
100
Infection prevention (level 2) 11 13 84.6% 90% No
At Queen Victoria Memorial Hospital community inpatient services, the trust’s training targets were
met for six of the seven mandatory training modules for which qualified nursing staff were eligible.
Infection prevention was the only module where the completion target was not met.
Mandatory training completion by module – medical staff – trust wide
The mandatory and statutory training data show a small number of medical staff in community
inpatient services. This is not consistent with the vacancy, turnover and sickness data supplied by
the trust, which show no medical staff in community inpatient services.
The data show medical staff working in the community inpatient services at Hemel Hempstead
General Hospital and Potters Bar Community Hospital only.
It should be noted that, because of the small numbers involved, at site level there were only one or
two members of medical staff eligible for each module.
The breakdown of compliance for mandatory courses for medical staff in community health
inpatient services from April 2017 to March 2018 is shown below.
Name of course
Number
of staff
trained
Number
of staff
eligible
Completion
rate
Trust
target
Met
Yes / No
Conflict resolution 2 2 100.0% 90% Yes
Information governance 3 3 100.0% 95% Yes
Infection prevention (level 2) 3 3 100.0% 90% Yes
Resuscitation - level 3 3 4 75.0% 90% No
Fire safety 2 3 66.7% 90% No
Equality and diversity 1 3 33.3% 90% No
In community inpatient services the trust’s training targets were met for three of the six mandatory
training modules for which medical staff were eligible.
Mandatory training completion by module – medical staff - Hemel Hempstead General
Hospital community inpatient services
A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for
medical staff in community health inpatient services at Hemel Hempstead General Hospital is
shown below:
Name of course
Number
of staff
trained
Number
of staff
eligible
Completion
rate
Trust
target
Met
Yes / No
Resuscitation - level 3 2 2 100.0% 90% Yes
Information governance 2 2 100.0% 95% Yes
Conflict resolution 1 1 100.0% 90% Yes
Infection prevention (level 2) 2 2 100.0% 90% Yes
Equality and diversity 1 2 50.0% 90% No
Fire safety 1 2 50.0% 90% No
At Hemel Hempstead General Hospital community health inpatient services, the trust’s training
targets were met for four of the six mandatory training modules for which medical staff were
101
eligible. Only one of the two eligible medical staff had completed the equality and diversity and fire
safety training modules.
Mandatory training completion by module – medical staff – Potters Bar Community
Hospital community inpatient services
A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for
medical staff in community health inpatient services at Potters Bar Community Hospital is shown
below:
Name of course
Number
of staff
trained
Number
of staff
eligible
Completion
rate
Trust
target
Met
Yes / No
Fire safety 1 1 100.0% 90% Yes
Information governance 1 1 100.0% 95% Yes
Conflict resolution 1 1 100.0% 90% Yes
Infection prevention (level 2) 1 1 100.0% 90% Yes
Resuscitation - level 3 1 2 50.0% 90% No
Equality and diversity 0 1 0.0% 90% No
At Potters Bar Community Hospital community health inpatient services, the trust’s training targets
were met for four of the six mandatory training modules for which medical staff were eligible.
Only one of two eligible medical staff had completed resuscitation level 3 training. The one
member of medical staff eligible for equality and diversity training had not completed it.
(Source: Universal Routine Provider Information Request (RPIR) – P40Training)
Staff were responsible for booking and completing their own mandatory training. However, ward
managers told us that they monitored compliance and reminded staff about completing their
mandatory training.
Staff completed mandatory training in dealing with medical emergencies such as resuscitation
level 2 and level 3. Level 2 resuscitation was for healthcare assistant and therapist staff, and level
3 was for registered nursing staff. The resuscitation training included basic life support and
intermediate life support knowledge and automated external defibrillation(AED) training. Not all
nursing and medical staff were compliant with their resuscitation training.
We were told that nursing staff on the community inpatient wards had received education on
recognising sepsis as part of recognising deteriorating patients training. Following the inspection,
the trust provided evidence of education resources that were communicated with staff. However,
we were not provided with the number of staff who were compliant with this. Sepsis is a life-
threatening condition that arises when the body’s response to infection causes injury to its own
tissues and organs. Pathways demonstrate how to recognise sepsis and the steps that are
necessary to treat patients appropriately. Patients suspected of having sepsis were transferred by
ambulance to acute hospitals.
Safeguarding
Staff understood how to protect patients from abuse and the service worked well with other
agencies to do so. Most staff received safeguarding training on how to recognise and
report abuse.
Processes and practices were in place to safeguard adults and children from avoidable harm,
abuse and neglect that reflected relevant legislation and local requirements.
102
Safeguarding adults and children policies were in date and accessible to staff through the
hospital’s intranet. They included clear guidance on how to manage suspected abuse and
radicalisation, and details of who to contact for further support and guidance. The hospital
received safeguarding support from the local clinical commissioning group (CCG) safeguarding
team.
Safeguarding training completion rates at our inspection in April 2016 were mostly compliant
except at Queen Victoria Memorial Hospital where 68% of staff had up to date safeguarding
training against a target of 90%. Langley house also didn’t meet the 90% target with 87% of staff
having completed safeguarding training. During this inspection, overall safeguarding completion
rates had improved and most were above the 90% target.
Safeguarding training was provided using both e-learning courses, with additional face to face
training. Training covered all aspects of safeguarding adults and children, including professional
responsibilities, the Mental Capacity Act, categories of abuse, safeguarding processes, child
protection. Prevent training was also provided. Prevent training is a national government initiative
which aims to improve awareness of how to protect people who may be a risk of radicalisation.
Staff we spoke with knew how to access and complete safeguarding training.
Nursing staff told us they were aware of their responsibilities to safeguard patients and
demonstrated how they could access the trust policy on the intranet. Staff were aware that there
was a safeguarding lead within the trust and told us they knew how to contact them for advice.
Staff could explain the process for raising concerns.
The trust had a dedicated safeguarding team, which included clinical nursing staff. The team could
support staff across all hospital sites, keep them informed on safeguarding issues and provide
additional training when required. Contact details for the safeguarding team were displayed
throughout the inpatient units.
Staff were aware of female genital mutilation (FGM) and the process to follow should they have
any concerns.
The safeguarding of adults in the service was monitored by the trust’s commissioners who had
carried out an annual review of adult safeguarding across all sites. Findings and recommendations
from the audit were presented to the safeguarding adult forum. This ensured a consistent
approach to safeguarding adults across all services within the area.
Safeguarding Training completion
The trust did not separate their mandatory training data by staff group. Therefore, the data below
includes nursing and midwifery staff, medical and dental staff, allied healthcare professionals and
healthcare assistants/infrastructure support staff in community inpatient services. We asked the
trust to provide this information during the inspection but we didn’t receive this.
The trust set a target of 90% for completion of safeguarding training.
Trust wide
A breakdown of compliance for safeguarding training courses from April 2017 to March 2018 for
staff in community health inpatient services is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Safeguarding adults (level 1) 26 26 100.0% 90% Yes
103
Safeguarding adults (level 2) 276 280 98.6% 90% Yes
Safeguarding children (level 2) 275 281 97.9% 90% Yes
Preventing radicalisation - levels 3, 4 & 5 (prevent awareness) 222 229 96.9% 90% Yes
Safeguarding children (level 1) 25 26 96.2% 90% Yes
Preventing radicalisation - levels 1 & 2 (basic prevent awareness) 58 62 93.5% 90% Yes
In community health inpatient services, the 90% target was met for all six safeguarding training
modules for which medical staff were eligible.
The trust supplied updated safeguarding training data as of August 2018. The breakdown by
training module for staff across community inpatients as of that date is shown in the table below.
Please note that the different levels of safeguarding adults and preventing radicalisation training
had been replaced by a single module for each of these two training subjects by August 2018.
Name of course
Number of
staff
trained
Number of
eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Preventing radicalisation 271 298 90.9% 90% Yes
SAFA Champions 9 10 90.0% 95% No
Safeguarding Adults 287 298 96.3% 90% Yes
Safeguarding Children (Level 1) 32 33 97.0% 90% Yes
Safeguarding Children (Level 2) 246 265 92.8% 90% Yes
Safeguarding Children (Level 3) 1 1 100.0% 90% Yes
In community health inpatient services, as of August 2018 the trust’s training targets were met for
four of the five safeguarding training modules for which qualified staff were eligible.
(Source: DR110, Mandatory training compliance August 2018)
Danesbury Home community inpatient services
A breakdown of compliance for safeguarding training courses from April 2017 to March 2018 for
staff in community health inpatient services at Danesbury Home is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Safeguarding children (level 2) 41 41 100.0% 90% Yes
Preventing radicalisation - levels
3, 4 & 5 (prevent awareness) 41 41 100.0% 90% Yes
Preventing radicalisation - levels
1 & 2 (basic prevent awareness) 4 4 100.0% 90% Yes
Safeguarding adults (level 2) 41 41 100.0% 90% Yes
Safeguarding adults (level 1) 4 4 100.0% 90% Yes
Safeguarding children (level 1) 4 4 100.0% 90% Yes
The 90% target was met for all six safeguarding training modules for which staff in community
health inpatient services at Danesbury Home were eligible.
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Hemel Hempstead General Hospital community inpatient services
A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in
community health inpatient services at Hemel Hempstead General Hospital is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Safeguarding adults (level 1) 4 4 100.0% 90% Yes
Safeguarding children (level 2) 52 52 100.0% 90% Yes
Safeguarding children (level 1) 4 4 100.0% 90% Yes
Safeguarding adults (level 2) 50 52 96.2% 90% Yes
Preventing radicalisation - levels
3, 4 & 5 (prevent awareness) 35 38 92.1% 90% Yes
Preventing radicalisation - levels
1 & 2 (basic prevent awareness) 12 14 85.7% 90% No
The 90% target was met for five of the six safeguarding training modules for which staff in
community health inpatient services at Hemel Hempstead General Hospital were eligible.
(Source: Universal Routine Provider Information Request (RPIR) –P40Training)
Hertfordshire and Essex Hospital community inpatient services
A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in
community health inpatient services at Hertfordshire and Essex Hospital is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Safeguarding adults (level 1) 4 4 100.0% 90% Yes
Safeguarding children (level 1) 4 4 100.0% 90% Yes
Safeguarding adults (level 2) 38 39 97.4% 90% Yes
Safeguarding children (level 2) 37 39 94.9% 90% Yes
Preventing radicalisation - levels
3, 4 & 5 (prevent awareness) 31 33 93.9% 90% Yes
Preventing radicalisation - levels
1 & 2 (basic prevent awareness) 6 8 75.0% 90% No
The 90% target was met for five of the six safeguarding training modules for which staff in
community health inpatient services at Hertfordshire and Essex Hospital were eligible.
(Source: Universal Routine Provider Information Request (RPIR) –P40Training)
Langley House community inpatient services
A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in
community health inpatient services at Langley House is shown below:
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Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Preventing radicalisation - levels
1 & 2 (basic prevent awareness) 15 15 100.0% 90% Yes
Safeguarding adults (level 1) 6 6 100.0% 90% Yes
Safeguarding adults (level 2) 74 74 100.0% 90% Yes
Safeguarding children (level 1) 6 6 100.0% 90% Yes
Preventing radicalisation - levels
3, 4 & 5 (prevent awareness) 55 56 98.2% 90% Yes
Safeguarding children (level 2) 71 75 94.7% 90% Yes
The 90% target was met for all six safeguarding training modules for which staff in community
health inpatient services at Langley House were eligible.
(Source: Universal Routine Provider Information Request (RPIR) –P40Training)
Potters Bar Community Hospital community inpatient services
A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in
community health inpatient services at Potters Bar Community Hospital is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Safeguarding children (level 2) 38 38 100.0% 90% Yes
Preventing radicalisation - levels
1 & 2 (basic prevent awareness) 8 8 100.0% 90% Yes
Safeguarding adults (level 1) 7 7 100.0% 90% Yes
Safeguarding adults (level 2) 37 38 97.4% 90% Yes
Preventing radicalisation - levels
3, 4 & 5 (prevent awareness) 36 37 97.3% 90% Yes
Safeguarding children (level 1) 6 7 85.7% 90% No
The 90% target was met for five of the six safeguarding training modules for which staff in
community health inpatient services at Potters Bar Community Hospital were eligible.
(Source: Universal Routine Provider Information Request (RPIR) –P40Training)
Queen Victoria Memorial Hospital community inpatient services
A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in
community health inpatient services at Queen Victoria Memorial Hospital is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Safeguarding children (level 2) 36 36 100.0% 90% Yes
Preventing radicalisation - levels
3, 4 & 5 (prevent awareness) 24 24 100.0% 90% Yes
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Preventing radicalisation - levels
1 & 2 (basic prevent awareness) 13 13 100.0% 90% Yes
Safeguarding adults (level 2) 36 36 100.0% 90% Yes
Safeguarding adults (level 1) 1 1 100.0% 90% Yes
Safeguarding children (level 1) 1 1 100.0% 90% Yes
The 90% target was met for all six safeguarding training modules for which staff in community
health inpatient services at Queen Victoria Memorial Hospital were eligible.
(Source: Universal Routine Provider Information Request (RPIR) – P38 Training)
Safeguarding referrals
A safeguarding referral is a request from a member of the public or a professional to the local
authority or the police to intervene to support or protect a child or vulnerable adult from abuse.
Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and
institutional.
Each authority has their own guidelines to investigate and progress a safeguarding referral.
Generally, if a concern is raised regarding a child or vulnerable adult, the organisation works to
ensure the safety of the person. In addition, when appropriate, an assessment of the concerns is
conducted to determine whether an external referral to Children’s Services, Adult Services or the
police should take place.
Referrals were provided on a trust wide level so we were unable to break this down to individual
core services. From April 2017 to March 2018 there were 382 safeguarding referrals for adults
made by HCT staff. During the same period the trust made 390 safeguarding referrals for children.
(Source: Universal Routine Provider Information Request (RPIR) – P11 Safeguarding)
Cleanliness, infection control and hygiene
The service mostly controlled infection risk well. Most staff kept themselves, equipment
and the premises clean. They used control measures to prevent the spread of infection.
During our inspection, we found the environment to be clean and most staff followed the
trust policy on infection prevention and control.
There was a nominated trust lead for infection prevention and control (IPC) supported by specialist
nurses and ward based infection prevention link champions to deliver the key objectives.
There were posters on display encouraging staff and visitors to clean their hands using the hand
sanitiser provided. Hand sanitising gel was available throughout the units, and on the end of each
patient bed.
Most staff we observed used hand sanitiser or washed their hands when entering ward bay areas
and before and after each patient contact. This is in line with the National Institute for Health and
Care Excellence (NICE) Quality Statement 61 (Statement 3). Staff had a good knowledge of the
trust hand hygiene policy and knew how to follow the five moments for hand hygiene guidance.
This is defined by the World Health Organisation as the key moments when health-care workers
should perform hand hygiene.
We observed that not all staff on Simpson ward carried out appropriate hand hygiene between
each patient contact, or followed the trust hand hygiene policy of being ‘arms bare below the
elbows’ in clinical areas. Arms bare below the elbows allows clinical staff to wash their hands
thoroughly. We observed one member of staff miss five out of six opportunities for hand hygiene in
a 10-minute observation period. We saw that three doctors had long sleeves and/or were wearing
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wrist watches, and a therapist was wearing nail varnish. Subsequent to our inspection the trust
submitted an action plan detailing the actions it had taken to address these issues including re-
circulating the dress code and personal presentation policy and commencing assurance visits.
In some clinical areas there were no dedicated handwashing sinks to enable compliance with
guidance contained within Health Building Note 00-09: Infection control in the built environment
(Health Building Note 00-09). For example, the clean utility room on Simpson ward did not have a
dedicated handwashing sink for staff to use when preparing medications. The handwashing sink
for staff to use before preparing food, located in the dining room within Danesbury unit was not
compliant with HBN 00-09 guidance. This guidance states that hands should be washed under
running water and the use of mixer taps allows this to be practiced safely in healthcare settings
where water temperatures may be necessarily high. Additionally, hand hygiene sinks should not
have a plug or a recess capable of taking a plug as this allows the sink to be used to soak and
wash equipment. Hand wash sinks should not have an overflow, as these are difficult to clean and
sinks should be wall-mounted with sealed waterproof splash-backs to allow effective cleaning of all
surfaces.
From April 2018 to August 2018 the inpatient services screened 100% of patients for MRSA,
meeting the services screening criteria for MRSA. At the time of our inspection, the MRSA policy
had expired but was under review, and we were told it was due to be re-published in October
2018.
Patients who had a known or suspected infection were nursed in isolation in a side room on the
inpatient units. Staff followed the necessary infection prevention precautions to minimise the risk of
spread to others. Details of the patient’s infection status, treatment and individual care plans were
recorded in their electronic patient record, along with any specialist advice from the IPC team.
There were no cases of MSSA or MRSA blood stream infections from April 2017 to March 2018
and from April 2018 to August 2018. There were two cases of trust apportioned (avoidable)
C.difficile, from April 2017 to March 2018, and from April 2018 to August 2018 there were a further
two cases of avoidable C.difficile.
There had been two outbreaks of Norovirus in the inpatient units from April 2017 to March 2018.
Norovirus can spread rapidly in hospitals and is often difficult to control. The outbreaks were
reported as serious incidents. We saw evidence that these outbreaks were managed by the trust
and fully investigated with an action plan to prevent further outbreaks. Whilst the trust concluded
that neither outbreak could have been avoided, the trust did consider lessons learnt. For example,
delays in obtaining stool samples and communication with the deep cleaning company.
There were separate clean and dirty utility areas which helped minimise the risk of infection.
Clinical and domestic waste was appropriately segregated and there were arrangements for the
separation and handling of high risk used linen. However, on Holywell unit, used clinical waste
bags were temporarily stored in a large low sided, unlidded skip, along with the used linen bags.
Disposal of sharp instruments complied with Health and Safety (Sharp Instruments in Healthcare)
Regulations 2013. Sharps bins we observed were stored away from patient areas and not over
full, were signed and dated, with temporary locks in place. Staff told us how they would respond if
they received a sharps injury, and this was in line with best practice.
Personal protective equipment (PPE), such as gloves and aprons were available in sufficient
quantities on all wards within the community hospitals. Most staff used PPE appropriately when
performing tasks where there was a risk of contamination. However, we observed that a member
of staff on Simpson ward escorted a patient into a bathroom and back while wearing a red
medication round, ‘do not disturb’ apron. The same apron was worn while the staff member
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emptied a urine bottle from another patient and disposed of it in the sluice, before returning to the
medication round.
‘I am clean’ stickers were in use across some units to indicate that equipment had been cleaned
and was ready for use. Stickers were dated. We saw staff cleaning equipment between patient
use.
Audits were carried out regarding infection control compliance. Areas included general
environment, clean and dirty utility rooms, commodes, storage and equipment, waste
management and sharps. Hand hygiene was monitored through regular audits and included the
audit of clinical and non-clinical staff. Hand hygiene audits from June 2018 to August 2018 showed
that the inpatient community units achieved above 90%. Hand hygiene and environment audit
results were displayed in each unit for staff, patients and visitors to see. During our inspection, all
units recorded scores above 90% in each category.
Kitchen areas on units were clean. Food products and patients own food stored in the fridge was
labelled and in date.
Cleaning schedules were displayed in each unit. Domestic staff could explain the different types of
cloths and cleaning products used for patients with an infection.
PLACE Assessments
These self-assessments are undertaken by teams of NHS and private/independent health care
providers, and include at least 50 per cent members of the public, known as patient assessors.
They focus on the environment in which care is provided, as well as supporting non-clinical
services such as cleanliness, food, hydration, the extent to which the provision of care with privacy
and dignity is supported. In addition, assessments are made to consider whether the premises are
equipped to meet the needs of people with dementia against a specified range of criteria.
PLACE scores are only available at site level. However, the trust reported the Holywell
neurological rehabilitation inpatient unit as a separate site for PLACE.
The 2018 PLACE scores for cleanliness at Danesbury Home and Queen Victoria Memorial
Hospital were both lower than the England average for NHS community inpatient services. The
trust’s remaining four sites all scored better than or similar to the England average, and three
scored 100%.
The trust’s overall scores for cleanliness and condition, appearance and maintenance were similar
to the England averages. The trust’s scores for being dementia friendly were both slightly better
than the England averages.
Although the trust scored slightly better than the England average for being dementia friendly,
Danesbury Home, Hemel Hempstead Community Hospital and Potters Bar Community Hospital all
scored worse than the England average for this metric.
Site name Cleanliness
%
Condition, appearance
and maintenance %
Dementia
friendly %
Disability
%
Danesbury Home 95.8% 93.6% 64.6% 81.5%
Hemel Hempstead Hospital 99.1% 83.3% 69.9% 83.5%
Hertfordshire and Essex
Hospital
100.0% 90.3% 86.2% 88.1%
Holywell at Langley House 100.0% 95.0% 92.2% 95.9%
Langley House 100.0% 92.4% 90.8% 94.2%
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Potters Bar Community
Hospital
98.8% 95.5% 76.6% 85.6%
Queen Victoria Memorial
Hospital
92.8% 98.7% 90.8% 89.6%
Trust 98.2% 92.8% 82.4% 88.2%
England average (NHS
community)
98.8% 93.1% 80.3% 86.1%
(Source: NHS Digital)
Environment and equipment
The service generally had suitable premises and equipment and looked after them well.
However, some buildings were old and in need of refurbishment or repair, some units had
insufficient storage space and some units had broken equipment.
Each of the community units we visited were set out slightly differently. Some units, for example,
Danesbury unit and Holywell unit were mostly made up of single side rooms, and some, for
example, Simpson ward, were mostly made up of bays with four patient bed spaces. Each patient
was given an armchair, locker and an over bed table. All accommodation was single sex with
separate male and female bathroom and toilet facilities for each bay area and side room.
We found that most patient rooms and patient furniture was in a good state of repair. However, at
Midway unit we saw damaged flooring in a patient bedroom, with sticky tape being used as a
temporary fix.
Some of the unit environments and pieces of equipment needed repair:
• St Peters unit: we saw that the sluice hopper lid was stuck together with elastoplastic tape.
• Midway unit: we saw chairs at the nurses’ station were fabric coated and ripped.
• Holywell unit: there was a broken cupboard in the patient dining room, with a hand-written
note advising people not to open the door, as it caused electrical shortages.
• Danesbury unit: we saw that most of the bathroom assistance call bell pull-cords had been
snapped off and a plug-in system had been installed to replace them. However, the plug-in
system required the use of long wires which we observed were draped across sinks to
reach the toilet area.
• Holywell unit: we saw chemical ant traps were placed on the kitchen window sill, next to the
hot drinks facilities and at Danesbury unit we saw mousetraps in the dining room.
There was insufficient storage space in some units to store all the required manual handling
equipment, for example, hoists and patient wheelchairs. At Holywell unit we saw patient
bathrooms being used to store hoists. A risk assessment had not been undertaken on the safety of
storing equipment in patient bathrooms. Staff told us that the equipment would be moved out if
patients wanted to use the bathroom for a shower. We saw that the equipment was not moved for
patients using the toilet facilities in these bathrooms. One ward manager told us that lack of
storage was on their risk register.
Emergency medical equipment such as resuscitation trolleys and suction machines were checked
daily. The resuscitation trolleys had a lockable seal which meant that the trolley could not be
tampered with. We saw on Danesbury unit there was one day in August when the resuscitation
trolley had not been checked. In addition, staff had documented the suction machine red light was
not working on one occasion in September 2018. There was no action recorded to state whether
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the suction machine was now working correctly. We highlighted this to the ward manager during
our inspection and they told us they would investigate it.
On Holywell unit, we found the defibrillator pads had expired in August 2018.We highlighted this to
the ward manager during our inspection and they told us they would replace the pads immediately.
There was no water for injection on the resuscitation trolley at Holywell unit, and staff said they
had sachets of water for irrigation instead. We highlighted this with the ward manager and they
told us they would replace these immediately.
On Oakmere ward, at Potters Bar Community Hospital, there was no adult mask to use with the
nebuliser on the emergency trolley on the north side of the ward. The oxygen cylinder on the south
side was only quarter full, and therefore did not comply with the trust policy.
The trust confirmed that the issues with emergency medical equipment had been rectified in an
action plan sent to us subsequent to our inspection.
At Midway unit one suction machine stored in the clean utility, had an electrical test due date of
January 2017. This machine had a sticker on it saying it was not working and had been reported.
Nursing staff we spoke to were unaware of the out of date electrical test, and were unable to say
when it had stopped working.
Hypoglycaemia (low blood sugar) monitoring machines (BM machines) were not always checked
daily and according to trust policy on some units. The BM machine had not been checked on St
Peters for two days in August 2018, and one day in June 2018 and one day in July 2018. Simpson
ward staff told us they did not carry out daily checks on the BM machine as they believed this was
done by the acute trust who owned the equipment. On the Midway unit, there were three identical
BM machines in use, with only one log book, which indicated one of the machines had been
checked. However, the log book only had one date recorded for a check which was carried out on
6 September 2018. There was no record book for the other two machines.
BM test strips should be discarded 3 months after opening. Some units did not record the date of
opening. We saw on Midway unit there was a ‘’discard day’’ written on the test kit of 7 July 2018.
Staff were unclear if this was the discard date, or if it was the date of opening the packet of strips.
The trust advised us subsequent to our inspection that all equipment associated with BM
machines and been checked and assurance visits to monitor ongoing compliance had
commenced.
Emergency call bells were located by each patient bed space throughout the service, and some
units had piped oxygen and suction in each bed space. Portable oxygen cylinders and suction
were available on the units we inspected. Portable oxygen cylinders were stored away from public
areas however we saw that they were not always stored securely. On Danesbury unit and
Simpson ward some cylinders were freestanding, but were secured to the wall or other
immoveable object.
Suitable equipment was available to prevent patients sustaining pressure ulcers, in line with Royal
College of Nursing for the management of pressure ulcers. Patients identified at being at risk of
developing pressure ulcers had access to pressure-relieving support surfaces and strategies for
example, mattresses and cushions 24 hours a day. Patients assessed as having a grade 1-2
pressure ulcer could be placed on a high-specification foam mattress or cushion with pressure-
reducing properties. Patients assessed as having grade 3-4 pressure ulcers, or at high risk of
developing pressure sores, were provided with an alternating pressure mattress or a continuous
low-pressure system. On St Peters ward there were five alternating pressures mattresses,
however four of these were on the wrong setting for the patient. We drew attention to this with staff
during our inspection.
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Disposable items and consumables, for example syringes, needles, dressings and hand gels were
within their expiry dates.
Hazardous chemicals were not always locked away and stored in line with the Control of
Substances Hazardous to Health (COSHH) regulations. In the dirty clinical room on St Peters
ward, we found bleach cleaning tablets in a locked cupboard with the key attached to a hanger on
the outside of the locked door. The dirty clinical room was not locked and patients and visitors had
access to it. This was highlighted to the trust and subsequent to our inspection they took action to
alert staff to the risk assessments for all COSHH items and assurance visits to commenced to
monitor compliance to the regulations.
We also found diluted bleach in dirty utility rooms on Simpson ward and Holywell unit which were
not locked away. We saw that an incident had occurred that had been discussed at the
Hertfordshire and Essex team meeting in August 2018, in which hazardous chemicals had not
been locked away and had resulted in a patient safety incident.
Electrical equipment throughout the inpatient units had been tested and had yearly expiry dates
that were visible and clearly written.
We observed a wide variety of mobility equipment used and stored within the units. Systems were
in place to remove broken or faulty equipment.
Some bariatric equipment was available, for example, a larger sized chair and hoist and a larger
size commode. Staff told us that extra bariatric equipment could be ordered in if required.
Hoists were available within all the ward areas which meant staff could provide safe and effective
manual handling processes. This was in line with the Manual Handling Operation Regulations
2002. Some bed spaces within the ward areas had overhead hoist equipment, so that a patient
could be moved safely while reducing any unnecessary risk to the patient or the staff member.
All inpatient units at the community hospitals had access to fire escapes. Staff told us that fire
tests were routinely carried out. Fire exits were clearly signed and not blocked.
Assessing and responding to patient risk
Although there were effective systems in place to recognise and respond to deteriorating
patients’ needs, not all risks in the service had been identified, assessed and monitored.
Not all staff were aware of local risk registers.
The National Early Warning System (NEWS) is used to identify deteriorating patients in
accordance with NICE Clinical Guidance (CG) 50: ‘acutely ill adults in hospital: recognising and
responding to deterioration’ (2007). The trust used standardised NEWS charts to document patient
observations, such as blood pressure, pulse, oxygen levels, and temperature. Staff we spoke with
said the system worked well and staff responded appropriately to patients with an elevated NEWS.
Compliance to NEWS escalation and frequency of observations was audited and we saw in June
2018, all inpatient community areas scored between 92% and 100%, except Holywell which
scored 37%. Action plans for non-compliance included re-audit, change of handover design,
further training and discussions with relevant staff to ensure improvements. The service also had a
NEWS trigger sheet, which staff were required to complete when a patient’s NEWS score was
raised above zero. The sheet had a space to record what action had been taken and by who.
During our inspection in April 2016 we found that repeat patient observations had not always been
completed within agreed timeframes for all patients at Danesbury Neurological Centre and
Hertfordshire and Essex Hospital. During this inspection we found that NEWS scores had been
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accurately assessed and escalated appropriately, and that the NEWS trigger sheets had been
completed for each patient.
Staff had an awareness of sepsis and received training in recognising the signs of sepsis. Patients
suspected of having sepsis were transferred to an acute NHS hospital provider by ambulance.
Risk assessments were carried out on patients when they were admitted to the community
services. This included risk assessments for falls, malnutrition, and pressure ulcers. These were
documented in the patient’s records and included actions to mitigate any identified risks.
Assessments were updated weekly or following any changes, such as a new fall. The service used
nationally recognised risk assessments such as the Malnutrition Universal Screening Tool (MUST)
and Morse falls scale. MUST is a five-step screening tool to identify patients, who are
malnourished, at risk of malnutrition (under nutrition) or obese. The Morse Fall Scale is a rapid and
simple method of assessing a patient’s likelihood of falling.
Falls assessments were completed on each patient on admission and updated following a fall or a
change in the patient’s condition. The trust had recently updated its falls policy which was due for
release October 2018. Staff were aware of the updated policy and told us falls link nurses had
received extra training about the new policy. Patient falls alarms were in use for those patients
deemed to be at a high risk. Falls care was in line with the National Service Framework (NSF) for
Older People – Standard 6, which requires hospitals to reduce the number of falls which result in
serious injury, and to ensure effective treatment and rehabilitation for those that have fallen. The
trust falls policy and falls risk assessments were available on the intranet and staff knew how to
access these. Patients who had fallen or at risk of falling were placed on a 30 minute observation
chart for three days after a fall. This required staff to check the patient every 30 minutes and to
document that the patient was safe and had everything they needed. We found evidence that 30
minute checks were in place for three days for patients following a fall or at risk of falling.
However, at Danesbury unit we saw two falls 30 minute observation charts had been completed
retrospectively, and at Midway unit we saw that one 30 minute observation chart had been
completed retrospectively. We fed this back to the trust who after our inspection put measures in
place to alert staff to the importance of regular observation of patients as risk of falls, and
assurance visits were arranged to ensure this learning had been embedded.
During our inspection we did not see any patients who had a ‘position chart’ or turn chart. Position
charts are used for patients who have difficulty in moving and repositioning themselves whilst in
bed, to help patients avoid pressure damage to their skin. Nurses at St Peters and Simpson wards
told us they did use turn charts, however during our inspection there were no patients who
required assistance with moving. We saw that most patients on these wards appeared quite
dependant, and were mostly in bed wearing hospital pyjamas. Some staff told us that positions
were checked during the two hourly comfort rounds. However, the comfort round chart did not
record the position of the patient, or that staff had moved them, for example, from right side, to left
side. During our inspection in 2016, we found turn charts were used but that they were not always
completed regularly. Therefore, there had been little improvement in this area.
Emergency buzzers were available by patient bed spaces. Staff we spoke to were unaware if
these had been tested or whose responsibility this was.
Some patients had ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions made in
their notes. The DNACPR was recorded electronically in the electronic system, and a paper
version was kept in the patient’s medical file. DNACPR status was not recorded on the nurse
handover sheets. However, most agency nurses working in the units did not have access to the
electronic system. There was a risk to patients in that they might not get the correct response,
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should they collapse while in hospital because staff may be unaware of the patient’s DNACPR
status.
During our inspection in April 2016 we reported that at the Queen Victoria Memorial Hospital and
Midway unit there wasn’t a policy outlining the frequency that patients should receive therapy or
how soon after admission their assessment should be made. Patients at Queen Victoria Memorial
Hospital and Midway unit were not always seen daily by a therapist, which may have delayed their
rehabilitation and progress. This was raised with senior staff at the time of that inspection. During
this inspection we found that there was still no policy on how often patients should receive therapy
and not all units provided therapy at a weekend. Staff told us that some patients who were
admitted on a Friday, were not assessed by the therapy team for three or four days, which could
delay their recovery.
Staffing
The service did not always have enough nursing staff with the right qualifications, skills,
training and experience. The service did not report any incidents of harm due to staff
shortages.
Staffing levels, skill mix and caseloads were planned and reviewed so patients received safe care
and treatment at all times, in line with relevant tools and guidance.
The Safer Nursing Care tool (SNC) was used by the community hospitals to calculate staffing
requirements across the inpatient services. The SNC tool determined acuity and dependency
levels of patients in hospitals; it was used to assess the care needs of patients, estimated care
hours and suggested care arrangements. This meant that appropriate skill mix and staffing levels
were planned, which met the Royal College of Nursing safe staffing guidance.
Each unit displayed a board which showed the number of nurses that should have been on duty
and the actual number of nurses on duty. The number of therapy staff was not displayed. During
our previous inspection in April 2016 we found that most wards had the required amount of staff
on duty, each shift. During this inspection, most wards had the correct amount of staff on duty,
except Simpson ward on 19 September 2018, where they were one registered nurse short, and
Midway unit on 18 September 2018 where they were also one registered nurse short. However,
ward managers told us they were regularly short staffed and often had shifts without the required
number of nurses. For example, on Midway unit, in August 2018, there had been 32 unfilled nurse
shifts; 17 unfilled healthcare assistant (HCA) shifts; 12 occupational therapy unfilled shifts; four
physiotherapy shifts short and 32 rehabilitation shifts unfilled. On Holywell unit, from 4 September
to 17 September there had been eight unfilled nurse shifts and seven unfilled HCA shifts.
Where qualified nursing staff availability was lower than required, unqualified staff, healthcare
assistants (HCAs) made up the staffing numbers if possible. However, on Holywell unit, from 4
September to 17 September there were five days when both the nurse staff actual number and the
HCAs actual number fell below planned staffing. Ward managers told us they worked clinically
when they were short staffed and that staffing numbers were escalated every day at management
meetings and to the bed bureau. If possible, staff would move from one unit to another, to support
each other. We were told this was particularly easy to arrange on sites where there was more than
one unit, for example at Langley House, Holywell and Midway units where staff were shared. We
were told that rehabilitation assistants sometimes assisted with nursing duties and shared work
with the HCAs.
Monthly staffing reports were produced which considered unit staffing, linking shortages to events
on the ward, to look for any impact because of having reduced staff. Reports recorded the number
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of complaints, the number of falls, pressure ulcers and infections. Reports from April 2018 to June
2018 indicated there had been no avoidable moderate or severe harm because of staff shortages.
Most units had above 90% staffing for day and night shifts.
The ward manager told us that Midway unit had five nurse vacancies and one member of staff on
long term sickness. The ward manager at Danesbury unit told us there were four nurse vacancies.
Staff of all grades told us they sometimes had insufficient numbers of staff. During our inspection,
we did not see any evidence of patient care being compromised. However, two patients told us
they had waited a long time for call bells to be answered, one on Holywell unit and one on
Simpson ward.
Nursing staff and managers told us it was the trust policy to report staff shortages as incidents.
The trust had a safe staffing reporting and escalation Standard Operating Procedure (SOP). The
SOP outlined safe staffing ratio’s and was in place to help inpatient unit staff manage staff
shortage and minimise the risk to patient safety. The SOP set out a clear escalation process that
staff should follow to notify senior management and the bed bureau. Where the staff shortage is
unresolvable, an incident notification should be completed on the trust’s electronic reporting
system which all staff had been trained to use. From September 2017 to August 2018, the service
had reported one incident due to staff shortages. This was reported as no harm. Managers were
unable to say why there had only been one incident reported.
The service was actively trying to recruit new staff and developing new roles to increase the skills
of their existing staff. For example, therapy assistants were helping patients washing and dressing.
HCAs were learning basic skills in physiotherapy to help patients mobilise safely and increase the
rehabilitation opportunities for patients when a physiotherapist was not available.
The unit managers told us that recruitment was a priority and that they used targeted recruitment
drives which were bespoke to each unit. Managers planned to offer staff flexible working as much
as possible and to use incentives for difficult to fill roles, such as occupational therapists.
Safer staffing levels
Staff fill rates compare the proportion of planned hours worked by staff (nursing, midwifery and
care staff) to actual hours worked by staff (day and night). Community health trusts are required to
submit a monthly safer staffing report and undertake a six-monthly safer staffing review by the
director of nursing. This is to monitor and in turn ensure staffing levels for patient safety. Hence,
an average 70% fill rate in January 2018 for nursing staff during the day means; In January 2018,
70% of the planned working hours for daytime nursing staff were actually ‘filled’.
Details of staff fill rates within community inpatient services for registered nurses and care staff in
May 2018 for each site published on their website by the trust are below:
For community inpatient services, there is information for seven locations. These are:
• Danesbury Home
• Hemel Hempstead General Hospital
• Potters Bar Community Hospital
• Hertfordshire and Essex Hospital
• Holywell
• Queen Victoria Memorial Hospital
• Langley House
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Community inpatient services – Danesbury Home
Registered nursing staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,227 1,116 713 713
Care staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,426 1,719.58 713 1,104
Registered nursing staff at Danesbury Home had an average fill rate of 85.6% for day shifts and
a 100% average fill rate for night shifts. Care staff had an over-establishment of 20.6% for day
shifts and an over-establishment of 54.8% for night shifts.
Over-establishments are when there are more staff on duty than planned. Over establishments
are often required when there are patients, who require one to one care.
Community inpatient services – Hemel Hempstead General Hospital
Ward/unit
Registered nursing staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
St Peters ward 1,227 1,163 713 713
Simpson ward 1,227 1,116 713 713
Total 2,454 2,279 1,426 1,426
Ward/unit
Care staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
St Peters ward 1,426 1,695.5 1,069.5 1,426
Simpson ward 1,265 1,374.25 1,265 1,252.92
Total 2,691 3,069.75 2,334.5 2,678.92
Registered nursing staff in St Peters ward at Hemel Hempstead General Hospital had an average
fill rate of 94.8% for day shifts and a 100% average fill rate for night shifts. Care staff had an
over-establishment of 18.9% for day shifts and an over-establishment of 33.3% for night shifts.
Registered nursing staff in Simpson ward at Hemel Hempstead General Hospital had an average
fill rate of 91% for day shifts and a 100% average fill rate for night shifts. Care staff had an over-
establishment of 8.6% for day shifts and an average fill rate of 99% for night shifts.
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Community inpatient services – Potters Bar Community Hospital
Oakmere
Registered nursing staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,940 1,933.58 1,426 1,425.75
Care staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,426 1,458.83 713 713
Registered nursing staff in Oakmere ward at Potters Bar Community Hospital had an average fill
rate of 99.7% for day shifts and a 100% average fill rate for night shifts. Care staff had an over-
establishment of 2.3% for day shifts and an average fill rate of 100% for night shifts.
Community inpatient services – Hertfordshire and Essex Hospital
Cambridge/
Oxford ward
Registered nursing staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,940 1,933.58 1,426 1,425.75
Care staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,426 1,458.83 713 713
Registered nursing staff in Cambridge/Oxford ward at Hertfordshire and Essex Hospital had an
average fill rate of 97.5% for day shifts and a 95% average fill rate for night shifts. Care staff had
an over-establishment of 11.2% for day shifts and an over-establishment of 20.1% for night shifts.
Community inpatient services – Holywell
Holywell
Registered nursing staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,227 1,234 713 712
Care staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,069.5 1,510.75 713 1,058
Registered nursing staff in Holywell had an over-establishment of 0.6% for day shifts and a
99.9% average fill rate for night shifts. Care staff had an over-establishment of 41.3% for day
shifts and an over-establishment of 48.4% for night shifts.
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Community inpatient services – Queen Victoria Memorial Hospital
Rehabilitation
unit
Registered nursing staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,227 1,164.17 713 713
Care staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,426 1,408.53 1,069.5 1,069.25
Registered nursing staff in the rehabilitation unit at Queen Victoria Memorial Hospital had an
average fill rate of 94.9% for day shifts and a 100% average fill rate for night shifts. Care staff had
an average fill rate of 98.8% for day shifts and an average fill rate of 100% for night shifts.
Community inpatient services – Langley House
Langley
Registered nursing staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,583.5 1,644.67 713 713
Care staff
Day Night
Required shifts Filled shifts Required shifts Filled shifts
1,782.5 2,312.75 1,426 2,023
Registered nursing staff Langley House had an over-established fill rate of 3.9% for day shifts
and a 98.9% average fill rate for night shifts. Care staff had an over-establishment of 29.7% for
day shifts and an over-establishment of 41.9% for night shifts.
(Source: Safer Staffing Data – Trust website)
Planned v Actual Establishment
Year 1 section:
Details of staffing levels within community health inpatient services by staff group as at March
2018 are below.
Community inpatient services total
Staff group Planned staff
WTE
Actual Staff
WTE
Staffing
rate (%)
NHS infrastructure support 24.3 18.9 77.9%
Other Qualified Scientific, Therapeutic &
Technical staff (Other qualified ST&T) 5.4 5.4 100.0%
Public Health & Community Health Services 2.9 1.7 57.9%
Qualified Allied Health Professionals
(Qualified AHPs) 46.5 33.2 71.3%
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Qualified nursing & health visiting staff
(Qualified nurses) 145.9 105.3 72.1%
Support to doctors and nursing staff 144.8 118.9 82.1%
Support to ST&T staff 17.8 12.7 71.2%
Total 387.7 296.0 76.4%
Year 2 section:
Details of staffing levels within community health inpatient services by staff group as at March
2018 are below.
Community inpatient services total
Staff group Planned staff
WTE
Actual Staff
WTE
Staffing
rate (%)
NHS infrastructure support 27.1 16.7 61.6%
Other Qualified Scientific, Therapeutic &
Technical staff (Other qualified ST&T) 5.4 4.0 74.6%
Public Health & Community Health Services 2.3 2.7 116.4%
Qualified Allied Health Professionals
(Qualified AHPs) 42.8 37.5 87.7%
Qualified nursing & health visiting staff
(Qualified nurses) 140.1 110.4 78.8%
Support to doctors and nursing staff 131.3 108.0 82.2%
Support to ST&T staff 17.5 15.8 90.2%
Total 366.4 295.1 80.5%
(Source: Universal Routine Provider Information Request (RPIR) – P16 Total Staffing)
Vacancies
The trust set a target of 10% for vacancy rate, that is no more than 10% of posts were vacant.
From April 2017 to March 2018, the trust reported an overall vacancy rate of 22.1% in community
health inpatient services. This did not meet the trust’s target. Across the trust overall vacancy
rates for nursing staff were 22.4% and for allied health professionals were 51.9%.
A breakdown of vacancy rates by staff group in community health inpatient services at trust level
is below:
Community inpatient services total
Staff group
Total number
of
substantive
staff
Number of
substantive
vacancies
Total % vacancies
overall
(excluding
seconded staff)
Other Qualified Scientific,
Therapeutic & Technical staff (Other
qualified ST&T) 9.1 12.2 74.8%
Support to ST&T staff 136.6 261.3 52.3%
Qualified Allied Health Professionals
(Qualified AHPs) 160.9 310.2 51.9%
NHS infrastructure support 25.1 64.7 38.8%
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Qualified nursing & health visiting
staff (Qualified nurses) 255.3 1,138.4 22.4%
Support to doctors and nursing staff 157.1 1572.8 10.0%
Public Health & Community Health
Services -0.3 7.1 -4.8%
All staff 743.8 3,366.7 22.1%
The trust set a target of 10% for vacancy rate, that is no more than 10% of posts were vacant. From April 2017 to March 2018, the trust reported an overall vacancy rate of 19.5% in community health inpatient services. This did not meet the trust’s target. Across the trust overall vacancy rates for qualified nursing staff were 21.2% and for allied health professionals were 12.2%. A breakdown of vacancy rates by staff group in community health inpatient services at trust level is below:
Staffing group
Total number of
substantive staff
Total number of
substantive vacancies
Vacancy
rate (%)
NHS Infrastructure Support Staff 10.41 27.1 38.4%
Other Qualified Scientific,
Therapeutic, Technician Staff 1.36 5.36 25.4%
Public Health and Community Health
Services -0.38 2.32 -16.4%
Qualified Allied Health Professionals 5.23 42.75 12.2%
Qualified Nursing and Health Visiting
Staff 29.69 140.06 21.2%
Support to doctors and nursing staff 23.23 131.34 17.7%
Support to Scientific, Therapeutic and
Technical Staff 1.76 17.51 10.1%
Total 71.3 366.44 19.5%
(Source: Universal Routine Provider Information Request (RPIR) – P17 Vacancy)
Turnover
All nurses leaving the service were given the opportunity of an exit interview with the senior
matron. This helped identify any themes to understand why staff left. Some staff left due to
promotion within the organisation or for promotion to another healthcare provider.
The trust set a target of 12% for turnover rates. From April 2017 to March 2018, the trust reported
an overall turnover rate of 14.7% in community health inpatient services. This did not meet the
trust’s target. Across the trust overall turnover rates for nursing staff were 14.9% and for allied
health professionals were 27.9%.
A breakdown of turnover rates by staff group in community health inpatient services at trust level
is below:
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Community health inpatient services total
Staff group
Total number
of
substantive
staff
Total number of
substantive
staff leavers
in the last 12
months
Total % of
staff
leavers in
the last 12
months
Qualified Allied Health Professionals 36.6 10.2 27.9%
Qualified Nursing and Health Visiting
Staff 109.6 16.4 14.9%
Support to Doctors and Nursing Staff 128.1 11.9 9.3%
NHS Infrastructure Support Staff 3.9 0.0 0.0%
Public Health and Community Health
Services 2.3 0.0 0.0%
Support to Scientific, Therapeutic and
Technical Staff 15.4 4.4 28.6%
Other Qualified Scientific, Therapeutic,
Technician Staff 4.5 1.4 31.5%
Grand Total 300.3 44.3 14.7%
(Source: Universal Routine Provider Information Request (RPIR) – P18 Turnover)
Sickness
Staff who had a period of sickness absence had a return to work/welfare interview immediately
upon their return. The purpose of the interview was to ensure the staff member was fit to be back
at work, and to ensure any reasonable assistance required was identified. Sickness and absence
rates were monitored and there were policies in place to ensure that absence monitoring was
carried out correctly. Monthly staff sickness days were displayed on units in public areas.
The trust set a target of 3.6% for sickness rates. From April 2017 to March 2018, the trust reported
an overall sickness rate of 5.9% in community health inpatient services. This did not meet the
trust’s target. Across the trust overall sickness rates for nursing staff were 5.4% and for allied
health professionals were 2.1%.
A breakdown of sickness rates by staff group in community health inpatient services at trust level
is below:
Community inpatient services total
Staff group Total % permanent staff sickness
overall
NHS Infrastructure Support Staff 17.8%
Support to Doctors and Nursing Staff 7.2%
Support to Scientific, Therapeutic and Technical Staff 6.9%
Qualified Nursing and Health Visiting Staff 5.4%
Qualified Allied Health Professionals 2.1%
Other Qualified Scientific, Therapeutic, Technician
Staff 1.9%
Public Health and Community Health Services 0.0%
All staff 5.9%
(Source: Universal Routine Provider Information Request (RPIR) – P19 Sickness)
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Nursing – Bank and Agency Qualified nurses
From April 2017 to March 2018 the trust reported bank and agency usage for qualified nurses in
community health inpatient services as below:
Type of shift Total number of shifts
Shifts available 5,881
Filled by bank 2,941
Filled by agency 2,092
Shifts not filled 848
The trust reported that the following community health inpatient wards/units had among the
highest bank usage and agency usage across all core services:
Ward/unit Bank use (shifts) Agency use
(shifts)
Plans in place to address overuse
of temporary staffing
Rehabilitation unit
Cambridge Oxford
ward
975 2,242 Escalation beds have now been closed.
Recruitment to vacancies is ongoing.
There have been a large number of
health care assistants required to
provide one to one care for at risk
patients, but this has now reduced
Langley House 1,625 1,361 Escalation beds have now become
permanent so permanent staffing has
increased. Escorts and one to one
carer has been required, but this has
now reduced. On-going recruitment to
vacancies.
St Peters ward 1,357 674 Escalation beds have now been closed.
Recruiting to vacancies on-going.
One to one care has been required
for some patients, but this is now
being managed more carefully.
Holywell unit 1,331 643 Actively recruiting to all vacant posts.
However, highest proportion used to
manage patients requiring 1:1
supervision, as this is identified in the
enhanced care risk assessment.
These patients lack capacity and also
have a DOLs in place, are at higher
risk of falls and lack insight into their
level of need
(Source: Universal Routine Provider Information Request (RPIR) – P20 Nursing Bank Agency)
Nursing - Bank and Agency Non-Qualified nurses
From April 2017 to March 2018 the trust reported bank and agency usage for non-qualified
nurses in community health inpatient services as below:
Type of shift Total number of shifts
Shifts available 11,625
Filled by bank 6,154
Filled by agency 4,559
Shifts not filled 912
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(Source: Universal Routine Provider Information Request (RPIR) – P20 Nursing Bank Agency)
Medical locums
From April 2017 to March 2018 the trust reported agency usage for speciality doctors in
community health inpatient services as below:
Staff group Shifts available Agency shifts filled Not filled
Speciality doctor 1,343 844 499
The trust states that they do not currently have a medical bank due to low usage; however, one is
being set up via National Health Service Professional (NHSP) in 2018.
(Source: Universal Routine Provider Information Request (RPIR) – P21 Medical Locum Agency)
Suspensions and supervisions
During the reporting period from April 2017 to March 2018, community health inpatient services
reported that there was one case where a staff member is under supervision at Langley House.
(Source: Universal Routine Provider Information Request (RPIR) – P23 Suspensions or
Supervised)
Quality of records
Staff did not always keep appropriate records of patients care and treatment, not all patient
records were kept in secured areas. Several staff had difficulties navigating a new
electronic notes system, and not all records were completed in line with best practice.
During our inspection in April 2016 we found that patient records were not always
comprehensively completed for all patients, particularly at Danesbury Neurological Centre.
During this inspection we found that records we reviewed were not always comprehensively
completed or securely stored. We found some records were not completed contemporaneously
and some paper records did not contain the patient’s identity details.
On Simpson ward we found two patient’s NEWS observation charts did not contain patient
identification. At St Peters ward, used nursing handover sheets were collected in a tray left by the
nurse’s station and could be accessed by unauthorised people, and at Midway unit we found a
handover sheet on top of an unattended nursing station. Handover sheets were between six and
15 pages long and contained full patient identifiable details plus full clinical condition and social
circumstances. On St Peters ward, notes trolleys were lockable, but unlocked during our
inspection and were kept in the ward reception area. We highlighted these issues with staff during
our inspection.
The community hospitals had recently implemented an electronic record system. The system used
was one of the accredited systems in the government's programme of modernising IT in the NHS.
Nursing staff told us they had received training in the new system and managers told us extra
training was available to everyone, alongside a ward based ‘superuser’ who was confident in using
the system and could assist staff on duty. Some staff said they found it difficult to use the system
despite extra training and we saw this when they showed us patients records. Some nursing staff
said the system involved a lot of duplication and some units were still using paper based records
for some things, as well as the electronic version.
Therapy staff had used the electronic notes system before the nursing teams and most therapists
said they found the system helpful to them.
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Managers told us the electronic notes system would allow for greater quality and safety because it
could easily identify when patients’ risk assessments were carried out. Managers could identify
when there were gaps in patient assessments, and provide feedback to individual staff when
necessary.
All staff had access to patients’ notes which were written on the electronic system. This led to a
greater understanding of the patient’s condition because all documentation was stored together.
For example, nurses could view the therapists’ assessments and could check if doctors had
completed patient discharge letters, or referred the patient on to other services.
Compliance with record storage and documentation was audited. Documentation was reviewed
and monitored by senior staff. Audits carried out from December 2017 to March 2018, had
considered 25 sets of notes. The audits demonstrated that compliance had improved from 84% to
100%.
Care pathways were mostly completed in line with recommendations. We looked at 10 patient
records and found one patient did not have a fully completed care pathway for nutrition. The aim of
a care pathway is to enhance the quality of care by improving risk-adjusted patient outcomes and
promoting patient safety.
We reviewed 18 DNACPR forms in the inpatient units. A DNACPR form is a document issued and
signed by a doctor, after ensuring the patient can understand its implications, which tells the
medical team not to attempt cardiopulmonary resuscitation if the patient collapses. However, we
found that 10 DNACPR forms had not been completed in line with British Medical Association,
Resuscitation Council (UK) and the Royal College of Nursing, October 2014 guidance. Gaps in
form completion were largely due to a failure to document the decision of an indefinite DNACPR
and a failure to document the consultant review.
On Simpson and St Peters wards, the DNACPR forms were not reviewed following patient
transfers from local acute hospitals. The trust resuscitation policy stated that all documentation
should be reviewed and communicated to staff. Not all copies of the decisions regarding the
DNACPR status of each patient had been recorded in both the paper and electronic notes. During
our inspection we asked staff about patient’s resuscitation status. We were told that several
patients were for resuscitation however, their hospital records showed that DNACPR forms had
been completed. This was escalated to the inpatient ward sisters at the time of our inspection.
DNACPR forms were kept as paper copies in the patient notes and recorded on the electronic
notes system. DNACPR status was not recorded on the handover sheet which meant that some
staff may not have been able to access the information easily, for example agency staff. This may
have resulted in the wrong treatment being given.
There had been four incidents reported from September 2017 to August 2018 which related to
patient records, including one which related to a DNACPR form. There had been no themes
identified from the incidents reported.
Medicines
The service did not always prescribe, give, record or store medicines in line with best
practice. Patients did not always receive the right medication, at the right dose, at the right
time.
During our previous inspection in April 2016 we found there had been some anomalies in
medicines management, particularly at the Hertfordshire and Essex Hospital where there had
been three occasions where the Controlled Drugs (CD) checks had not been recorded. During this
inspection we found medicines management across the inpatient services had got worse.
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Pharmacy services provided to the inpatient units were under service level agreements with the
local NHS providers or with local private pharmacies, depending on unit. At Holywell and Midway
units, medications were supplied on individual prescriptions only, and a pharmacist visited the
units four days per week. At Hertfordshire and Essex hospital, medications were supplied by a
local NHS provider, and a pharmacist visited the units for half a day per week. We were told a
pharmacist visited each unit once per week to check patient prescriptions and ensure patients had
sufficient medication for their hospital stay. Nursing staff told us the pharmacy service were very
responsive and could supply medicines on the same day if required urgently. However, medicines
were generally not available out of hours. Nurses told us they would ring duty managers if a
medicine was required urgently.
Some of the inpatient units only had ‘patient own’ medications. This meant that all the medicines
were stored separately in individual boxes for each patient. Some wards had a limited availability
of stock medicines which could be used when required, for example Simpson ward. However,
there were no stock drugs on Holywell unit or Midway unit. This meant that staff did not have
access to routine medications such as simple analgesia, or laxatives and indigestion remedies.
The service used medication trolleys when carrying out medication rounds. At Hertfordshire and
Essex hospital there were nine medicines found across two trolleys which belonged to patients
who had been discharged between July and September 2018.
Nursing staff at the Hertfordshire and Essex Hospital told us they could administer some
medicines against a patient group direction (PGD). PGDs are written instructions which allow
healthcare professionals who are not prescribers, to supply or administer medicines to defined
groups of patients. This meant they could offer simple analgesia, for example, Paracetamol and
other medicines, to patients without waiting for a doctor to write a prescription. However, there was
no record available to state which staff had received training in PGDs and who was authorised to
administer medicine against the PGD. Staff on Holywell unit told us they did not use PGDs and
were unable to supply and administer simple medications without a written prescription from a
doctor. Staff told us most patients had simple analgesia prescribed as an ‘on request’ medication.
Following our inspection, we requested information from the service on the use of PGDs and we
were told that none of the inpatient units used PGDs.
Medicines used in the inpatient units were mainly stored in locked clinical rooms. On St Peters
ward there was no lock on the clinical room door, however, all medicines within the room were
locked inside cupboards. On Simpson ward, there was a lock on the clinical room door, however
we witnessed the door not being locked, slightly open and accessible to unauthorised people.
Medicines inside this room were not locked away in cupboards. We found Aspirin, Glycerine
Trinitrate, Naloxone, and Diazepam rectal suppositories in a box on the counter top. We
highlighted the open door to staff during our inspection and it was then locked. The medicine room
on Holywell unit was on the ground floor. We noted that the window to this room was large and
fully open. Metal bars were across the window; however, these were quite wide apart which
enabled the room contents to be fully observed. This lack in security was raised with the trust,
who alerted ward managers and pharmacists and added safe storage of medicines to the weekly
inpatient check list.
Medicines were all within their expiry date, except for one bottle of reconstituted antibiotics which
we found in the fridge on Simpson ward. This had been opened on 25 August 2018, with a use by
instruction of seven days from reconstitution. Staff disposed of this medicine during our inspection.
Controlled drugs (CDs) were stored in the medicines cupboard, there was a separate key for this
cupboard which was kept by the nurse in charge. CDs were mostly stored correctly according to
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the Misuse of Drugs (Safe Custody) Regulations 1973 and usage of CDs was recorded in secure
records, checked and administered by two nurses. CDs had been checked daily in line with trust
policy on all units except for Holywell unit where we found they had not been checked on 3 or 17
Sept 2018. We found on Oakmere ward south at Potters Bar hospital, the CD cabinet was made of
wood, which did not comply with the Misuse of Drugs (Safe Custody) Amendment 2007. This was
replaced shortly after our inspection.
Some medications can become less effective if exposed to heat and it is good practice to monitor
the temperature where medicines are stored. Most inpatient units monitored the ambient
temperature in the main drugs rooms daily, except for Hertfordshire and Essex Hospital where
there were frequent omissions, and from 1 to 11 September 2018, there were no temperatures
recorded. Room temperatures were largely within expected ranges across all units.
Temperature sensitive medicines were stored in fridges. However, fridge medicines were not
always stored within the required temperature range. Fridge temperatures had exceeded the
maximum in Holywell unit on 15,16,17, and 18 September 2018 and for 15 days in August 2018.
The only action recorded was to ‘reset’ the temperature.
At Midway unit, fridge temperatures exceeded their recommended range from 3 September 2018
through to 6 September 2018 with no actions logged.
At Hertfordshire and Essex hospital, fridge temperatures were not being monitored at the
weekends and when the housekeeper was away. The maximum fridge temperatures had gone
above 8 degrees on several occasions, however no actions or escalation were recorded. The ward
manager did not know what action had been taken.
After our inspection the trust informed us that processes had been put in place to monitor and
escalate any deviances from recommended temperatures for the storage of medicines.
Emergency medicines were readily available, were stored securely and checked regularly.
However, on Holywell unit we saw that the supply of water for injections in the resuscitation trolley
was in a sachet format and was not in an ampoule. This meant that water for injections, required in
the event of an emergency was not available. We highlighted this as a concern during our
inspection and we were told this would be rectified immediately.
Not all patients received all the medicines they had been prescribed.
We looked at prescription charts at all the sites we inspected as follows.
• Hertfordshire and Essex Hospital:
o We looked at four prescription charts. Not all medicines had been signed for.
Nurses we spoke with said they were unsure if the medicines had been
administered and suggested staff may have given it, but had forgotten to sign to say
they had.
• Danesbury unit:
o We looked at six prescription charts. Three of them had not always been signed to
indicate medicines had been administered. This included one patient with 15
unsigned medications. We highlighted this to the ward manager during our
inspection. Holywell unit:
o We looked at two prescription charts and saw one unsigned medication.
• St Peters unit:
o We looked at two prescription charts and saw one unsigned medication.
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• Simpson ward:
o We looked at three prescription charts and saw two unsigned medications.
• Potters Bar hospital:
o We looked at six prescription charts and found that five had gaps in medicines
administration. The ward sister told us the gaps were due to a shortage of staff on
26 September 2018, when there were only two nurses on duty and no health care
assistants, however we didn’t find an incident report to correspond to this.
Unsigned for medications included antibiotics, analgesics, anti-epileptics, anti-hypertensives, and
deep vein thrombosis prophylactics.
Not all patients received the medicines they had been prescribed in a timely manner. On
Simpson ward the 8am medication drugs round was still ongoing at 10.30am and at the
Hertfordshire and Essex Hospital we saw that one medicine, out of stock from 15 September
2018, had not been ordered until 18 September following our intervention.
Not all patients had been prescribed the correct medicine. At Danesbury unit we saw a
prescription for an antiretroviral medicine which had been prescribed incorrectly (wrong dose).
This had not been noticed for 20 days when it was identified by the pharmacist and corrected.
We also saw a prescription for an antidepressant which had been prescribed at a dose of 150mg,
instead of 30mg. On investigation, we found that this patient was self-administering their
medication, and was in fact taking the correct dose. However, nurses had signed to say 150mg
had been taken each day. We saw a prescription for paracetamol which had been prescribed in
such a way, that if all had been given, the patient would have exceeded the recommended daily
dose. However, a nurse had recognised this error, so it had not been given.
Following our inspection, the trust told us it did not do audits that checked patients had received
the correct medication and at the time in was prescribed, although it had carried out some audits
including controlled drugs management, high-risk medicines, and antibiotics use. The audit gap
had been identified and was raised for discussion, however, due to a lack of pharmacy capacity,
the audits had not been undertaken. After this was raised by us this was added Trust Risk
Register.
Patients’ weights had not been recorded on medication charts which is best practice to ensure
correct doses of medication were prescribed, although they were recorded on the electronic
records system. After our inspection the trust implemented weekly assurance checks to ensure
patients weights were recorded on medication charts on admission and if a new weight was
recorded.
Prescription charts we checked contained details of patients known allergies.
The community hospitals had reported 40 medication incidents from September 2017 to August
2018. Most of these were due to medication errors. There were 13 incidents reported which
related to medication charts – either missing charts, or charts which were confusing due to
transcribing errors, or to duplicate charts. Nursing staff told us it was difficult to get prescriptions
changed or written out of hours.
We observed nursing staff administering medicines in line with the Nursing and Midwifery Council
Standards (NMC) for Medicines Management. Staff ensured they checked the patient identity
confirming the patients name and date of birth verbally, as well as checking their wrist band.
Nurses carrying out the medication round wore a red tabard. This identified them to other staff,
patients and members of the public not to disturb the nurse while they were administering the
127
medication. This is a recognised national approach to improve the effectiveness of a drug round
and reduced incidence of medication errors. However, on Simpson ward the nurse was called to
carry out additional tasks several times during the drug round. This included taking patients to the
bathroom, and assisting with personal hygiene.
Medicines management training was not part of the services mandatory training programme.
Ward managers told us new staff were assessed to ensure they were competent to administer
medications before being allowed to carry out the medication rounds, and that following an error,
extra training and support had been provided.
Incident reporting, learning and improvement
Staff recognised incidents and reported them, but not all incidents where categorised
correctly. It was difficult to ascertain the correct number of each type of incident.
Staff understood their responsibilities regarding reporting incidents. The trust used an electronic
reporting system that all staff had been trained to use. Teams and the organisation learnt from
incidents and there was evidence of clear action planning following reviews.
Managers investigated incidents and shared learning with the whole team and the wider service.
Examples of incidents that were reported included medication errors, pressure ulcer incidents and
falls.
From September 2017 to August 2018 there had been 781 incidents reported across the inpatient
services. We were unable to break the number of incidents down by hospital site. 492 incidents
had been reported as no harm and 268 incidents had been reported as low harm. Five incidents
had resulted in severe harm and 12 had resulted in moderate harm. Most incidents, 223 were
reported due to patient falls.
The type of incident was not consistently recorded. For example, in addition to the 223 patient
falls, recorded under ‘patient falls’ type of incident, there was a further 162 incidents reported as
‘patient accidents’ which were also mostly patient falls. Four incidents were recorded as ‘other’
which were also patient falls. We saw that 31 incidents had been classed as ’infection control’ type
incidents, however there were also 16 instances of patient infection which had been reported
under ‘delay or failure to monitor’. We asked staff about this during our inspection and they told us
categories of falls were often changed by the investigating team. Staff had undergone training to
use the electronic online incident reporting system, however, this did not include training on
categorising incidents. Following our inspection, we requested further information from the trust
about incident categorisation. They told us when an incident is reported staff categorise the
incident according to where the most significant risk lies. The incident is then escalated to the
manager to review the incident and at this point the incident category may be amended if
necessary.
Incidents were discussed at team meetings and we saw evidence of this. Nurses told us about an
incident which involved a patient falling. Changes in practice as a result of the fall included the
introduction of 30 minute observation checks for each patient who had fallen to be carried out for
three days, or longer if there were still concerns about the patient’s safety.
Staff we spoke with understood their responsibilities regarding duty of candour. Ward managers
explained that if any incident caused harm to a patient, a formal letter was issued by the service
and the incident was discussed with the patient and their family. Patients would be advised about
the root cause of any errors and would be provided with copies of the investigation if required.
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Never events
Never events are serious patient safety incidents that should not happen if healthcare providers
follow national guidance on how to prevent them. Each never event type has the potential to cause
serious patient harm or death but neither need have happened for an incident to be a never event.
From August 2017 to July 2018, the trust reported no never events in its community health
inpatient services.
(Source: Strategic Executive Information System (STEIS))
Serious Incidents
Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).
These include never events (serious patient safety incidents that are wholly preventable).
In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents
(SIs) in its community health inpatient services which met the reporting criteria set by NHS
England from August 2017 to July 2018.
There was one SI each of the following types:
• Abuse/alleged abuse of adult patient by staff
• Slips/trips/falls.
(Source: Strategic Executive Information System (STEIS))
Serious Incidents (SIRI) – trust data
From April 2017 to March 2018, trust staff within community health inpatient services reported
five SIs. Note the earlier time period compared to the previous section.
Despite the earlier time period, these include the two SIs reported through STEIS that are listed
in the previous section.
Of these, none involved the unexpected death of a patient.
The breakdown by incident type was as follows:
• Slips/trips/falls: two
• Abuse/alleged abuse of adult patient by staff: one
• Healthcare associated infection/infection control incident: one
• Sub-optimal care of the deteriorating patient: one
The breakdown by site and incident type is detailed below.
Danesbury Home
One “slips/trips/falls”. incident in May 2017 that resulted in hydrocephalus diagnosed post fall.
Hertfordshire and Essex Community Hospital
One “healthcare associated infection/infection control incident” incident in March 2018 when
outbreak of norovirus resulted in some bed closures.
Langley House
One “abuse/alleged abuse of adult patient by staff” in September 2017.
Potters Bar Community Hospital
Two SIs. These was one SI each of the following types:
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• Slips/trips/falls in September 2017 resulting in fractured neck of femur
• Sub-optimal care of the deteriorating patient in June 2017 relating to burns and
management of a category 3 pressure ulcer.
(Source: Universal Routine Provider Information Request (RPIR) – P29 Serious Incidents)
Prevention of Future Death Reports (Remove before publication)
The trust has not had any deaths requiring Coroner's Inquest in the last 12 months for community
health inpatient services.
(Source: Universal Routine Provider Information Request (RPIR) – P76 Prevention of future
death reports)
Safety performance
The service used safety-monitoring results well. Staff collected safety information and
shared it with staff, patients and visitors. The service used information to improve safety.
The senior hospital staff explained the actions they took to minimise the risk of avoidable harm.
They monitored the use of patients’ risk assessments and the use of the NEWS observation charts
and post falls checklists.
Each unit displayed safety information in the public areas using a ‘safety cross’ system. The
information included: the number of falls; the number of pressure ulcers; the number of bed days
lost to diarrhoea and vomiting (D&V); cleanliness audit results; the number of complaints and staff
sickness. For example, on Simpson ward in August 2018, there had been zero days lost to D&V,
zero cases of new pressure ulcers, and zero cases of falls. On Midway unit in August 2018, there
had been two falls, zero acquired pressure ulcers and zero days lost to D&V.
Safety Thermometer
The Safety Thermometer is used to record the prevalence of patient harms and to provide
immediate information and analysis for frontline teams to monitor their performance in delivering
harm free care. Measurement at the frontline is intended to focus attention on patient harms and
their elimination.
Data collection takes place one day each month. A suggested date for data collection is given but
wards can change this. Data must be submitted within 10 days of suggested data collection date.
From June 2017 to June 2018 the trust reported 14 new pressure ulcers, 97 falls with harm and
100 new urinary tract infections in patients with a catheter within all community inpatients wards.
There were peaks in prevalence of both new pressure ulcers and falls with harm in September
2017, while there was a peak in prevalence of new Urinary Tract Infections (UTI’s) in patients with
a catheter in August 2017. There were peaks in prevalence of new UTI’s in patients with a
catheter and new pressure ulcers in February and March 2018 respectively.
130
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter urinary tract infections at Hertfordshire Community NHS Trust – all community inpatients wards
(Source: NHS Safety Thermometer: https://www.safetythermometer.nhs.uk/index.php/classic-
thermometer)
131
Is the service effective?
Evidence-based care and treatment
The service provided care and treatment based on national guidance and evidence of its
effectiveness. Managers checked to make sure staff followed guidance.
Policies were up to date and followed guidance from the National Institute for Health and Care
Excellence (NICE) and other professional associations. Local policies, such as the infection
control policy were written in line with national guidelines. Policies were available on the trust
intranet and clinical staff we spoke with knew how to access them.
Relevant NICE guidelines, quality standards and other good-practice guidance, for example
prevention and management of pressure ulcers and stroke rehabilitation were used. This provided
patients with long-term conditions a clear personalised care pathway and aimed to improve the
rehabilitation for people who have had a stroke. Patients had a personalised treatment plan which
was underpinned by evidence based healthcare. Treatment plans contained realistic patient
reported outcome measures.
Patients were assessed using recognised risk assessment tools. For example, the risk of
developing pressure damage was assessed using the Waterlow Score, a nationally recognised
practice tool. Staff undertook falls risk assessments using the Morse fall score and completed
post-fall check lists following patient falls. Patients’ dependency was measured using the
Northwick Park dependency score, and patients’ balance was assessed using the Berg balance
scale. These assessment measures allowed staff to provide each patient with the right amount of
support and supervision to keep them safe while in hospital.
The service was working towards the11 standards in the National Service Framework for Long
Term Conditions and was currently following NICE Guidance for Parkinson’s Disease and Multiple
sclerosis in the neurological rehabilitation units.
Nutrition and hydration
Staff gave patients enough food and drink to meet their needs and improve their health.
Adjustments were made to take into account patients’ religious, cultural and other
preferences.
Nursing staff completed nutrition and hydration assessments using the Malnutrition Universal
Screening Tool (MUST) on admission, for each patient. Dieticians assessed all patients whose
nutritional needs were highlighted as a risk. Danesbury unit had a full-time dietician based on site
and other units had dieticians who visited daily or when required following a patient referral. Staff
had access to advice from speech and language therapists (SALT) and we saw that the SALT
team worked closely with nurses and other therapy staff to ensure patients received appropriate
food, for example softened diets, to meet their needs.
Patients who required their nutrition through a tube into their stomach (enterally) had their needs
assessed by a dietician. We saw that enteral nutrition was provided for patients on the stroke and
neurological rehabilitation units. Alternative texture meals were available for people with
swallowing difficulties and thickeners were added to drinks for some patients to allow them to drink
fluids safely.
Food and fluids were placed within patients’ reach and those who required assistance with eating
and drinking were identified in the initial care assessment, and provided with red trays at
mealtimes. Fluid balance charts were completed for patients whose hydration was an identified
issue. Hydration was monitored during the two-hourly care rounds and recorded in the patients’
132
records. We looked at food records and found these were mostly completed and up to date. Fluid
balance charts were not always comprehensively completed and that totals at the end of the day
were not normally added up to indicate either a positive or negative fluid balance.
Specific food care plans were available for patients with certain medical conditions, for example,
those undergoing kidney dialysis. We saw that the food charts suggested safe alternative food
types which enabled patients to achieve the right amount of nutrition without compromising their
health.
Pain relief
Patients’ pain was assessed, we saw evidence that analgesia prescribed was administered.
Patients told us that their pain was adequately controlled. They told us that pain relief was offered
and given when it was requested. Pain scores were recorded using a numeric rating scale on the
NEWS record sheet. We saw this was being used correctly. Staff also recorded pain scores on the
electronic notes system.
The Abbey pain scale is a pain assessment tool for patients who cannot express how they are
feeling, for example, patients who have dementia or communication difficulties. Staff we spoke
with were aware of this pain assessment.
Patients were offered analgesia before therapy sessions. This provided patients with pain relief to
enable them to complete their rehabilitation sessions. This meant that they continued their therapy
and increased their long-term mobility.
Patient outcomes
The service monitored its effectiveness of care and treatment and used the findings to
improve them. They compared local results with those of other services to learn from them.
All patients admitted to the service for rehabilitation underwent the Patient Specific Functional
Scale (PSFS). The PSFS is a measure which allows staff to know if is making a difference to each
patient. The PSFS was based on a patient’s self-assessment of their ability on admission, and
then continued self-reassessment on their abilities throughout their hospital stay, to see if set
goals had been achieved. Therapy staff told us these outcomes were not audited and therefore
they were unaware of how effective overall patients’ treatment and rehabilitation had been.
We asked how effectiveness was measured. We were told that patients outcomes were measured
in relation to percentage of days of harm free care, For example percentage of days without a
pressure ulcer or a reduction in falls with harm. We were not provided with the results of these
audits, or of evidence that the service compared its results with other similar providers.
Some monthly data was collected and audited by the service. This included hand hygiene and
cleanliness audits. Each ward manager collected monthly data for their business unit performance
review (BUPR). This reported on quality, workforce, performance and finance. Senior staff told us
the BUPR provided a dashboard of data that was used to identify trends and improve the service
by altering polices or working practices.
The community inpatients service told us they were on target to meet their Commissioning for
Quality and Innovation National targets(CQUIN) for 2017- 2019 in the following areas:
• Personalised Care and Support Planning
• Improving the assessment of wounds
• Preventing ill health by risky behaviours
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• Pro-active and Safe Discharge
• Introduction of health and wellbeing initiatives- Option B
• Improving the Uptake of Flu Vaccinations for Front Line Clinical Staff
• Healthy food for NHS staff, visitors and patients.
Therapy staff told us they encouraged all patients to get out of bed and wear their own clothes
while in the rehabilitation units. They were taking part in promoting the end PJ Paralysis
Campaign, which was a campaign launched by National Health Service Improvement (NHSi) in
Spring 2018.The campaign aimed to improve patient outcomes by getting them out of bed, into
their own clothes, and get moving to boost their recovery. We saw that patients were mostly
dressed in their own clothes and out of bed, except on Simpson and St Peters wards, where most
patients remained in hospital nightwear and were in bed.
Therapy leads told us they used length of patient stay as a measure of their effectiveness, and
that at Danesbury and Holywell units, length of stay had been reduced from 42 days, to 32 days.
Audits – changes to working practices
The trust did not participate in any clinical audits in relation to community health inpatient services
as part of their Clinical Audit Programme.
(Source: Universal Routine Provider Information Request (RPIR) – P35 Audits)
The trust participated in 12 clinical audits in relation to this core service as part of their Clinical
Audit Programme.
Audit name Area covered Key Successes Key actions
National
Parkinson's Audit
NCAPOP Quality
Account Audit
2017/18
Neurological
Service
100% cases
submitted -
minimum of 10
responses for
Speech and
Language Therapy,
Occupational
Therapy and
Physiotherapy.
Full report still to be
issued, so cannot
yet demonstrate
where practice has
been changed.
Report yet to be
presented.
National Sentinel
Stroke National
Audit Programme
(SSNAP) NCAPOP
Quality Account
Audit 2017/18
Community
Hospitals and
all Integrated
Community
Teams
Ongoing data
collection from 1
November 2013 -
data submitted for
737 in 2017/18.
As part of the
Sentinel Stroke
National Audit
Programme
(SSNAP) our Acute
No key actions.
134
Therapy Services
(Occupational
Therapy and
Physiotherapy) at
the Achieving the
rating of ‘A’ puts the
Service in the top
23% out of 215
stroke services
across the country.
SSNAP audit
results [Q3 2017]
(released to the
public in March)
show that
Danesbury have
maintained their `A`
rating and Holywell
have achieved their
first `A` rating.
National COPD
Rehabilitation Audit
NCAPOP Quality
Account Audit
2017/18
Pulmonary
Rehabilitation
Service
Data submitted for
118 eligible
patients’
Organisational
questionnaire
completed.
Full report is to be
presented to
Clinical
Effectiveness
Group in August
2018, so cannot yet
demonstrate where
practice has
changed.
Report yet to be
presented.
ANNUAL NHS
Safety
Thermometer
(Pressure Ulcers,
Falls, Catheters,
Urinary Tract
Infections and
Venous
Thromboembolism)
National. (12)
Community
Hospitals and
all Integrated
Community
Teams
• For the year
2017/18 there has
been a significant
decrease in the
number of
avoidable category
2 pressure ulcers.
• Increased scrutiny
of all avoidable
pressure ulcers has
demonstrated that a
high percentage of
those patients with
• Record all harms
documented are
accurately recorded
as ‘new’ or ‘old’ in
line with Safety
Thermometer
criteria.
• Continue to meet
and discuss actions
at the Pressure
Ulcer/Tissue
Viability Forum to
maintain the focus
135
avoidable pressure
ulcers receive joint
care, either from a
carer at home or in
a residential home.
• Analysis of data
has also highlighted
that the majority of
patients referred
onto HCT’s with an
existing pressure
ulcer are either in
their own home or a
residential home.
on pressure ulcer
prevention.
• Work in
partnership with
Princess Alexandra
Hospital and a
commercial
dressings company,
to deliver a training
programme for
residential home
and home-care
providers to upskill
the local workforce.
• A train-the-trainer
programme will also
be delivered to
managers to
provide
sustainability of
knowledge.
• Employ a staff
member to be
seconded into the
Community
Equipment Service
to support
equipment provision
and training thereby
maintaining close
working
relationships.
• Task and Finish
Project to review
the use of the
Waterlow risk
assessment tool to
evaluate whether it
meets the needs.
An alternative,
PURPOSE T, is
being considered.
• Continue to focus
on the reduction of
pressure ulcers and
the improvement of
wound care
136
management as a
Quality Priority.
National Audit of
Intermediate Care -
NAIC NCAPOP
Quality Account
Audit 2017/18 (4)
Bed Based IC,
home based IC
and re-
enablement
services
Intermediate Care
Teams/Community
inpatient units: 65
questionnaires
submitted
Community ICT
Teams: 52
questionnaires
submitted
• Dependency
levels recorded
were 31% for
homebased, 35%
for bed-based and
36% for re-
ablement services.
• The dependency
levels of people on
admission, and the
improvements
made during their
stay, were similar to
the 2015 results for
home and re-
ablement services.
• Over 96% of
service users
replied ‘yes –
definitely’ to the
question ‘I was
aware of what we
were trying to
achieve’.
• Over 91% of
people felt they had
been treated with
dignity and respect.
Evidenced that we
are treating people
with respect and
kindness.
It is suggested that
the audit content is
reviewed in the light
of the NICE
Guidelines issued in
2017: NICE
guideline, NG74
Intermediate care
including re-
ablement.
• Share results at
the Operational
Senior Management
Team
(OSMT)/Operational
Services at HCT to
identify whether
there is any learning
to be shared
(feedback at CEG
meeting in October
2018 once this work
stream has been
undertaken).
• Work with
Operational Teams
to improve the
Average Length of
Stay in hospital.
Work has been
done with the
CCGs, in particular
Hertfordshire Valley
to address this and
improve practices.
• Work with the
Acute Trusts and
the local CCGs to
improve the winter
pressure planning
and ensure
admission criteria
are being followed.
Falls and Fragility
Fracture Audit
Programme:
Bed Bases • 73% of
Trusts/Community
Hospitals report all
• National report
findings discussed
at the Falls Working
137
National audit of
inpatient falls.
NCAPOP Quality
Account Audit
2017/18 (5)
severe harm
incidents. 92% said
there is an
executive director
who has specific
roles/responsibilities
for leading falls
prevention.
• 97% answered
that the information
on the number of
falls is routinely
presented and
discussed at most
falls prevention
working group
meetings.
• Lying and
standing Blood
Pressure (BP)
results [Q3
2017/18] showed
that 27% of patients
(41/151) had their
lying-standing BP
monitored. Potters
Bar Community
Hospital (63%) and
Langley House
(59%) were the
units where most
patients had been
monitored whilst
Holywell,
Danesbury and
Hertfordshire and
Essex Hospital
were the units
where fewest
patients had been
monitored (all 0%).
This shows how the
majority of falls are
reported, acted on
and learning is
disseminated.
Group (FWG).
• Collaborated with
West Hertfordshire
Hospital Trust, East
and North
Hertfordshire Trust
and Hertfordshire
Partnership
Foundation trust, to
share good practice
and learning –
actioned 8th
December 2017.
• Guidance and
training for the
assessment of lying
and standing BP
Rolled out.
• Inpatient falls
policy aligned with
NICE guidance.
Policy due to be
ratified 25th June
2018 at the Patient
Safety and
Effectiveness
Group.
• Monitor
improvements as
part of quarterly
snapshot audits. (In
progress).
An Audit on the
MUST Score and
Adult
Community
• The MUST Score
was recorded in
• SystmOne used to
ensure that the
138
Use of Oral
Nutritional
Supplements
(ONS) - Re-audit
(14)
Hospitals:
Nutrition &
Dietetics
91% of patient
notes.
• In 86% of cases,
the MUST score
was calculated
correctly.
• In 94% of cases,
the weight had
been calculated.
• The height was
calculated in 64% of
cases, and
estimated only in
30% of cases.
• MUST is being
completed correctly
by ward staff in
86% of patients in
the HCT bed based
units. 21 patients
had a score that
was incorrect. On
two comments
made this was
related to the
incorrect calculation
of the % weight
loss.
Highlighted the
need for further
nurse training to
ensure MUST score
is calculated
correctly.
software used for
MUST calculations
reflects a realistic
time frame to report
% weight loss.
• Patients who are
admitted to an
inpatient unit and
have a MUST score
of less than 2 have
their prescribed
ONS discontinued
and the patient
encouraged to
choose high protein,
high energy option
snacks between
their meals.
• MUST training
(face to face) is
facilitated by the
Dietitians across the
Community
Hospitals to
empower the ward
staff to promote a
food first approach
and is an important
component of
nursing care. MUST
training is available
as e-learning for
staff working on the
wards to be
undertaken at an
agreed time period.
Infection Control
(IPC) (40)
Environment/Safety
Audit - includes
Sharps Safety (I)
Hand Hygiene (ii)
MRSA Screening
(iii) Urinary
Catheter Care (1)
Insertion and (2)
Continuing Care
(iv) Peripheral
Bed Bases
monthly audits:
Integrated
Community
Teams quarterly
audits: Health
Visitors, MIU
(HEH) RAU
(SACH) Dental
service.
All audits reported at the Infection Prevention
and Control Forum.
139
Vascular Catheter
(v) Enteral Feeding
(vi) Commode (vii)
a) Hand Hygiene
Urinary catheter
care insertion and
continuing care.
Vascular devices b)
Hand Hygiene
Environment/safety
audit (and specific
dental service
audits).
Oral Care Audit -
Hyper Acute /
Acute Stroke Lister
(56)
Adult Speech
and Language
Therapy
• 147 oral hygiene
assessments in
total were done
over the two week
period (excluding
refusals or where a
patient was
unwell/unable to
tolerate)
• Of these, 14
dysphagia
assessments were
unable to be carried
out due to poor oral
hygiene
(approximately
10%)
Only 2% (4/147)
assessments were
rated as 'Severe,'
with 70% (103/147)
being rated as 'Mild
Need'.
• Patients have a
documented record
of receiving oral
hygiene received
(prioritising at risk
patients).
• Increased
education of Nurses
and Health Care
Assistant’s (HCA's)
in the East and
North Hertfordshire
Oral Hygiene
Assessment Tool is
required.
• Sponges are
withdrawn – Trial
and pilot of
replacements e.g.
Moutheze (re-
usable) brushes in
the next month.
Community
Hospital Catheter
Passport Audit (80)
Bed Bases • 100% of patients
have a catheter
care pathway in
place
• 68% (13/19) of
patients with an
indwelling catheter
had a catheter
passport
• 61% (11/18) of the
patients had a plan
for discharge in
• Training on the
revised Syringe
Pump Policy
(including the
importance of why
the patient and
family should be
provided with the
patient information
leaflet) – ongoing as
all staff have to
attend an annual
140
place
100% (19/19) of the
patients had a
catheter care
pathway in place
update.
• Training on the
Individualised Care
Plan for the Dying
Patient (to ensure
that staff
understand why this
is used and when to
implement it).
Continual training
now introduced via
several different
training sessions
offered to HCT staff.
• Ensure all new
Band 5 and 6 staff
have palliative care
competencies
(within the
competency
booklet) and signed
off within 3 months
of starting with
HCT. Band 6 and
Band 7 mentors
now review
competency booklet
to provide
assurance of
completion. (Action
complete).
• Report findings at
the CEG meeting in
February 2018.
(Action complete).
• Monitoring via re-
audit by the Clinical
Professional Lead
(Nursing).
Community
Hospital Catheter
Passport Audit (81)
Re-audit
Bed Bases • Over 60% of the
Community
Hospitals wards
had details of the
date and time of
Catheter recorded
for initial insertion.
100% of Wards had
plans in place to
• Ensure details of
insertion completed
in the catheter
passport
• If there was no
discharge plan,
ensure information
is recorded
141
inform the District
Nurse/GP/Care
Agency when the
patient was
discharged.
• Re--audited again
3 months later.
Plus size patients
management audit
(46)
East & North &
Hertfordshire
Valleys (adult
bed bases,
ICTs and clinic-
based services
- leg ulcer,
podiatry,
diabetes,
bladder & bowel
• 90% (18/20) of
staff were aware of
the management of
plus-size patients
policy
• 70% (14/20) were
aware of the risk
assessment tools
for plus size
patients.
• 95% of staff were
aware of how to
report an incident
related to the
moving and
handling of a
patient.
• 90% (18/20) staff
would know how to
report moving and
handling equipment
if it is not fit for
purpose.
• In response to the
question, ‘Are you
aware of how to
access moving and
handling and other
specific equipment
for plus-size
patients?’, 18
responded
positively (90%).
Over 90% of staff
were aware of how
to manage and
handle plus-size
patients effectively,
in accordance with
HCT's management
of plus size patients
policy (2015).
• Re-launch of the
plus size patients
policy following
review with a
requirement for
managers to ensure
that staff are aware
of the content of the
policy, specifically
relating to the risk
assessments,
patient pathway and
processes to be
taken when
accepting plus size
patients on referral.
• There was an
apparent lack of
awareness of which
trust director is the
nominated
responsible person
for risk and health
and safety. This
was addressed
through the re-
launch of the policy
and training.
• All staff who
provide care for
plus size patients
should be aware of
how to order
appropriate
equipment; this is
addressed through
raising awareness
of the policy and
through manual
handling training
sessions.
(Source: Universal Routine Provider Information Request (RPIR) – P35 Audits)
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Competent staff
Staff were sufficiently qualified and had the right qualifications, skills, training and
experience to keep people safe from avoidable harm and abuse and to provide the right
care and treatment. Managers appraised staff’s work performance and held supervision
meetings with them to provide support and monitor the effectiveness of the service.
Role specific training requirements were allocated to staff for example, registered nurses were
expected to complete resuscitation training level 3, and healthcare assistants received
resuscitation level 2; clinical staff received manual handling, people and non-clinical staff received
training manual handling, object.
Managers had oversite of the staff training compliance. The community hospitals provided a list of
competencies that were non-compulsory. Staff we spoke with said they had completed extra
training sessions to provide evidence of ongoing professional development. For example,
continence and male and female catheterisation.
Some senior nursing staff had attended, or were currently attending leadership and management
training programmes. Managers told us the course had helped them to develop their leadership
skills and to carry out the necessary tasks needed to manage a community inpatient ward. This
included sessions such as difficult conversations with staff, return to work interviews and appraisal
training. Band six nurses were encouraged to attend training workshops specific for their role,
including staff appraisals. Band five staff nurses attended mentorship training so that they could
train nursing students while they were on their practical placement from university.
Therapy staff we spoke with said that the trust supported them in the learning beyond their
registration. This allowed the therapy teams to access both inhouse and external training updates
and conferences. Some therapy staff had completed masters training, for example in stroke
patient rehabilitation.
Clinical Supervision
Nurses told us clinical supervision was available if required. Clinical supervision is an activity that
brings skilled supervisors and practitioners together to reflect upon their practice. At Holywell unit,
we saw a poster with dates listed for the forthcoming clinical supervision sessions for therapy staff.
The trust provided the following information about their clinical supervision process:
Supervision is delivered in line with the clinical supervision framework policy; supervision
happened in groups - action learning sets; individual supervision and informal support to enable
staff to reflect on their practice. There was no formal prescription of either frequency or percentage
compliance.
Supervision was managed and monitored, however, there was a variation in the robustness of
processes and recording. Data from 2017 identified gaps where supervision did not happen or was
incorrectly recorded.
Further work was being undertaken in the trust to enable improved access to supervision,
including development of formal groups within services by the locality quality leads and more
robust monitoring systems.
(Source: CHS Routine Provider Information Request (RPIR) – CHS4 Clinical Supervision)
Appraisal rates
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From April 2017 to March 2018, 92.3% of staff within the community health inpatient services had
received an appraisal compared to the trust target of 90%.
(Source: Universal Routine Provider Information Request (RPIR) – P39 Appraisals)
During our inspection in April 2016, we found most staff had received an appraisal in the previous
12 months, except at Langley House and Hertfordshire and Essex Hospital where the rate was
78%, against the trust target of 90%. During this inspection we found appraisal rates across the
inpatient units were 92%. We were not provided with a breakdown of appraisal rates at each site.
At Simpson ward, the manager told us their appraisal rate was 99%.
The trust’s appraisal policy stated that all staff were required to have an annual appraisal. Staff we
spoke with told us their appraisal had been useful, and that they had been given agreed objectives
for the following year.
Multidisciplinary working and coordinated care pathways
Most staff of different disciplines worked together as a team to benefit patients. Doctors,
nurses and other healthcare professionals supported each other to provide good care.
Relevant professionals were involved in the assessment, planning and delivery of patient care. We
observed good working relationships between a range of health professionals within the service.
Members of the multidisciplinary team (MDT) had access to each other’s notes and assessments.
We observed good working relationships between staffing groups and comprehensive MDT
working practices. We observed a close working relationship between the allied health and nursing
leads. The staff included nursing staff, rehabilitation assistants, occupational therapists,
physiotherapists, and doctors. Updates regarding specific patients were shared, specific patient
care needs were discussed and any relevant incident learning was shared during ward handovers.
Some staff in different units told us that nurses and therapists did not always work together for the
benefit of patients. A physiotherapist told us they believed it was not their job to assist patients to
the bathroom during or after their therapy session. A nurse told us that not all therapy staff were
willing to help with basic patient care when nurse staffing was short. A therapist told us that some
nurses failed to carry out their therapy recommendations for each patient on a weekend.
Therapy leads told us they were providing training for nursing staff to increase their confidence
provide weekend therapy. Therapy assistants were also being developed to assist with some
health care assistant roles.
We observed the consultant ward round at Simpson ward. There was positive interaction between
the doctor, patient and nursing staff. There was a communication book to ensure doctors reviewed
relevant patients, received results from investigations and updated medication charts. Nursing
staff escorted the doctor when they visited patients and care was planned and agreed
There were weekly multidisciplinary team (MDT) meetings involving all disciplines of staff at the
inpatient units. We observed an MDT meeting at Holywell unit and found it was well attended and
carried out to the benefit of patients using the service. Medical, therapy and nursing staff were
joined by social workers and unit managers. The goal of the MDT meeting was to promote the
patient’s care sufficiently so they could be discharged from the unit as soon as safely possible.
There was an emphasis on maintenance at home and admission avoidance strategies.
Documented discussions were held around patient’s care needs.
Health promotion
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Patients and their relatives were supported to manage their own health and well-being, and to
maximise their independence wherever possible.
We saw a wide range of health promotion material available to patients during our inspection.
Posters were displayed throughout the units which promoted healthy living, including, for example,
dietary advice, exercise advice, alcohol and smoking advice.
The units provided a range of health information leaflets for patients and relatives, including
dementia information, pressure ulcer and falls prevention.
Notice boards contained contact details for support services, including for dementia support
service, stroke community groups, as well as details of care agencies and where to obtain advice
about welfare benefits and financial assistance.
The smoking status of patients was recorded in the service’s electronica data system and in April
2018, 95% of all patients had a smoking status documented in their care records.
In December 2017 the trust rolled out, ‘my health plan’ which specifically helped to support
patients to identify their own personal health goals. Alongside this, 90% of patient facing staff
received training in how to have conversations with patients that promoted self-care.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the
Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health
and those who lacked the capacity to make decisions about their care. However, policy and
best practice was not always followed when a patient lacked capacity to make their own
decisions.
Staff understood their roles and responsibilities regarding the Mental Capacity Act 2005. Staff we
spoke with described the process they would follow should someone be found to not have mental
capacity to agree to treatment or be able to make decisions in relation to their care.
Nursing and therapy staff understood the trust’s process for completing the necessary
assessments and referrals when they suspected a patient might be experiencing mental ill health.
Nursing staff told us the assessments were undertaken by two staff together, and usually involved
a band six nurse or above and a therapist or social worker.
Staff could demonstrate where to access guidance on the Deprivation of Liberty Safeguards policy
(DoLS) and Mental Capacity Act (MCA) using the trust’s electronic database. DoLS is the
procedure prescribed in law when it is necessary to deprive the liberty of a resident or patient who
lacks capacity to consent to their care and treatment to keep them protected from harm.
Staff demonstrated an understanding of fluctuating capacity and ensuring patients were in the best
environment to enable them to make informed decisions about their care. We were shown the
assessments which had been carried out on a patient in Danesbury unit and saw that they
followed guidance. Ward managers explained that they would apply for a DoLS if there was a
confused patient who needed to be kept on the unit for their own safety. We saw a patient under a
DoLS who was nursed with one to one support.
Some patients with a DNACPR form were deemed to have lacked capacity. However, there was
no evidence of a documented MCA assessment being carried out in the patient’s notes. Mental
capacity assessment guidance recommends that where long-term or significant decisions are
made in relation to a person who may lack capacity, professional staff must keep a record of how
capacity was assessed and of how any decisions about that person have been made. Out of the
eighteen DNACPR forms reviewed, nine patients were deemed to be lacking in capacity. Out of
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the nine patient records, no MCA forms were documented in either paper or electronic records.
This was escalated at the time of our inspection.
Mental Capacity Act and Deprivation of Liberty training completion
The trust did not separate their mandatory training data by staff group. Therefore, the data below
includes nursing and midwifery staff, medical and dental staff, allied healthcare professionals and
healthcare assistants/infrastructure support staff in community inpatient services.
The trust did not provide completion rates for Mental Capacity Act (MCA) level 1 training.
The trust set a target of 90% for completion of MCA level 2 and Deprivation of Liberty Safeguards
training.
From April 2017 to March 2018 the trust reported that MCA training had been completed by 98.6%
of staff within community health inpatient services.
Deprivation of Liberty Safeguards (DoLS) training had been completed by 98.7% of staff.
Trust level
A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in
community health inpatient services is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Deprivation of Liberty Safeguards 147 149 98.7% 90% Yes
Mental Capacity Act level 2 276 280 98.6% 90% Yes
The 90% target was met for both courses for staff in community health inpatient services.
The trust supplied updated MCA and DoLS training data as of August 2018. By that date the trust
had a single level of MCA training. The breakdown of compliance for MCA and DoLS courses for
staff across community inpatient services as of August 2018 is shown in the table below.
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Deprivation of Liberty Safeguards 130 138 94.2% 90% Yes
Mental Capacity Act 258 265 97.4% 90% Yes
Again the 90% target was met for both courses for staff in community health inpatient services.
Danesbury Home
A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in
community health inpatient services at Danesbury Home is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Deprivation of Liberty Safeguards 24 24 100.0% 90% Yes
Mental Capacity Act level 2 41 41 100.0% 90% Yes
The 90% target was met for both courses for staff in community health inpatient services at
Danesbury Home.
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Hemel Hempstead General Hospital
A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in
community health inpatient services at Hemel Hempstead General Hospital is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Deprivation of Liberty Safeguards 26 26 100.0% 90% Yes
Mental Capacity Act level 2 48 52 92.3% 90% Yes
The 90% target was met for both courses for staff in community health inpatient services at Hemel
Hempstead General Hospital.
Hertfordshire and Essex Hospital
A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in
community health inpatient services at Hertfordshire and Essex Hospital is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Mental Capacity Act level 2 39 39 100.0% 90% Yes
Deprivation of Liberty Safeguards 18 19 94.7% 90% Yes
The 90% target was met for both courses for staff in community health inpatient services at
Hertfordshire and Essex Hospital.
Langley House
A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in
community health inpatient services at Langley House is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Mental Capacity Act level 2 74 74 100.0% 90% Yes
Deprivation of Liberty Safeguards 38 39 97.4% 90% Yes
The 90% target was met for both courses for staff in community health inpatient services at
Langley House.
Potters Bar Community Hospital
A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in
community health inpatient services at Potters Bar Community Hospital is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Deprivation of Liberty Safeguards 22 22 100.0% 90% Yes
Mental Capacity Act level 2 38 38 100.0% 90% Yes
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The 90% target was met for both courses for staff in community health inpatient services at
Potters Bar Community Hospital.
Queen Victoria Memorial Hospital
A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in
community health inpatient services at Queen Victoria Memorial Hospital is shown below:
Name of course
Number of
staff
trained
Number
of eligible
staff
Completion
rate
Trust
Target
Met
(Yes/No)
Deprivation of Liberty Safeguards 19 19 100.0% 90% Yes
Mental Capacity Act level 2 36 36 100.0% 90% Yes
The 90% target was met for both courses for staff in community health inpatient services at Queen
Victoria Memorial Hospital.
(Source: Universal Routine Provider Information Request - P38 Training)
Deprivation of Liberty Safeguards
From April 2017 to March 2018 the trust reported that 114 Deprivation of Liberty Safeguard
(DoLS) applications were made to the local authority for community health inpatient services.
Three applications were approved and three had direct notifications sent to CQC.
(Source: Universal Routine Provider Information Request (RPIR) – P13 DoLS)
Routine patient consent was not always documented. For example, nurses wrote in patient care
records that they had assisted the patient with a wash, but did not write that they had obtained
consent first. Nurses told us they always asked the patient before carrying out any procedure,
including assisting a patient with a wash. Therapy staff often documented that they had received
consent to carry out their therapy.
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Is the service caring?
Compassionate care
Staff continually cared for patients with compassion. Feedback from all patients confirmed
that staff treated them well and with kindness.
Staff interacted with patients and relatives in a respectful and considerate manner. They respected
patients’ privacy and dignity. Staff knocked on doors before entering rooms and ensured care and
treatment was provided behind curtains or closed doors. We observed all staff speaking with
patients in a kind, compassionate and sensitive way in a variety of situations.
We spoke with eight patients and three relatives across the community inpatient units. Patients
and relatives, we spoke with told us staff were kind and caring and that they had received care
they were happy with.
Patients praised the work of staff looking after them including nurses, therapists, cleaners and the
domestic staff who provided patient’s meals and hot drinks.
We saw many positive examples of nursing staff and patient interaction, for example, we heard
staff talking about shared hobbies and interests, including pets and gardening.
Patients told us they felt listened to by staff and that they were given choices about their care.
Patients told us they had been treated with dignity and respect. For example, staff knocked on
bathroom doors before entering, and asked patients if they needed assistance with dressing.
We observed examples of allied health professionals and patient interactions, for example,
physiotherapy staff actively engaging patients to achieve their goals. We saw a patient who was
having difficulty standing up from a seated position in a chair. We heard the physiotherapist
providing encouragement which slowly resulted in the patient standing safely.
Two patients told us staff sometimes took a long time to respond to their call bells. However, both
said this had been mainly at night. One patient said they had waited over half an hour to go to the
bathroom.
Danesbury unit used a therapy dog one day per week. Staff told us this was a huge benefit to their
patients. Staff understood the benefit patients received from being close to or touch the therapy
dog.
All the units we visited provided single sex accommodation. This was either in single or double
rooms or in bays of four to six patients. Bays were spacious, with curtains between each bed
space to enable privacy and dignity.
Some units had day rooms which allowed patients to watch TV or play games together. Families
could visit patients any time during the day or evening, except during protected mealtimes and told
us staff always made them feel welcome.
PLACE - data in relation to privacy, dignity and wellbeing
PLACE self-assessments are undertaken by teams of NHS and private/independent health care
providers, and include at least 50 per cent members of the public (known as patient assessors).
They focus on the environment in which care is provided, as well as supporting non-clinical
services such as cleanliness, food, hydration, the extent to which the provision of care with privacy
and dignity is supported and whether the premises are equipped to meet the needs of people with
dementia against a specified range of criteria.
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The 2018 PLACE score for privacy, dignity and wellbeing at the trust was 85%. This was slightly
better than the England average for NHS community services of 83.5%.
Although the trust achieved scores better than the England average overall, Hemel Hempstead
Hospital’s score of 65.7% was worse than the England average. All other trust locations scored
better than the England average.
Site Name Privacy, dignity and wellbeing score 2018
(%)
Danesbury 91.2%
Hemel Hempstead Hospital 65.7%
Hertfordshire and Essex Hospital 83.9%
Holywell at Langley House 86.8%
Langley House 88.3%
Potters Bar Community Hospital 89.7%
Queen Victoria Memorial Hospital 88.2%
Trust 85.0%
England average (NHS community) 83.5%
(Source: NHS Digital)
Emotional support
Staff provided emotional support to patients to minimise their distress.
We observed that staff constantly provided emotional support to patients when they displayed
anxiety during their rehabilitation activities. Therapy staff actively provided emotional support to
patients to help them achieve their individual care goals. We saw therapists talking with patients
before their therapy sessions, asking them how they were feeling and if they needed any pain
relief.
Staff actively listened to their patient’s wishes. For example, we heard a patient asking the nurse
to come back later to assist with their morning wash, as they were too tired at that time. Individual
preferences and needs were reflected in how patient care was delivered.
The inpatient units did not have a carers’ overnight room where they could be accommodated
while visiting inpatients. However, they did provide the names and addresses for local
accommodation where rooms could be booked when required.
There were arrangements that supported the emotional and spiritual needs of patients. Patients
and their relatives had access to religious services and chaplains. Patients from all faiths were
accommodated.
Counselling services within the community hospitals were available by a referral system. NICE
clinical guidance (CG 162) suggests that a stepped approach to psychological care is
recommended for rehabilitation patients. This meant that extra provision was in place to consider
patients’ emotional needs and the management of depression.
We observed staff caring for a patient living with dementia who became distressed. They
displayed appropriate and calming behaviour to the patient to ease their distress.
Understanding and involvement of patients and those close to them
Staff involved patients and those close to them in decisions about their care and treatment
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Patients and relatives told us, and we saw, that nursing staff kept patients fully informed about
their treatment and they felt included in the decisions about their care. We saw evidence in patient
records and observed staff involving patients in shared decision making.
Staff communicated with patients so that they understood their care, treatment and condition. We
saw staff explaining a treatment process to a patient. Staff recognised when people who used
services needed additional support to help them understand and be involved in their care and
treatment and enable them to access this. We observed staff speaking to patients so they
understood their treatment options.
The inpatient ward teams ensured that all patients and relatives felt they could contribute to
individualised care pathways. This encouraged patients and relatives to understand and manage
the care requirements needed to maintain independence. We saw a specific care plan for a patient
who could become very angry because of their illness. The care plan addressed the specific
concerns of the patient to enable their care needs to be met, as well as keeping staff safe. For
example, the care plan advised staff not to try and touch the patient while they displayed signs of
anger, as this was likely to upset them further. The care plan had been written with assistance
from the patient’s family.
Patient feedback notice boards were present on the inpatient units. We saw cards from both
patients and relatives who expressed thanks for the support the service had provided to them and
their loved ones.
Staff demonstrated understanding of different communication needs. We saw that communication
aids such as picture books, writing pads, language interpreters and sign language interpreters
were available to support patients during care.
Is the service responsive?
Planning and delivering services which meet people’s needs
The trust planned and provided services in a way that met the needs of local people.
The inpatient services reflected the needs of the local population and ensured continuity of care.
The service worked closely with the acute NHS trusts, local authorities, social workers and
commissioners to meet the needs of patients in the area, particularly those with complex needs,
long-term conditions and life-limiting conditions.
The design, maintenance and use of facilities and premises were appropriate. Patient areas were
mostly at ground level with easy access for people with wheelchairs or walking aids. Lifts were
available where required. Parking, including disabled parking spaces was available. There was
signage throughout the units which allowed people, including those with a cognitive impairment, to
navigate their way around with ease.
Information boards were provided for each of the community inpatient units. This displayed
guidance on visiting times, mealtimes, telephone numbers and displayed pictures of staff uniforms
so patients and relatives knew healthcare professionals’ nursing grades. All staff wore name
badges to help visitors and patients clearly identify who they were talking with. Some units had
pictures of each individual member of staff alongside their name and job role.
The inpatient units were open to visitors for most of the day. The wards had protected mealtimes
to ensure patients could eat their meals without interruption, however family members were
encouraged to attend at lunchtime if the patient required assistance with eating so that they could
provide support.
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The different requirements of the local people were understood as planning, design and delivery of
services were done with this in mind. Services were planned in a way which ensured flexibility and
choice. For example, patients discharged from acute hospitals were placed in units as close to
their own homes and families whenever possible. This increased the likelihood that friends and
relatives would visit the patient more often.
The service responded to patient feedback. We saw the inpatient units had, ‘you said we did’
notice boards. At Holywell unit, patients had requested that their nails were cut. Following this,
staff had training on cutting patient nails and were carrying this out when required.
Danesbury unit had had self-contained rooms which had been set up like a home, including
separate living and sleeping areas and a kitchen where patients could prepare their own food.
These rooms were used for patients living with long term neurological conditions and supported
patients in their rehabilitation and a return to independent living where possible.
Patients had access to drinks and snacks at any time of the day. Some units had large
kitchen/dining rooms available for patients and relatives to make hot drinks. A hairdresser was
available on some of the units regularly, and we saw this during our inspection on St Peters ward.
Patients were provided with a wide range of information on discharge including details of their
continued care and treatment, health promotion and a contact number to call if they experience
any problems or required advice.
Ward moves
The trust was asked to detail ward moves for a non-clinical reason during the last 12 months. For
example, if a patient had to move wards several times because there was no room in the speciality
ward they should have been on.
From April 2017 to March 2018, 2,049 individuals (98.3%) in community health inpatient services
did not move wards during their admission, and 36 individuals (9.2%) moved once or more.
A breakdown by ward/unit is shown below:
Potters Bar Hospital – Oakmere ward
Number of ward moves Number of patients % share of all patients
0 360 98%
1 5 1%
2 1 0%
3 0 0%
4+ 0 0%
Total 366 100%
Langley House – Midway ward
Number of ward moves Number of patients % share of all patients
0 292 98%
1 6 2%
2 0 0%
3 0 0%
4+ 0 0%
Total 298 100%
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Langley House – Holywell ward
Number of ward moves Number of patients % share of all patients
0 166 99%
1 1 1%
2 0 0%
3 0 0%
4+ 0 0%
Total 167 100%
Hemel Hempstead General Hospital – St Peters ward
Number of ward moves Number of patients % share of all patients
0 196 96%
1 8 4%
2 0 0%
3 0 0%
4+ 0 0%
Total 204 100%
Hemel Hempstead General Hospital – Simpson ward
Number of ward moves Number of patients % share of all patients
0 143 94%
1 9 6%
2 0 0%
3 0 0%
4+ 0 0%
Total 152 100%
Danesbury ward
Number of ward moves Number of patients % share of all patients
0 167 99%
1 1 1%
2 0 0%
3 0 0%
4+ 0 0%
Total 168 100%
Queen Victoria Memorial Hospital
Number of ward moves Number of patients % share of all patients
0 412 99%
1 3 1%
2 0 0%
3 0 0%
4+ 0 0%
Total 415 100%
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Hertfordshire and Essex – Oxford and Cambridge Wards
Number of ward moves Number of patients % share of all patients
0 313 99%
1 2 1%
2 0 0%
3 0 0%
4+ 0 0%
Total 315 100%
The trust has stated that the above data represents non-clinical and clinical related moves of
patients within the adult HCT bed base. Non-clinical related moves were mainly due to patient
choice with patients and families preferring their care to be delivered within the locality that they
live. HCT tried to accommodate this.
Clinical reasons for moves can be due to patients needing to be observed closely due to
mental/physical deterioration, and this not being able to be provided on their current ward.
The data shows moves were minimal across all units. Simpson ward had the highest number of
moves due to the type of patients accepted onto this ward. This ward is predominately continuing
healthcare (CHC) assessment and other patients who required complex discharge planning from a
local acute trust. These patients often were admitted to Simpson ward in the first instance, then
transferred to one of the rehabilitation wards/units for further treatment.
The Hertfordshire community bed bureau is a central access hub for all community hospital bed
based units. There are well established triage processes to ensure that patients are placed into
community hospital settings appropriate to their clinical needs to minimise the need for future
transfers. The bed bureau team had an understanding of the differences between the units which
included their location, layout and clinical competencies of the staff.
(Source: Universal Routine Provider Information Request (RPIR) Universal P43 – Ward moves)
Moves at night
The trust was asked to list ward moves between 10pm and 8am for each core service for the most
recent 12 months
From April 2017 to March 2018, the trust reported that transfers were planned. It was not expected
that moves will be undertaken between 10pm and 8am. Data that the trust provided showed that
there had been only one night move in 12 months. This was in February 2018 at Hemel
Hempstead General Hospital in St Peters ward.
(Source: Universal Routine Provider Information Request (RPIR) Universal P44 – Moves at night)
Mixed sex breaches
Mixed sex breaches are defined by CQC and the NHS Confederation as members of the opposite
sex having to share accommodation. Whilst these are specifically for mental health providers the
same definitions apply to community and acute providers. Included in the definition is the need to
provide gender sensitive care, which promotes privacy and dignity, applicable to all ages, and
includes children’s and adolescent units. This means that boys and girls should not share
bedrooms, bed bays or toilets and washing facilities. An exception to this might be in the event of
a family admission on a children’s unit, in which case brothers and sisters may, if appropriate,
share bedrooms, bathrooms or shower and toilets.
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The trust reported that there have been no mixed sex breaches in any of Hertfordshire Community
Trust adult inpatient units at any time night or day since 2015.
(Source: Universal Routine Provider Information Request (RPIR) P47 –Mixed sex)
Meeting the needs of people in vulnerable circumstances
The service took account of patients’ individual needs. Patients were assessed on
admission to identify any additional support needs.
Services were planned to take account of the needs of different people, for example, on the
grounds of age, disability, gender and race. Staff could access interpreting services for patients
who did not speak or understand English. Patient information leaflets were readily available,
including information on how to raise a concern or complaint, and could be translated into
languages other than English as required. Access to the wards was sensitive to the needs of those
patients living with a disability.
We saw reasonable adjustments were made to consider the needs of different people on the
grounds of religion, disability, gender, or preference. Patients living with a learning disability or
other cognitive impairment were flagged on the electronic patient record system and an, ‘all about
me’ booklet was used to identify their individual needs. This ensured that staff were aware of any
adjustments that might be required.
Patients living with dementia were not routinely visible flagged by different coloured wristbands or
a symbol in their bed space. For example, by using a recognised scheme, such as the Butterfly
Scheme. Flagging systems allow all staff to instantly recognise patients who may require extra
assistance. Nurses told us there was a symbol added electronically to the notes of patients living
with dementia. The trust has a process for recognising dementia. Each patient has a ‘this is me
document’ that helps staff understand individual patient needs and preferences. It also helps staff
to easily identify a patient with dementia as the document is placed in the patient’s paper file and
recorded on system one. Nursing and therapy staff had a good understanding of managing and
helping patients living with dementia and patients with delirium. There was a specialist dementia
nurse available, and staff had access to dementia link nurses for advice and support.
The trust’s overall 2018 PLACE scores for being disability and dementia-friendly were both slightly
better than the England average. However, the dementia friendly scores at Danesbury Home,
Hemel Hempstead Community Hospital and Potters Bar Community Hospital were all lower
(worse) than the England average. The service told us that ongoing action plans in place had
resulted in some improvements.
Patients had access to therapy rooms and gym areas. Therapy sessions included physical
exercise, relaxation therapy, breakfast clubs and craft sessions. This provided holistic care to
Site name Dementia friendly
PLACE score % Disability PLACE score %
Danesbury Home 65 82
Hemel Hempstead Hospital 70 84
Hertfordshire and Essex Hospital 86 88
Holywell at Langley House 92 95
Langley House 91 94
Trust average 82 88
UK average 80 86
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patients helping them achieve maximum independence in daily living activities and improving their
wellbeing.
Dayrooms were available on most units and this made it easier for patients to socialise together.
Some therapy sessions were carried out in groups and this increased opportunities for patients to
mix with others.
Social workers attended the wards regularly for multidisciplinary meetings and assisted patients to
make informed decisions. Nurses told us that the social work team worked closely with them to
ensure that patients had access to the required support for their physical and psychological needs.
Transport services were available externally for service users with mobility problems. The booking
team provided patients with contact details of an external transport organisation when required.
Where delays in transport were encountered staff would record this as an incident and share
learning.
There was a range of patient information leaflets in all the inpatient units, including advice on
diabetes, stroke, dementia, meningitis, smoking cessation and mental health and wellbeing. We
also saw leaflets clearly displayed which informed patients and visitors on the processes to report
compliments, concerns and complaints.
Access to the right care at the right time
Although arrangements to admit, treat and discharge patients were in line with good
practice, people could not always access the service when they needed it.
The service was trying to improve access for patients. There was a centralised bed bureau which
showed where the available inpatient unit beds were. This was updated daily and enabled staff to
offer beds nearest to the patients preferred location whenever possible. It also ensured beds did
not remain empty when there was a patient waiting to be admitted. Clinical leads were regularly
attending units to join daily sweeps, looking at individual patient pathways. Where required, a local
‘situation report’ was used to determine the bed position in individual services. There were daily
assurance calls by senior managers with each unit manager in which any delays were discussed
and escalated. In addition, the trust performance team had produced an improvement plan, which
all therapy leads and ward managers were aware of, and understood their individual areas of
responsibility.
The service declared its bed escalation status twice per day and had an adult bed capacity
escalation plan which categorised bed pressures based on Operational Pressures Escalation
Levels 1- 4 (OPEL). For example, OPEL 1 was business as usual; OPEL 3 meant the ability of the
hospital to provide all agreed services was compromised.
The multidisciplinary team at each of the services’ inpatient units held ‘red to green’ meetings
every morning to improve patient flow. The use of ‘red and green bed days’ are recommended by
NHS Improvement as a visual management system to assist in the identification of wasted time in
a patient’s hospital stay. A green day is a day when everything planned, gets done, and a red day
is for example, when a planned investigation or assessment, does not occur. The aim is to reduce
internal and external delays as part of the SAFER patient flow bundle which the community
hospitals had implemented.
There was an action plan in place to reduce delayed transfers of care and to get patients home
sooner. The action plan included the use of red to green days and daily assurance calls. The
action plan had been circulated to ward managers along with a short video demonstrating effective
red to green day board rounds. Ward managers and therapy staff were actively involved in
promoting red to green days.
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Records were updated daily to provide effective discharge planning. The electronic record system
had a discharge planning tab which was updated by the MDT teams. On admission, targets for
discharge planning were allocated: patients admitted for rehabilitation were targeted with specific
timeframes for discharge, depending on specific pathways. For example, patients admitted to
Danesbury unit were given 42 days for rehabilitation, and patients admitted for general
rehabilitation at Hertfordshire and Essex Hospital were targeted with 19 days.
Nurses and doctors told us some patients were transferred into their service that did not meet their
admission criteria regarding their rehabilitation suitability. We were told some patients were too
unwell to be rehabilitated within the given timeframes, and that local commissioning teams
sometimes insisted the service accept patients to remove them from the acute hospital trusts. We
asked how many inappropriate transfers they had received and we were told that this information
was not recorded. However, we saw that from June to September 2018, 18% of all discharges
(121 patients) were discharges to an acute trust.
The service was actively trying to reduce inappropriate admissions through an ‘in-reach’ team.
This was a team of experienced nurses and therapists who went into the acute hospitals and
reviewed prospective patients before they were discharged. Patients suitability and requirements
for rehabilitation were assessed by the team. The in-reach team knew the admissions criteria for
each of the inpatient units, aiming to improve appropriate admissions.
The service was actively trying to get patients home sooner, and had an established ‘discharge to
access’ service. This involved discharging patients home sooner, so they could be assessed by
therapy teams in their home environment and supported for a few days at home by community
staff.
Inpatient unit nursing staff told us they had waiting lists for admission, and that waiting times
varied from a few days to several weeks. We were not provided with average length of delays
during the inspection, however after the inspection the trust confirmed that the current length of
wait for admission was three days for St Peters, Langley House and Holywell units. Hertfordshire
and Essex and Danesbury units had zero days wait for admission at the time of the inspection.
The trust told us that patients waiting from acute trusts remain in patients with clinical responsibility
remaining with the acute trust until a bed becomes available in the community. Priority is given to
patients who are deemed to be ‘prevention of admission’ to acute trust, for example, patients
being admitted from their own home. These patients continue to be assessed and managed by
community teams until the bed becomes available.
Weekly conference calls were undertaken to review all new referrals into the service and to
discuss any clinical risk to the patient as a result of any admission delays. Managers and quality
leads looked at the reason for any delays, for example staffing capacity and incorrect triage at
referral. However, despite several measures to improve the flow of patients through the hospital,
some units still reported a high number of patients experiencing delays to their discharge. This
included for example, from April 2017 to March 2018, 47% of patients on St Peters ward and 43%
of patients on Simpson ward had delayed discharges. Overall, 2085 patients, or 36% of all
patients leaving the inpatients services experienced a delayed discharge.
Accessibility
Bed occupancy
The breakdown of average bed occupancy levels from April 2017 to March 2018 by site for
community health inpatient services below:
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Site Average bed occupancy
St Peter’s ward, Hemel Hempstead General Hospital 97.3%
Simpson ward, Hemel Hempstead General Hospital* 96.1%
Holywell neurological rehabilitation unit, Langley House 95.0%
Inpatient unit, Langley House 94.7%
Danesbury Home 94.1%
Potters Bar Community Hospital 93.8%
Hertfordshire and Essex Hospital 89.9%
Queen Victoria Memorial Hospital 88.0%
*Opened in October 2017. Therefore, data are for October 2017 to March 2018 (eight months)
only.
(Source: Community Routine Provider Information Request (RPIR) Community CHS7 – Bed
occupancy & LOS)
Average length of stay data
The breakdown of average length of stay by the site for community health inpatient services for
the period from June 2017 to May 2018 is shown below:
Site Average length of stay
Danesbury Home 33.0
Hemel Hempstead Hospital 52.5
Hertfordshire and Essex Hospital 29.5
Holywell neurological rehabilitation unit, Langley House 36.1
Langley House inpatient unit 37.2
Potters Bar Community Hospital 28.2
Queen Victoria Memorial Hospital 16.6
St Albans City Hospital 27.0
Invalid site code 28.8
Overall 28.6
(Source: Hospital episode statistics)
Referrals
The trust did not identify any community health inpatient services as measured on ‘referral to initial
assessment’ and ‘assessment to treatment’.
(Source: CHS Routine Provider Information Request – CHS10 Referrals)
Delayed discharges
Langton and Sopwell wards, which closed in April and July 2017 respectively, are excluded from
the charts below. To aid comprehension the trust reporting units have been spread over three
charts. Data are only available for Simpson Ward from August 2017. The trust note that this ward
was transferred to this trust from another in October 2017.
From April 2017 to March 2018, there were 2,085 delayed discharged in community health
inpatient services. This amounts to 36.0% of the total discharges.
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Delayed discharge trends from April 2017 to March 2018, Hertfordshire Community NHS
Trust
159
Delayed discharge trends from April 2017 to March 2018, Hertfordshire Community NHS
Trust
A breakdown of delayed discharges by reporting unit for community health inpatient services is
shown below:
Ward Total
Discharges
Total Delayed
Discharges
% Delayed
Discharges
St Peters ward 204 95 46.6%
Inpatient unit, Langley House 298 129 43.3%
Simpson ward 152 65 42.8%
Queen Victoria Memorial Hospital 415 155 37.3%
Potters Bar Community Hospital 366 129 35.2%
Holywell neurological rehabilitation
inpatient unit, Langley House
167 52 31.1%
Hertfordshire and Essex Hospital 315 96 30.5%
Danesbury Home 168 29 17.3%
Total 2,085 750 36.0%
(Source: Universal Routine Provider Information Request (RPIR) Universal P49 – DTOC)
Delayed transfers of care had been consistently high for over a year despite various initiatives to
address this. The most significant cause of delayed discharge is due to a lack of care packages in
the community or residential or nursing home placements.
The inpatient teams were actively using Red to Green methodology to improve patient flow and to
reduce the average length of stay for patients who are appropriate for rehabilitation.
Addressing patient flow was the biggest priority and they were in the process of finalising an action
plan with the local acute trust and was working with CCGs and partners to review patients who are
inpatients but do not meet the trust criteria.
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Learning from complaints and concerns
Although the service treated concerns and complaints seriously, investigated them and
learned lessons from the results, they did not always do so in a timely manner.
Patients knew how to make a complaint or raise a concern, and were encouraged to do so.
Information about the complaint process was clearly displayed within the inpatient units. Staff we
spoke with could describe the complaints process and explain how they would advise patients to
raise a complaint.
Nursing staff understood the process for receiving, handling and responding to concerns and
complaints.
Patients told us the nursing staff were approachable and if they wished to raise a concern they
would do this by speaking with the nurses who were caring for them at that time.
The hospital had a patient advice and liaison service (PALS) and complaints team.
All feedback received was reviewed. Each unit had a learning poster to display their, ‘you said –
we did’ actions. The ward managers updated the ‘you said – we did’ action posters each month.
Complaints
From April 2017 to March 2018 there were 22 complaints about community inpatient services. The
trust took an average of 33.7 working days to investigate and close complaints. This is not in line
with the trust’s complaints policy, which states that complaints should be dealt with within 25
working days.
A summary of complaints within community health inpatient services by subject and site is below:
Community inpatient services total
Subject Number of complaints
All aspects of clinical treatment 13
Admissions, discharge and transfer arrangements 3
Communication/information to patients (written and oral) 2
Attitude of staff 2
Patients' property and expenses 1
Others 1
Total 22
Community inpatient services – Danesbury Home
Subject Number of complaints
All aspects of clinical treatment 1
Community inpatient services – Hemel Hempstead General Hospital
Subject Number of complaints
All aspects of clinical treatment 2
Attitude of staff 1
Total 3
Community inpatient services – Hertfordshire and Essex Hospital
Subject Number of complaints
All aspects of clinical treatment 4
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Admissions, discharge and transfer arrangements 2
Attitude of staff 1
Total 7
Community inpatient services – Langley House
Subject Number of complaints
Patients' property and expenses 1
Communication/information to patients (written and oral) 1
Total 2
Community inpatient services – Potters Bar Community Hospital
Subject Number of complaints
All aspects of clinical treatment 2
Admissions, discharge and transfer arrangements 1
Total 3
Community inpatient services – Queen Victoria Memorial Hospital
Subject Number of complaints
All aspects of clinical treatment 2
Communication/information to patients (written and oral) 1
Total 3
Community inpatient services – St Albans City Hospital
Other 1
All aspects of clinical treatment 1
Total 2
In addition, there was one complaint about “all aspects of clinical treatment” that was not mapped
to a location. This concerned the St Albans, Harpenden and Hertsmere neurological rehabilitation
service.
(Source: Universal Routine Provider Information Request (RPIR) – P52 Complaints)
Compliments
From April 2017 to March 2018, the trust received over 12,000 compliments; however, they did not
provide the data by core service so we are unable to identify how many compliments were
received for community health inpatient services.
(Source: Universal Routine Provider Information Request (RPIR) – P53 Compliments)
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Is the service well-led?
Leadership
Although some managers at all levels had the right skills and abilities to run a service
providing high-quality sustainable care, some leaders were very new to their role and were
developing their leadership skills.
The service had recently introduced a new management structure in order clarify escalation routes
for staff and commissioners. Some ward managers and leaders were very new in post. There was
a lack of oversight of medicines management however, the trust had recently appointed a new
chief pharmacist who recognised that the pharmacy service needed improvement.
The inpatient service was headed by an associate director of operations with two divisional
general managers (DGM) leading the service. Each DGM worked with a clinical service manager.
Clinical service managers were responsible for several wards and ward managers, and were
present in the clinical environment daily. Uniforms had recently been introduced, rather than
business clothes, for the clinical service managers, to improve the recognition of leaders in the
clinical environment. Both clinical service managers were new in post.
Each ward was managed by a ward manager, several wards had more than one manger due to
part time working arrangements. Some ward managers were new in post. Ward managers were
not rostered to work clinical shifts, however, they often did so, due to staffing shortages.
Ward managers and clinical service managers told us they had attended leadership training or
were currently on leadership courses. Mangers told us the training was effective in enabling them
to acquire the skills necessary for their role.
Inpatient service leaders and managers attended regular ‘trust leaders’ and ‘senior leaders’ forums
to share and promote good practice across the trust. During these meetings, staff showcased
examples of successful changes or improvements, which they called ‘glimpses of brilliance’. For
example, we were told about how the therapy team had promoted the ‘red to green days’ across
the service.
Extra leadership skills training was planned by the trust learning and development department for
ward managers, which was due to be rolled out in October 2018. Individual targeted leadership
was also being delivered for specific managers.
Most nursing staff we spoke with said they felt supported, recognised and valued by their
managers and reported good communication between senior management and staff working in
the clinical areas.
Clinical service managers and ward managers were visible throughout our inspection, and staff
said they regularly saw senior staff in the inpatient units.
Vision and strategy
The service had a vision for what it wanted to achieve and workable plans to turn it into
action developed with involvement from staff, patients, and key groups representing the
local community.
The community hospitals did not have local strategy; however, the trust’s vision and strategies
were embedded within the community hospitals.
The trust’s vision was ‘to maintain and improve the health and wellbeing of the people of
Hertfordshire and other areas served by the trust'.
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The trust strategy was to focus on:
• Health and Wellbeing – working with other organisations to develop local, community
approaches to maintaining health and wellbeing
• Self-management – supporting people with health conditions and disabilities to manage
their own care as far as possible
• Coordinated Care – providing well-co-ordinated, personalised, multi-agency care for people
with complex needs
The trust worked with their staff and other service users to develop its strategy, although the staff
we spoke with said they had not been involved in developing the strategy. The strategy and
approach to change was communicated to staff through a series of roadshows.
The trust values were:
• Care - We put patients at the heart of everything we do
• Respect - We treat people with dignity and respect
• Quality - We strive for excellence and effectiveness
• Confidence - We do what we say we will do
• Improve - We will improve through learning and innovation
Staff employed within the service knew and understood the trust values and most staff we spoke
with could describe the trust’s vision and values and how they would apply them to their role. Staff
were less familiar with the trust’s overall strategy. We saw staff demonstrating the values of the
trust in all areas we visited.
Individual objectives for each staff member had been created to support delivery of the vision and
values and were managed through individual staff appraisals. This enabled staff to understand the
vision and values and their role in achieving this.
The service worked closely with local clinical commissioning groups (CCGs) and had agreed
pathways for patients leaving the acute hospitals. The CCGs had carried out recent inspections of
the services and had provided the organisation with feedback. The local health watch team were
actively involved in the trust and attended board meetings and provided feedback to the service.
Culture
Managers across the trust promoted a positive culture that supported and valued staff,
creating a sense of common purpose based on shared values.
During our focus groups we held with staff before our inspection, we were told that staff culture
within the inpatient units had been a challenge. However, the service had recognised this and put
some actions in place to improve the culture. This included; an away day supported by the leaning
and development team to identify and embed change; increased assistance from the human
resources department for ward managers to manage staff where appropriate; improving
consistency of communication with team leaders to ensure expectations were fully understood.
Staff across all areas of the inpatient units said they were committed and passionate about the
care they provided to patients. They reported feeling proud to work within the community hospitals
and were positive about the job they did. Staff told us they felt listened to and supported by each
other and the trust.
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Most staff we spoke with said they felt respected and valued by managers and by each other, and
that the culture within their unit was improving. Some staff said there were difficulties when the
units were short staffed, and everyone felt under pressure. Some staff told us that therapy and
nursing staff did not always help each other to provide seamless care for patients. Weekly ward
manager and therapy leads meetings had been recently introduced to drive shared accountability.
During our inspection we saw therapy leads and ward managers working together closely.
There were mechanisms in place for providing staff at all levels with the professional development
they needed. This included training, support with revalidation, appraisals, one to one feedback and
clinical supervision. Staff also gave examples of how they had been promoted into new roles
within the service. We were also told that 360 review processes were being introduced, which was
aligned to staff appraisals. The 360 review involves leaders asking staff of all grades to provide
feedback on their performance. It was hoped that the culture amongst leaders would be improved
by using this approach.
There was a freedom to speak up guardian (FSUG) in the trust, and some staff in the inpatient
units had accessed this service. We saw evidence that concerns raised by staff had been
investigated and actions had been put in place as a result. However, most staff we spoke with
were not aware there was a FSUG, or who they were.
Governance
Although the trust used a systematic approach to continually improve the quality of its
services and safeguarding standards of care, they did not always create an environment in
which excellence in clinical care flourished.
There were processes and systems of accountability in place. Staff were clear about their roles
and what they were accountable for. Senior leaders, ward managers and clinical staff across the
inpatient services demonstrated awareness of the trust’s governance arrangements. They
described the actions taken to monitor patient safety and risk. This included a quality dashboard,
incident reporting and the undertaking of audits.
Performance monitoring was done through a newly implemented quality dashboard, called
business unit performance reports (BUPR). Ward managers had been made responsible for
completing these monthly reports to improve ownership of the units, which included data on
performance, quality, workforce and finance.
BUPR data was shared with ward staff at team meetings and at governance meetings to ensure
local actions were undertaken. However, we found that not all aspects of quality and safety was
being monitored in a sufficiently robust way. For example, we found several issues with medicines
managements across the inpatient units, and in particular we found issues with medications
prescribed but not administered. We highlighted this to clinical service leads during our inspection
and we were told that each month ward managers audited 10 patient records and this included
scrutiny of medication charts. However, as this audit had not identified any issues with medicines
management, we were not assured of the robustness of this process.
The trust had an audit programme which was reported to the audit committee. This provided
oversight of the governance arrangements and systems of internal control.
Mortality review meetings were held four times a year with the medical director and included
medical and nursing staff. The meetings were used to discuss deaths and to identify any learning
as a result.
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Management of risk, issues and performance
The trust did not have effective systems for identifying risks, planning to eliminate or
reduce them, and coping with both the expected and unexpected.
At the time of our inspection, the community hospital inpatient units did not all have an individual
risk register which was used to identify the risks in each unit. Two ward managers we spoke with
were confused by the term, risk register, and could not identify any specific risks in their area,
other than staffing. We highlighted these concerns to clinical service managers during our
inspection and we were told that the local risk register was new and was currently being
implemented as part of increasing local ownership of individual units.
Local risks had not been identified, for example:
• The storage of clinical waste bags in the unit corridors and storage of equipment in patient
bathrooms at Holywell unit.
• The long call bell wires in the patient bathrooms at Danesbury unit.
• The damaged kitchen cupboard door leading to possible ‘electrical shortages’ at Holywell.
There was an electronically maintained high level risk register and risks were discussed at the
healthcare governance committee meetings. Risks on the high level risk register were reviewed
regularly and we saw that actions had been recorded to mitigate the risks where possible.
However, we saw that the high level risk register did not contain the risks of delayed discharges,
the risks of nurse vacancies, or the lack of frequent pharmacy provision at some sites.
The service had a continuing problem of high numbers of delayed discharges, despite several
initiatives which had been introduced to reduce delays.
The service participated in local audits which provided a systematic approach to processing
information. The actions required from the completed audits were shared at team meetings and
staff we spoke with were aware of the audits undertaken in their areas. Information about incidents
was also discussed at ward meetings to ensure any learning was shared and minutes we
reviewed, confirmed this.
There clear lines of accountability including clear responsibility for cascading information to the
senior management team, nursing staff and MDT teams. During our inspection we saw evidence
in meeting minutes that quality and risk information was reviewed and actioned.
There were business continuity plans in place detailing the actions to be taken by ward staff in the
event of a major incident, for example disruption to staffing or facilities. Staff we spoke with were
aware of major incident policies and contingency plans and gave recent examples of when these
had been implemented.
Information management
While the trust collected, analysed, managed and used information to support its activities,
some information was not accurately recorded, some information was not stored securely,
and some information collected was duplicated and/or difficult to access.
The trust had an information governance policy which managed and controlled information through
the trust’s policies and protocols. The policy identified measures to ensure the security of
information held on patients and staff and identified measures to be implemented in the event of
an information governance breach. There had been no breaches in information governance
reported within the community hospitals over the past year.
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Information on service performance measures including falls, pressure ulcers, staffing, infections
and patient feedback were reported monthly and displayed in public areas.
The service had recently implemented an electronic patient record system which was accessible
to all employed staff. The new system improved the quality and accuracy of the services data
collection. This data was used to monitor performance and produce clinical data quality reports.
Examples of data collected included, the number of patients having their NHS numbers recorded
(100%), patient ethnicity recorded (96%), and smoking status (95%). The system was also used to
monitor response times to referrals for treatment and for collecting patient outcomes.
Not all staff were proficient in using the new electronic system and we were told some information
recorded electronically was also collected on paper. This had led to a duplication of work. Some
information recorded on paper was different to that recorded electronically, for example DNACPR
forms. Some staff had difficulty assessing information electronically, this included patients’
electronic records. Agency staff could not access the electronic records. We highlighted our
concerns around staffs’ ability to use the electronic notes system and we were told that extra
training was available for all.
Not all information had been stored securely and we saw patients’ notes outside their rooms in
corridors, which were accessible to the public. Notes trolleys were not always locked.
Nurse handover sheets were generated by the electronic notes system and contained full patient
identifiable data and were up to 15 pages long. These were not always stored securely. Some
ward managers and sisters told us that the ward handover sheets were too long, and this meant
they were difficult to refer to quickly while working in the clinical environment. We were told that
this had been raised with senior managers, however, no solution had been found.
An electronic patient safety reporting system was in place to ensure that information about
incidents could be collected, and any themes identified. However, we found that there were
inconsistencies in the categorisation of incidents and therefore we were not assured about the
robustness of this data. For example, some staff categorised a patient with diarrhoea and vomiting
incident as an ‘infection’, and some staff reported it as ‘delay or failure to monitor’. This made it
difficult to get a true picture of how many incidents were happening in each category.
We saw that an incident had occurred that had been discussed at the Hertfordshire and Essex
team meeting in August 2018, in which hazardous chemicals had not been locked away and had
resulted in a patient safety incident. We were not provided with details of this incident prior to the
inspection and cannot be assured that the incident had been reported as an incident and fully
investigated.
Engagement
The trust engaged well with patients, staff, the public and local organisations to plan and
manage appropriate services, and collaborated with partner organisations effectively.
Patient and relatives’ views concerning the community inpatient wards were actively encouraged
by the staff. Ward staff worked closely with relatives and patients to improve the services provided.
Staff, patients and relatives on some of the inpatient units raised money to improve facilities for
patients.
Patients and members of the local community had opportunities to get involved in the
improvement of the services and were encouraged to become volunteers or members of
Hertfordshire Community Trust. PLACE inspections took place regularly using locally sourced lay
people.
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Staff were encouraged to improve services through a variety of ways including the staff survey,
involvement with working groups, and through staff training. Staff engagement was also
encouraged by regular sessions, which involved staff meeting the senior clinical team in an
informal setting.
The trust ran a quarterly pulse survey as part of its ongoing engagement with staff. This covered
16 core questions, plus a small number of ‘hot topic’ questions to get more detailed feedback.
Staff were also able to provide free text comments. We were not provided with individual results
for the impatient units, however we were told that generally, the trust had saw an overall trend of
improvement, particularly on staff recommending the trust as a place to work, staff health and
wellbeing questions and the quality of appraisals. The trust had actions for areas of the survey
where staff had reported concerns. For example, to improve staff morale, a health and wellbeing
programme had been introduced, along with resilience training and improved use of technology.
Staff excellence was celebrated through an annual awards ceremony, ‘Leading Lights’ and to
celebrate the NHS’s 70 birthday this year, the trust introduced ‘NHS70 star’ awards, where
individuals nominated colleagues for their outstanding work. A star badge and certificate was then
presented to them by the CEO or senior manager.
Engagement with staff from the CEO was through Keeping in Touch visits, as well as recording
briefing videos which were cascaded to all staff. Board members also visited the inpatient units to
speak to staff and patients.
In response to the staff survey we were told that the inpatient services had recognised the level of
pressure staff were under and several initiatives had been introduced to reduce workloads. This
included the launch of a new e-scheduling tool and improvements to electronic staff rostering. It
was hoped this would enable staff to make more effective use of their time. They had also
introduced new service models and increased the use of new technology, including electronic
patient records.
Staff working in the inpatient units had access to workshops on ‘building personal resilience’ and
‘managing change’ which the trust had introduced as part of their new focus of health and
wellbeing.
The service engaged with the public through engagement meetings. We were told about an
engagement meeting held with the public prior to the closure of a community unit in St Albans.
There had also been two events to provide information and obtain feedback on the redevelopment
plans for Harpenden Memorial Hospital. This included joint working with community groups to
deliver a joint communications and engagement plan. Events had also taken place with the local
health watch team to gain feedback from potential service users in the Hertfordshire Valley area
as a result of service redesign proposals.
Learning, continuous improvement and innovation
The trust was mostly committed to improving services by learning from when things go
well and when they go wrong, promoting training, research and innovation.
The service was committed to improving care for patients. It had invested in a new electronic
patient records system which would allow for greater scrutiny of patient care plans. Current and
future performance, including patient outcomes was regularly reviewed and improved through
ward safety dashboards, audits, and clinical patient assessment tools. For example, in response to
delayed discharges and patient flow blockages, the inpatient units developed and implemented:
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• Red to green days to identify patient flow blockages. This was managed in the daily ward
rounds and there was an escalation process to management should patients care not
achieve care plan targets.
• A progress chaser had been employed, who managed each patient’s discharge.
• An in-reach team at the acute hospitals to assess patients’ suitability for the inpatient units.
However, not all issues highlighted in our 2016 inspection had been resolved: Medications were
not always administered as prescribed; there was no policy which set out specifically how often all
patients should receive therapy; turn charts were not routinely used for patients and fluid balance
charts were not always comprehensively completed.
While the service demonstrated it had learned from incidents, incidents were not always
categorised appropriately. Therefore, the full number of each type of incident, could not be
accurately determined.
Managers and staff told us they had access to training courses and were encouraged to attend
extra training to extend their roles and increase their skills wherever possible.
The trust wide audit programme included standardised national audits, for example the stroke
rehabilitation audit, and audits like the Patient Led Assessments of the Care Environment
(PLACE), infection prevention and control audits and documentation audits. Results of audits were
shared and plans for improvement were made. Changes as a result of an audit include the
rationalisation of care plans used in the integrated community teams and community inpatient
hospitals. Following the audit, the number of care plans was reduced from 196 to 58, based on
best practice using a recognised framework. This enabled staff to personalise each care plan
according to individual patient needs and benefits included standardisation and a reduction in
variation, reduced duplication, and ensured that care plans better reflect patient needs.
Accreditations
NHS trusts are able to participate in a number of accreditation schemes whereby the services they
provide are reviewed and a decision is made whether or not to award the service with an
accreditation. A service will be accredited if they are able to demonstrate that they meet a certain
standard of best practice in the given area. An accreditation usually carries an end date (or review
date) whereby the service will need to be re-assessed in order to continue to be accredited.
There were no services reported within community health inpatient services that have been
awarded an accreditation.
(Source: Universal Routine Provider Information Request (RPIR) – P66 Accreditations)
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Community health services for end of life care
Facts and data about this service
Hertfordshire community trust (HCT) is responsible for delivering a wide range of community and
inpatient health services across Hertfordshire. The trust serves the communities of Broxbourne,
Dacorum, East Hertfordshire, Hertsmere, North Hertfordshire, St Albans, Stevenage, Three
Rivers, Watford and Welwyn/Hatfield.
HCT was commissioned by two clinical commissioning groups (CCGs). East and North
Hertfordshire CCG, commission HCT to provide specialist palliative care (SPC) and end of life
care as part of the community and inpatient nursing provided in North Hertfordshire, Stevenage
and Royston localities. In Hertfordshire Valleys CCG, HCT provide SPC nurses within Watford
and Hertsmere localities. Hospices within the area provide care for the St Albans, Harpenden and
Dacorum localities.
The trust’s vision for end of life care is to ensure health and wellbeing is maximised in the last
year of life and that patients and carers are supported to access appropriate services and jointly
plan treatment with a preferred place of death. The community trust aims to increase the number
of patients identified to be in the last year of life and for all patients at the end of their life to
ensure they received high quality, personalised care.
During our inspection we visited community inpatient areas at Queen Victoria Memorial Hospital,
Danesbury House, Potters Bar Community Hospital and Hemel Hempstead Hospital. We also
visited community adult services within the HCT localities. During our inspection we were told
that there were seven patients undergoing end of life care within the community setting and that
there were no inpatients within the trust’s community hospitals, requiring end of life care. We
attended four home visits with both SPC nurses and community nurses. We reviewed six care
records including six medicine charts, and reviewed 22 do not attempt resuscitation (DNACPR)
forms within the community inpatient and community settings. We also reviewed ten patients’
Mental Capacity Act (MCA) documentation.
We spoke with 18 staff including, specialist palliative care nurses, community end of life
champions, ward inpatient end of life champions, a palliative care medical consultant, a specialist
Macmillan clinical education manager and locality managers within HCT. In addition, we spoke
with a range of staff including ward and community nurses and sisters, medical staff and allied
healthcare professionals and clinical nurse specialists. We also spoke with four patients and six
relatives.
The trust was last inspected in April 2016. At that inspection it was rated requires improvement
overall.
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Is the service safe?
Mandatory training
Although the service provided mandatory training in key skills to all staff and made sure
end of life specialist nurses, community and inpatient staff had access to it, not all staff
had completed mandatory training.
Staff received mandatory training on a rolling annual programme which was provided through a
mix of classroom based sessions and e-learning.
Mandatory Training completion
The trust did not separate their mandatory training data by staff group. Therefore, the data below
includes nursing and midwifery staff, medical and dental staff, allied healthcare professionals and
healthcare assistants/infrastructure support staff in community inpatient services.
The trust set a target of 90% for completion of all mandatory training courses except for health and
safety and information governance, which both had a target of 95%.
From April 2017 to March 2018 the breakdown of compliance with mandatory training for staff in
community services for end of life care is shown below.
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Infection Prevention (Level 1) 3 3 100% 90% Yes
Equality and Diversity 5 5 100% 90% Yes
NHS |CSTF| Resuscitation - Level 2 3 3 100% 90% Yes
Information Governance 5 5 100% 95% Yes
Manual Handling - Object 5 5 100% 90% Yes
NHS |CSTF| Fire Safety 5 5 100% 90% Yes
Conflict Resolution 2 3 67% 90% No
Health and safety 2 5 40% 95% No
The trust met the target for six of the eight courses.
Medical device training had been completed and updated in line with trust policy. Medical devices
included; medication pumps, vital signs monitoring equipment and syringe drivers, all of which
were used within the community and inpatient settings.
Staff had received additional training to the mandatory topics dependant on their specific roles. For
example, end of life care training was offered to all staff within the inpatients and community
settings. Additional training was given which included, how to ask difficult questions, holistic
assessments for patients and carers and how to implement the Gold Service Framework (GSF).
The trust supplied updated mandatory training data as of August 2018. The breakdown by training
module for staff in community services for end of life as of that date is shown in the table below.
Please note that the health and safety training module was not included in the updated data. In
addition, some other training modules had been amalgamated or renamed.
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Information Governance 4 5 80.0% 95% No
Fire 4 5 80.0% 90% No
Conflict Resolution 3 4 75.0% 90% No
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Resuscitation 3 4 75.0% 90% No
Infection Control Mandatory 3 4 75.0% 90% No
Equality and Diversity 3 5 60.0% 90% No
In community health inpatient services, as of August 2018 the trust’s training targets were not met
for any of the six mandatory training modules for which staff were eligible.
(Source: DR110, Mandatory training compliance August 2018)
Safeguarding
Staff understood how to protect patients from abuse and the services worked well with
other agencies to do so.
Staff showed an awareness of safeguarding procedures and how to recognise if someone was at
risk or had been exposed to abuse. Staff had access to the trust’s safeguarding policy and knew
how to escalate concerns to the wider trust safeguarding team.
Specialist palliative care, inpatient and community nurses demonstrated a good understanding of
safeguarding and their responsibilities in relation to reporting and escalating concerns. For
example, nursing staff had raised a safeguarding alert for a patient at the end of life, who was at
home in vulnerable circumstances and did not want to be admitted to hospital. This led to a
multidisciplinary approach to ensure they were able to stay at home safely.
Staff received equality and diversity training as part of their required mandatory training. Staff we
spoke with were aware of the adaptations necessary when caring for patients with cultural and
physical requirements. For example, we were told of an incident where a patient would only let a
male nurse care for him, therefore, arrangements were made to ensure this need was met, which
ensured their protected belief had been listened to and complied with.
Safeguarding Training completion
The trust set a target of 90% for completion of safeguarding training.
From April 2017 to March 2018 the breakdown of compliance for mandatory courses for staff in
community services for end of life care is shown below.
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Safeguarding Adults (Level 1) 2 2 100% 90% Yes
Safeguarding Children (Level 1) 2 2 100% 90% Yes
Safeguarding Adults (Level 2) 3 3 100% 90% Yes
Safeguarding Children (Level 2) 3 3 100% 90% Yes
NHS |CSTF| Preventing - Radicalisation - Levels 1 & 2 (Basic Prevent Awareness)
2 2 100% 90% Yes
NHS |CSTF| Preventing Radicalisation - Levels 3, 4 & 5 (Prevent Awareness)
2 3 67% 90% No
The trust met the target for five of the six courses.
SPC nurses safeguarding training was at 75% within the East and North Hertfordshire localities
and 100% within the Hertfordshire Valleys team. This did not meet the trust target of 90%.
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The trust supplied updated safeguarding training data as of August 2018. The breakdown by
training module for staff in community services for end of life as of that date is shown in the table
below. Please note that the different levels of safeguarding adults and preventing radicalisation
training had been replaced by a single module for each of these two training subjects by August
2018.
Name of course Staff
trained Eligible
staff Completion
rate Trust
Target Met
(Yes/No)
Safeguarding Children (Level 1) 1 1 100.0% 90% Yes
Safeguarding Adults 4 5 80.0% 90% No
Safeguarding Children (Level 2) 3 4 75.0% 90% No
Preventing radicalisation 3 5 60.0% 90% No
In community health inpatient services, as of August 2018 the 90% target was met for one of the
four mandatory training modules for which staff were eligible.
(Source: DR110, Mandatory training compliance August 2018)
Safeguarding referrals
A safeguarding referral is a request from a member of the public or a professional to the local
authority or the police to intervene to support or protect a child or vulnerable adult from abuse.
Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and
institutional.
Each authority had their own guidelines relating to investigating and progressing a safeguarding
referral. Generally, if a concern was raised regarding a child or vulnerable adult, the organisation
worked to ensure the safety of the person. In addition, an assessment of the concerns was
conducted to determine whether an external referral to children’s services, adult services or the
police should take place.
Referrals were provided on a trust wide level so we were unable to break this down to individual
core services.
(Source: Universal Routine Provider Information Request (RPIR) – Safeguarding)
Cleanliness, infection control and hygiene
The service controlled infection risk in line with best practice.
Staff kept themselves, equipment and the premises clean. Staff complied with the trust’s infection
prevention and control policy.
During our inspection, we found the community inpatient environments we visited to be visibly
clean. There were posters on display encouraging staff and visitors to clean their hands using the
hand gel provided, which was available within the inpatient ward corridors and the community
nursing areas.
We observed community and inpatient staff groups complying with the arms ‘bare below the
elbow’ policy. This is an infection prevention and control plan to prevent the transfer of infection
from clothing that could be contaminated, and allows clinical staff to wash their hands thoroughly.
We accompanied SPC nurses and community nurses on home visits, with the patient’s
permission. We saw that staff adhered to good practice regarding hand washing in patients’
homes. We observed that community nurses and the SPC nurses carried personal protective
clothing, for example, gloves and aprons when providing care for patients. These were also
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available within the patient’s home surroundings. All clinical waste was disposed of according to
trust policy using the appropriate clinically coloured bags.
There was a mortuary at Hemel Hempstead hospital that was used by the community inpatient
wards. The mortuary was run by a local acute trust. Porters were responsible for cleaning the
specific trolley used following a patient’s death. We were assured that the trolley was cleaned
following each patient transfer. We noted on our inspection that the trolley was maintained and the
wipeable cover over the trolley was kept in good condition, with no obvious tears.
Environment and equipment
The service generally had suitable premises and equipment and equipment was serviced
according to the manufacturer’s instructions.
Patients admitted for end of life care within the community inpatient wards were cared for in single
rooms. This provided the patient and relatives with privacy and ensured a quiet peaceful
environment. In Hemel Hempstead hospital, St Peters ward had two beds specifically allocated to
patients who required end of life care. Occasionally these beds were allocated to patients not
requiring end of life care. We were assured by the staff that if a dying patient required a side room,
adjustments would be made to facilitate the needs of that patient and their relatives.
Equipment or aids required by patients in their own homes, was accessed from Hertfordshire
Equipment Services. Types of equipment that were required to help patients at home included
hoists, commodes, hospital beds and special mattresses to prevent pressure ulcers. We were told
by community nurses that equipment was accessible and delivered within a timely manner.
Medical devices such as syringe drivers were used within both the community inpatient wards and
community settings. A syringe driver is a small, portable, infusion device and is used to provide a
continuous delivery of pain killers, sedatives or anti sickness drugs. They are suitable for patient
use in the hospital and at home. The syringe drivers we saw, had all been electronically tested and
were sealed in a locked clear box. Each syringe driver used in the community was maintained and
tracked within the specific locality of the patient. During our inspection we saw that all syringe
drivers being used were renewed appropriately in line with the recommended National Institute for
Health and Care Excellence (NICE) guidance CG140 -palliative care for adults.
Community nurses undertook risk assessments to ensure sharps containers were stored safely
within the patient’s home environment. A sharps container is a hard-plastic container that is used
to dispose of needles and other sharp medical consumables. Used sharps containers were
disposed of by the community nurses by placing the sealed container in a plastic bag and
disposing it within the clinical waste area allocated at the main locality base.
Assessing and responding to patient risk
The service had systems in place to ensure the safety of patients.
Comprehensive risk assessments were carried out, and risk management plans were developed
in line with national guidance. These included assessments of patients’ susceptibility to pressure
ulcers, dehydration and malnutrition where it was appropriate. In accordance with the end of life
care planning, these assessments were adapted according to the patient’s needs.
During our inspection the community nurses and specialist palliative care nurses described how
they would implement specific risk assessments for example, when using home oxygen. They
showed us an initial home assessment form which would be completed prior to arranging delivery
and consent to use oxygen within the patient’s home. Home oxygen risk mitigation assessments
were completed to eliminate and prevent incidents happening within the community setting.
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In inpatient areas and community settings, staff worked proactively to ensure they could meet the
needs of patients requiring end of life care. They were prepared for times when less medical
support was available. Specialist palliative care support was available seven days a week and an
out of hours advice line service was available from one of the local hospices. The community
nursing facility also provided a 24-hour service, nurses prioritised patients who had required
advanced pain control and management of associated symptoms. The trust was in the process of
approving a new policy on ‘deferred visits guidance’ to assist with the decision making around
responding to patient’s needs.
During our inspection we observed a team meeting with the specialist palliative care nurses. The
palliative care team discussed the patients receiving end of life care within the specific locality.
Discussions took place amongst the locality manager, the palliative medical consultant and SPC
nurses regarding new patients and ongoing needs of the patients within the community.
Staffing
The service generally had enough staff with the right qualifications, skills, training and
experience to keep patients safe from avoidable harm and abuse and to provide the right
care and treatment.
Staffing levels, skill mix and caseloads were planned and reviewed so patients received safe care
and treatment, in line with relevant national guidance. NHS England specialist level palliative care
April 2016, suggests that to provide a safe and effective specialist level palliative care service it
must be adequately resourced to meet the characteristics of the service commissioned, taking into
account the need for 24hour cover seven days a week and cover for study leave, holidays and
other absences. During our inspection we were assured that this had been achieved.
There was no dedicated team delivering end of life care either in the community setting or in the
trust’s bed bases. Care was provided by teams, for example community nurses, who also gave
care to other patient groups. Advice was available from the SPCT. The trust captured data for this
staffing group. Within the inpatient and community settings there were end of life care champions
based in each locality. These champions were multi-disciplinary practitioners that had received
enhanced end of life training. During our inspection we spoke with end of life champions in all the
localities we visited.
Where necessary staff were doubled up to ensure safety within the community. Staff we spoke
with were aware of the lone working policy and would complete a risk assessment if they felt more
than one practitioner was required during a patient visit.
Staffing - Planned v Actual
Details of staffing levels within community services for end of life care by staff group as at March
2018 are below.
Community end of life care total
Staff group Planned WTE Actual
WTE Staffing rate (%)
NHS Infrastructure Support Staff 3.8 1.6 42%
Other Qualified Scientific, Therapeutic,
Technician Staff 0.81 0 0%
Public Health and Community Health
Services 2.14 1 46.7%
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Qualified nursing & health visiting staff
(Qualified nurses) 2 2 100%
Total 8.75 4.6 52.6%
(Source: Routine Provider Information Request – Staffing tab)
Specialist Palliative Care Nurses employed within the community trust
Specialist Palliative Care – Staff currently in post:
Locality Band WTE
North Herts/Royston Band 7 0.8
Band 6 0.8
Band 6 0.8
Stevenage Band 7 1.0
Band 7 1.0
Band 7 0.6
Hertsmere Band 7 1.0
Band 7 1.0
Watford Band 7 1.0
Band 7 1.0
Band 7 0.8
Total: 9.8
(Source: Information provided by operation lead for End of Life Services 20180919)
Vacancies
The trust set a target of 10% for vacancy rates. A breakdown of vacancy rates from April 2017 to
March 2018 by staff group in community services for end of life care is below:
Community end of life care total
Staff group Vacancy rate
Other Qualified Scientific, Therapeutic, Technician Staff 100%
Public Health and Community Health Services 50.6%
NHS Infrastructure Support Staff 42.8%
Qualified nursing & health visiting staff (Qualified nurses) 1.8%
Total 40.3%
(Source: Routine Provider Information Request (RPIR) – Vacancy)
Most of the community based staff we spoke with had some vacancies within their teams.
Recruitment was ongoing, and staff told us when new staff were appointed they felt fully informed
and could arrange their welcome and induction. The community trust was involved in the NHS
Improvement ‘national nurse retention programme’.
Turnover
The trust had set a target of 12% for turnover rates. From April 2017 to March 2018 there were no
leavers in community end of life services so the annual turnover rate was 0%.
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(Source: Routine Provider Information Request (RPIR) – Turnover)
Sickness
The trust set a target of 3.6% for sickness rates. A breakdown of sickness rates from April 2017 to
March 2018 by staff group in community services for end of life care is below:
Community end of life care total
Staff group Available
days
Sickness
days
Sickness
(%)
NHS Infrastructure Support Staff 474 9.8 2.1%
Other Qualified Scientific, Therapeutic, Technician Staff 400 0 0%
Public Health and Community Health Services 730 4 0.5%
Qualified nursing & health visiting staff (Qualified nurses) 341 2 0.6%
Total 1,945 15.8 0.8%
(Source: Routine Provider Information Request (RPIR) – Sickness)
Nursing – Bank and Agency Qualified nurses
From April 2017 to March 2018 the trust reported bank and agency usage for registered nurses in
community end of life care as below:
Shifts available 17
Filled by bank 16
Shifts not filled 1
(Source: Routine Provide Information Request – Bank and agency tab)
(Source: Universal Routine Provider Information Request (RPIR) – P23 Suspensions or
Supervised)
Medical Staffing
A whole time equivalent consultant in palliative medicine was employed by the trust to provide
medical cover within the localities. Additionally, further support was provided by a palliative care
consultant based at one of the local hospices within the community. NHS England specialist level
palliative care April 2016 states there should be a consultant in palliative care medicine providing
clinical leadership across a number of localities, therefore medical staffing was reflected current
guidelines.
Quality of records
Staff generally kept appropriate records of patients’ care and treatment.
The trust aimed to achieve good practice in record keeping across the localities. The trust
regularly completed monthly record keeping audits. To ensure that all records were effectively
communicated to other services, for example ambulance services and nursing care agencies,
relevant and up to date information regarding treatment escalation plans, DNACPR forms patient’s
wishes and preferences were stored in a bottle and placed in the patient’s fridge - ‘the message in
a bottle’ initiative.
The trust’s electronic record system relating to end of life care aims and objectives had recently
been updated. This upgrade ensured that all relevant information was accessible in the same on
the system, providing an easier system for the staff to navigate. The changes made within the
system were altered in agreement with the end of life care champions within each setting. This
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was reviewed by the locality managers, palliative care medical consultant and specialist MacMillan
clinical education manager. All staff within the localities were given training to ensure the new
change was effectively embedded.
Community nurses had access to electronic tablets. They accessed the electronic system and
completed the notes during visits to patients. We visited four patients within the community
services that were receiving end of life care, we observed all the nursing staff completing the
electronic and paper documents to a high standard.
Patient’s individual community care pathways included records of conversations with the patient
and family members about decision making at the end of life, this was documented both on a
paper copy and electronically stored within the advanced care plan.
Medicines
The service prescribed, administered, recorded and stored in accordance with good
practice.
Patients who were deemed to be at the end of their life, were prescribed a range of medicines that
could be administered when required to manage their symptoms, these were referred to as
‘anticipatory medicines’. We saw this worked well and staff were confident in making decisions
about when these medicines should be administered, for example, during a home visit with the
specialist care nurse we saw her discuss with the family how to best control the patients pain, the
anticipatory medication was adjusted, prescribed and given as necessary.
Anticipatory medicines were stored safety in the patient’s home, we saw that medication was kept
in a high-level cupboard out of reach of vulnerable adults and children. During our inspection we
saw the community nurse dispose of out of date medicines by completing a double check with
another health care professional and disposing of them in the correct manner on returning to the
locality base.
The community settings had palliative care ‘just in case ‘guidelines. This included types of
medicines that could be used and doses required. The guidelines contained a list of pharmacies
that could be used if medication was needed immediately but was not readily available. Standard
level agreements with outsourced pharmacies were in place to ensure an effective provision was
maintained for patients within the community.
Controlled drugs for use in end of life care were seen to be stored safely on in the inpatient and
community services. We observed community nurses discussing the safe storage of medicines in
patients’ homes. On community inpatient wards, we saw that controlled drugs were appropriately
monitored and audited.
Community and SPC nurses were non-medical prescribers (NMP). This meant registered nurses
could administer end of life care medications to patients in a timely way. NMPs were trained
appropriately and practiced within their level of competency, within the scope of their professional
bodies.
Safety performance
The safety thermometer is used to record the prevalence of patient harms and to provide
immediate information and analysis for frontline teams to monitor their performance in delivering
harm free care. Measurement at the frontline is intended to focus attention on patient harms and
their elimination.
Each inpatient unit displayed safety information in the public areas using a ‘safety cross’ system.
The information included; the number of falls, the number of pressure ulcers, the number of bed
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days lost to diarrhoea and vomiting, along with cleanliness audit results, the number of complaints
and staff sickness. This data is described in the community inpatients report.
Incident reporting, learning and improvement
The service managed patient safety incidents and generally learned from incidents. Staff
recognised incidents and reported them in a timely manner.
Staff we spoke with understood their responsibilities regarding reporting incidents. The trust used
an electronic reporting system on which all staff had been trained to use. Staff clearly understood
their responsibilities to report incidents, and spoke of a culture where this was actively
encouraged. All staff we spoke with, said they received feedback after reporting an incident
through their locality meetings.
The staff in both the inpatient and community settings, had a clear understanding of the types of
incidents that they felt could be classified as an incident relating to end of life care. For example,
the inability to provide side room facilities during the later stages of a patient’s care. There was a
clear process for communicating, investigating and learning from incidents. However, the trust did
not separate the incidents into specific categories for example, end of life care. Therefore, we
were unable to ascertain how many reported incidents actually related to the end of life services.
The community trust had monthly meetings to discuss Complaints, Litigation, Incidents, concerns
from the Patient advice liaison Service team, and Safeguarding - CLIPSS. In addition, risks were
discussed. We saw from the minutes of the July 2018 meeting specific discussions around the use
of end of life care plans within the inpatient units, because use of these plans had not always been
identified.
Staff working within the inpatient and community settings were aware of their responsibilities with
regards to duty of candour. The duty of candour is a regulatory duty that relates to openness and
transparency. It requires providers of health and social care services to notify patients (or other
relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that
person. Staff could provide examples of situations when an incident had occurred, how they had
informed the patient and their relatives of the incident, made an apology and explained what
investigation and actions had resulted from the incident.
Never events
Never events are serious patient safety incidents that should not happen if healthcare providers
follow national guidance on how to prevent them. Each never event type has the potential to cause
serious patient harm or death but neither need have happened for an incident to be a never event.
From August 2017 to July 2018, the trust reported no never events for community services in end
of life care.
(Source: Strategic Executive Information System (STEIS))
Serious Incidents
Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).
These include ‘never events’ (serious patient safety incidents that are wholly preventable).
In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents
(SIs) in community services for end of life care, which met the reporting criteria, set by NHS
England between August 2017 and July 2018.
(Source: Strategic Executive Information System (STEIS))
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Serious Incidents (SIRI) – Trust data
From April 2017 and March 2018, trust staff within community services for end of life care reported
no serious incidents.
(Source: Routine Provider Information Request (RPIR) – Incidents tab)
Prevention of Future Death Reports (Remove before publication)
There had been no deaths requiring a Coroner's Inquest in relation to community health services
in end of life care in the last 12 months.
(Source: Universal Routine Provider Information Request (RPIR) – P86)
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Is the service effective?
Evidence-based care and treatment
The service provided care and treatment based on national guidance. There was evidence
of its effectiveness.
During our inspection we saw that patients had personalised advanced care plans (ACP). The
care plans included individual’s preferences regarding the type of care they would wish to receive
and where they wanted to be cared for. The ACP is a fundamental part of the NHS End of Life
Care Programme.
Patients’ physical, mental health and social needs were assessed. Their care, treatment and
support was delivered in line with legislation and national evidence-based guidance. For example,
during our inspection we observed nurses controlling anticipatory medicines appropriately in line
with NICE guideline CG140 – strong opioids for pain relief and NG31 - care of the dying adult in
the last days of life. NG31 aims to improve end of life care for people in their last days of life by
communicating respectfully and involving them, and their relatives. We also observed the SPC
nurses following the NHS improving quality, ‘priorities for care of the dying person’. The priorities
of care are to recognise, communicate, involve, support, plan and do. These priorities were
embedded within the inpatient and community settings, we saw laminated advice sheets available
to assist staff in preforming these tasks.
The trust used the gold standards framework (GSF) standards. The GSF provides a clear
standardised set of objectives to provide high quality care for patients in the final months of life.
Nutrition and hydration
Staff gave patients enough food and drink to meet their needs and improve their health.
Staff gave patients enough food and drink to meet their needs within the inpatient setting and,
where relevant in the patient’s home environment. We saw the General Medical Council (GMC)
guidelines were followed for patients who were in the final days and hours of life in relation to
nutrition and hydration. To help those close to patients understand these decisions, we saw
community nurses fully explain their actions and reasons behind them.
We observed community nurses referring patients to dieticians to improve their nutritional intake.
During a visit we witnessed the SPC nurses performing mouth care and prescribing medication to
improve the patient’s oral health.
Pain relief
Patients’ pain was assessed and managed appropriately.
Patients we spoke with told us that their pain was adequately controlled.
We observed SPC nurses and community nurses assessing patients’ pain, as part of their routine
assessments when visiting patients. This included asking patients, who were able to
communicate, about their pain levels. The Abbey pain scale was used for those patients with
communication difficulties. We observed a community nurse visiting a patient who had
deteriorated and was experiencing pain on movement. We observed the nurse providing
increased pain control using the anticipatory medicines regime, all assessments were documented
and communicated to the patients GP.
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Patient outcomes
The service generally monitored the effectiveness of care and treatment and used the
findings to improve them.
Monthly data was collected via audits for end of life record keeping compliance, advanced care
pathway completion and preferred place of death. This data was disseminated using clinical
dashboards and was monitored by the appropriate locality managers. Senior staff told us that a
specific end of life dashboard had recently been implemented. The information on the dashboard
was linked to the trust’s electronic data system.
The clinical dashboard assimilated information such as patients’ preferred place of care, preferred
place of death, advanced care plan and end of life assessment. Due to recent changes within the
electronic record framework we were unable to gather sufficient information to ascertain how
thoroughly the dashboard had been completed, or how up to date the information was. However,
during our inspection, we were informed by senior staff that the end of life dashboard information
had shown an improvement in the compliance regarding patient requested place of care and place
of death.
The service had not been accredited with the GSF quality hallmark in end of life care. However,
the objectives and recognised framework achievements were used within the trust’s localities. We
saw evidence of this at the regular team meetings that were held in conjunction with the local GPs.
The National Audit for ‘care at the end of life’ is open to all organisations who provide inpatient
facilities, including acute trusts, mental health hospitals and community hospitals. HCT had not
participated in this audit, however they were in the process of submitting relevant data prior to
publication in May 2019.
In April 2016, we saw the trust did not have an end of life care policy. Staff we spoke during this
inspection were aware of, and knew where to find, the trust’s end of life policy which had been
implemented in 2017. The end of life policy provided staff with a clear set of guidelines and related
end of life policies.
The trust had participated in five clinical audits in relation to this core service as part of their
clinical audit programme.
Audit name Area covered Key Successes Key actions
Pain Audit (84)
CQC (re-audit)
Specialist
Palliative
Care
Service
• In 92% of cases, the pain
template had been
completed.
• In 79% of cases, the pain
had been scored from
0-10.
• A body map was
completed in 62% of
cases.
• In 64% of cases, there
was evidence that the
pain had been reviewed
following intervention. A
management plan has
been completed in 77%
of cases.
• Report results to the
medicines management
forum (MMF) (July 2017)
and patient safety and
experience group meeting.
(action complete).
• Review national tools and
gain permission to use
these at HCT. (action
complete).
• Collaborative working with
learning disability/children’s
services and adults’
services to standardised
pain templates. (action
complete).
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• 4 pain tools added on system
one (electronic data system
September 2017) and
accessible for all HCT
services abbey pain scale
for cognitive impairment,
entonox pain scale for
learning disabilities, Wong-
Baker faces for children,
pain sites for Adults].
(Action complete).
• Education and training plan
in place to help increase
awareness of the need to
assess all patients to
determine if they are in
pain and to ensure all staff
are aware of the pain tool
and feel confident and
competent to use it. (end of
life care champions are
completing this along with
the clinical nurse specialist
- ongoing)
• End of life care audit group
monitors progress of work
to meet quality
improvement requirements.
• Re-audit to monitor
compliance of the use of
the new pain tools. April
2018 re-audit results much
improved and due to be
shared at the next CEG
meeting on the 14th June
2018.
To audit the use
of opioid
information
leaflet for
adult
palliative
and end of
life care
patients
across HCT
(94)
Specialist
palliative
care
service
• 92% of patients were
asked about the
concern they may have
about starting treatment.
• 80% of patients were told
when and why opioids
were used to treat pain.
• When taking opioids for
background and
breakthrough pain, 80%
of patients were told
• Shared audit results with all
localities and community
hospitals
• Recorded on patient record
when written information is
given to patients about
strong opioids
• More staff awareness of the
2 information leaflets linked
to the medication templates
on System One
183
about how long pain
relief should last for.
• 88% of patients were
given information about
who to contact out of
hours.
• 76% of patients were
advised that
constipation affects
nearly all patients.
The majority of patients
were given appropriate
information about their
treatment and were
well-informed about
their side-effects.
• Reaudit in 3 months
Syringe pump
policy audit
(30)
Specialist
palliative
care
service
• 88% of staff were aware
of the HCT Syringe
Pump policy for adults &
children.
• 88% of staff knew where
to access this policy.
• If the battery was reading
38%, 95.8% of staff
would change it.
• 92% of staff know where
to access help and
support regarding
syringe pumps.
• 71% of staff were
confident to put up a
syringe pump.
Overall, over 80% of staff
were aware of the policy
and acted upon it, had
implemented it in their
practise.
• Training on the revised
syringe pump policy
(including the importance
of why the patient and
family should be provided
with the patient information
leaflet) – ongoing as all
staff have to attend an
annual update.
• Training on the Individualised
care plan for the dying
patient (to ensure that staff
understand why this is
used and when to
implement it). Continual
training now introduced via
several different training
sessions offered to HCT
staff.
• Ensure all new band 5 and 6
staff have palliative care
competencies (within the
competency booklet) and
signed off within 3 months
of starting with HCT. Band
6 and band 7 mentors now
review competency booklet
to provide assurance of
completion. (action
complete).
184
Syringe pump
policy audit
(re-audit)
(97)
Specialist
palliative
care
service
• 97% of staff were aware
of HCT syringe pump
policy for adults and
children.
• 94% of staff knew where
to access it.
• If battery is reading 38%,
98.61% of staff would
change it.
• 96% of staff know where
to access help and
support regarding
syringe pumps.
• 90% of staff were
confident to put up a
syringe pump.
Improvement noticed since
the previous audit,
regarding the
confidence of staff, and
awareness of where to
access the policy.
• Shared all results with
locality and service
managers and request that
all recommendations are
carried out
• Monitored numbers of
incidents involving syringe
pumps with the quality
team
• All staff ensured patients
receive an information
leaflet when commencing a
syringe pump
Internal peer
review for
end of life
issues CQC
(99)
Specialist
palliative
care
service
• In Royston ICT, 100% of
staff were aware of the
end of life care policy
and pain assessment
templates
• In Upper Lea Valley ICT,
100% of staff were
respectful, caring,
informed and discreet.
All audited staff were
respectful, caring and
informed about the
patient's care plan.
• To ensure literature
displayed on communal
boards and walls is up to
date - North Herts ICT.
• To ensure that all staff can
attend end of life education
sessions by the Macmillan
clinical educators.
(Source: Universal Routine Provider Information Request (RPIR) – P35 Audits)
Competent staff
Patients had their needs assessed, preferences and choices met by staff with the right
skills and knowledge.
Staff we met within inpatient areas and community localities felt confident to deliver end of life care
that met the needs of patients.
The trust had previously identified that there had been a gap within the completion of specific end
of life knowledge. The trust had undertaken a joint education project with the Macmillan cancer
support service. The Macmillan clinical education project was a jointly funded partnership to
provide clinical education, training and support to SPC nurses and community nurses across all
the localities.
185
Within each locality end of life champions had been appointed. The champions provided a direct
link between the locality teams and the Macmillan project team. During our inspection we spoke
with end of life champions who felt that they had received enhanced training to be able to pass on
information on to the staff within their teams. We saw evidence of this when visiting one of the
inpatient wards, the end of life champion was to provide an update and teaching session on the
new electronic word template implementation at the team meeting later that day.
Total number of courses run and HCT staff trained in end of life during the reporting period from
April 2018 to September 2018.
(Source; DR51- Additional data information request)
Within the trust there were competency packages specifically for advanced end of life care
practitioners. This package ensured that practitioners, for example the champions, had the
necessary skills and knowledge to provide enhanced care to patients and their relatives in
accordance within the identified end of life pathways.
Appraisal Rates
From April 2017 and March 2018, 67% of all staff within the community services for end of life care
core service had received an appraisal compared to the trust target of 90%.
(Source: Routine Provider Information Request (RPIR) – Appraisals tab)
Updated information received following our inspection showed the SPC nurses to have an
appraisal compliance of 100%
Courses run Frequency Total number of attendees
Advanced Care Planning(ACP) One Stop 3 99
ACP & Dementia Awareness (Induction) 5 97
Dementia & end of life 1 9
ACP workshop 1 7
Symptom Control & Palliative Care Emergencies
1 7
Syringe pump refresher 3 35
Syringe Pump beginners 3 24
Pal Care update & syringe pump refresher 3 99
2 day Intro to Palliative Care & end of life 1 16
Sage and Thyme 2 8
Intermediate Communications 1 7
Advanced Communications 2 3
Champion end of life training/forums 5 67
Total Total
31 478
186
Specialist Palliative Care for East & North Hertfordshire is only provided by HCT for North Herts &
Stevenage.
(Source- DR -152)
Multidisciplinary working and coordinated care pathways
Staff, teams and services within the trust across all the localities worked very well together
to deliver effective care and treatment.
The service coordinated with other providers and services, including GPs and hospices to ensure
patients approaching the end of life were identified and supported.
There were weekly multidisciplinary meetings where all patients referred to the palliative care team
were discussed. In addition, this meeting was attended by the hospice medical consultant who
worked closely with the palliative care team to deliver end of life care. The multidisciplinary
meetings provided a platform for a holistic review of patients’ care, where actions were allocated to
the appropriate professional. These regular meetings meant that patients were reviewed it a timely
manner and plans amended when necessary, to reflect their needs.
We spoke with the Macmillan clinical educator who told us about the out of hours prescription
project, which had recruited the help of volunteers within the community. The volunteers assisted
relatives and patients with the collection of medication during the out of hours periods, for
example, weekends and bank holidays. This multi-disciplinary collective working proved to be
effective and had provided good feedback from staff, patients and relatives who had used the
service.
Health promotion
Staff gave examples of patients who had been identified as needing extra support. For example,
patients requiring palliative care who had existing long-term conditions. The nursing staff gave
advice about equipment to aid mobility, dietary advice to help reduce the risk of pressure damage
and opportunities to increase their wellbeing, with information about local activities and support
groups. We observed staff giving health promotion advice about gentle exercise to aid mobility.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Staff were aware of the Mental Capacity Act 2005. However, during our inspection we found
that consent was not always obtained or recorded in line with relevant guidance and
legislation.
We reviewed 22 DNACPR forms, four within the community setting and 18 within the inpatient
community localities. A DNACPR form is a document issued and signed by a doctor, which tells
the attending medical team not to attempt cardiopulmonary resuscitation (CPR). Within the
community localities we found that all four DNACPR forms had been completed in accordance to
resuscitation guidelines ensuring that all relevant reviews had taken place. However, within the
community inpatient settings we found that, from 18 reviewed DNACPR forms, only eight had
Eligible for
appraisal
Completed appraisal
in past year
Compliance
rateNotes
812 Hertsmere CAHS C145402 2 100%
812 Stevenage Integrated Care Team C133351 1 100%
plus 2 new starters in past 2/12 812 Watford CAHS C14510
2 2 100%plus 1 new starter in past 2/12
812 North Herts Integrated Care Team C133300 n/a
plus 1 new starter in past 6/12
187
been completed correctly according to local policy and guidance. This included the incomplete
documentation of the indefinite decision review and the consultant review.
Within one of the inpatient localities we saw that the DNACPR forms were not reviewed following
transfers from the local acute trust. The trust resuscitation policy stated that all documentation
should be reviewed and communicated to staff. Not all copies of the decisions regarding the
DNACPR status of patients were recorded in the paper and electronic copies. During our
inspection we questioned the staff regarding patient resuscitation status and were told that several
patients were for resuscitation however, their hospital records showed that DNACPR forms had
been completed. This was escalated to the inpatient ward sisters at the time of our inspection.
Where the individual lacked capacity, a Mental Capacity Act (MCA) form should have been
completed and documented within the patient’s paper notes and on the electronic record system.
Mental capacity assessment guidance recommends that where long-term or significant decisions
are to be made in relation to a person who may have lacked capacity, professional staff must keep
a record of how capacity was assessed and any ensuing decisions made. Out of the 22 DNACPR
forms reviewed, nine patients were deemed to be lacking in capacity. Out of the nine patient
records, no MCA forms were documented in either paper or electronic records. This was escalated
at the time of our inspection.
Following our inspection, the trust advised us they had undertaken audits for the completion and
documentation of the DNACPR and MCA forms. Support and clarification was given to ensure
correct documentation and consistent alignment with electronic records were completed. A letter
discussing the correct processes had also been cascaded to staff via ward managers to ensure
both medical and nursing staff complied with the required practices.
The community trust was in the process of implementing a standard DNACPR form throughout all
the localities. We did not see any ReSPECT (Recommended Summary Plan for Emergency Care
and Treatment forms during our inspection.
Mental Capacity Act and Deprivation of Liberty training completion
The trust set a target of 90% for completion of Mental Capacity Act / deprivation of liberty
standards training.
From April 2017 to March 2018 the trust reported that Mental Capacity Act (MCA) training had
been completed by 100% of staff within community health services for end of life care.
The trust supplied updated MCA and DoLS training data as of August 2018. By that date the trust
had a single level of MCA training. As of that date this training module had been completed by
three of the four eligible staff within community health services for end of life care (75%). This was
lower than the trust’s 90% target for completion of MCA training.
As of August 2018, both of the eligible qualified nursing staff had completed MCA training.
However only one of the two eligible medical staff had completed this module.
(Source: DR110, Mandatory training compliance August 2018)
Is the service caring?
Compassionate care
Staff cared for patients with compassion. Feedback from patients confirmed that staff
treated them well and with kindness.
188
Staff interacted with patients and those close to them in a respectful and considerate manner.
Patients and their relatives were positive about experiences of care and kindness offered to them.
During our visits with the community and SPC nurses we saw that staff demonstrated an
understanding of the patients’ emotional needs. Staff made sure that patients’ privacy and dignity
was always respected, during physical or intimate care.
The services regularly received compliment cards and letters of thanks from patients, their friends
and relatives. One recently received card said, ‘Thank you for your kindness during this difficult
period,’ another said the staff were caring and thanked them for their support.
Emotional support Staff provided emotional support to patients to minimise their distress. Staff showed
awareness of the emotional and social impact of patients care and treatment.
Patients and relatives that we spoke with were positive about the support they had received from
the community nurses and SPC team. Patients could access and be given appropriate, timely
support and information to cope emotionally and mentally with their care.
Staff ensured the needs of families and others important to the patient were actively explored,
respected and met as far as possible. People we met told us that they felt welcome to stay with
their loved ones, and that the facilities available to them were highly thought of.
Treatment options were discussed with patients and those close to them. Staff said whilst this was
sometimes difficult and challenging it was important to involve the patient. Staff signposted
patients and those close to them to relevant services that could provide support and advice.
Psychological support and complementary therapies were available to patients in the community
receiving end of life care, through the local hospices.
Understanding and involvement of patients and those close to them
Staff involved patients and those close to them in decisions about their care and treatment.
Staff provided emotional support to patients to minimise their distress. Psychological, religious and
spiritual support were available to patients. Bereavement information was available to assist
relatives to suitable services.
Patients and relatives felt that staff communicated with them in a way which they could
understand, when explaining their care, treatment and condition. Staff communicated with patients
in a way that was appropriate and respectful. We observed staff involving patients and their
relatives during assessments within the patient’s home. We observed community nursing staff
taking time to involve patients during their care giving them time to ask questions.
We observed nurses, doctors and therapists introducing themselves to patients and relatives and
involving patients in decisions about their care.
189
Is the service responsive?
Planning and delivering services which meet people’s needs
The trust planned and provided services in a way that met the needs of patients and their
relatives.
End of life services within the inpatient and community localities provided flexibility, choice and
continuity of care.
Inpatient, community and hospice teams worked together to support the patient’s wishes regarding
their preferred place of care and death. Inpatient staff told us that they had recently facilitated a
difficult transition of care from an inpatient ward to a community care setting. This transfer of care
was problematic due to the lack of social care packages available within the area, however,
through liaising with the community teams this had been managed and the patient’s preferences
had been met.
The community trust had recently redesigned the integrated community team referral hub for East
and North Hertfordshire. The hub created a single point of contact for all the teams within the
community, including referrals to rapid response and Homefirst. The rapid response and Homefirst
services supported those patients with long term or complex conditions to remain at home rather
than going into hospital. The hub was open from 8am till 6pm seven days a week. Out of hours
calls were diverted to specific locality teams.
The community services supported those patients who were uncertain about their future. An end
of life champion with the inpatient community setting, explained a situation where a patient had
been told that they were rehabilitating and they believed their condition would improve, in this
situation the patient did not want to have any conversations relating to the advanced care plan.
The inpatient nurse informed us that she respected the patient’s wishes and documented the
outcome in the electronic record system.
We were told that patients at the end of their life needing a bed within inpatient settings were
prioritised to facilitate their needs and wishes. There were single rooms, some with en-suite
facilities, where friends and family could stay with patients throughout the day and night. There
were facilities for relatives that provided a comfortable environment.
Meeting the needs of people in vulnerable circumstances
The service took account of patients’ individual needs.
End of life services were accessible to all members of the community including people with
conditions such as heart failure, dementia and neurological conditions.
Inpatient areas and community based staff had many resources available to meet the needs of
patients at the end of their life who had other associated conditions. For example, information
leaflets were available in braille, audio format, large print, easy read and a variety of languages.
Patients approaching the end of life were offered spiritual and religious support appropriate to their
needs and preferences in accordance with NICE Quality Statement 13. Some of the inpatient
hospitals had dedicated chaplains, with different religious faiths. During our inspection we saw
relatives within the community arranging spiritual support for patients at the end of life.
Services were delivered and coordinated to ensure that patients who may be approaching the end
of their life were identified and that this information was shared. Nurses described a positive
working relationship with GPs, this enabled them to collectively identify when a patient was
190
entering the end of life phase. We saw that this happened for a patient during our inspection which
prompted the implementation of an advanced end of life care plan.
Staff told us how they had co-ordinated the needs of a patient requiring end of life care, who was
particularly vulnerable due to their social circumstances. The staff liaised with the palliative care
social worker and local government to secure appropriate accommodation for the patient.
Translation and interpretation services, including British Sign Language, services were available
across the community trust, staff knew how to access these services if necessary.
Access to the right care at the right time
Patients could access most services when they needed it. However, the trust did not
provide information on how rapidly patients were discharged from inpatient services,
although information was provided which showed that 28% of patients achieved their
preferred place of death.
Community home visits were never cancelled however, they were sometimes delayed due to the
nature of the service. For example, staff were encouraged to stay with patients for as long as was
required to ensure the patient received suitable care depending on their clinical and psychological
status. If a patient was near to dying at the time of a home visit, staff said they would stay with the
patient and their relatives if requested. Delays were communicated to other patients to reduce any
unnecessary worry and concern. Disruption to the smooth running of the service, for example
delays caused by traffic were also communicated to patients. Patients generally had the choice of
whether they wanted to be visited in the morning or afternoon and if they did not have a
preference, they would be informed in advance of when a member of the team would be arriving.
Community hospitals prioritised admission for patients near to, or at the end of life, if they had
made a choice to be admitted as an inpatient. During our inspection we spoke with staff who said
that the local acute trusts referred patients requiring end of life care to them however, their
condition status was documented for ‘rehabilitation’. This lack of information from the acute trust
had precipitated the implementation of the ‘in-reach’ team. The in-reach team provided robust
clinical decision making for the admission of patients within the community inpatient hospitals,
ensuring that all patients at or near the end of their life, were identified and placed on the correct
care pathway.
Community out of hours calls were triaged and assessed according to patient needs. Patients
requiring end of life care were prioritised. Staff who worked out of hours said they were busy, but
able to work together with colleagues to ensure patients’ needs were met.
In October 2015, the trust stated that staff had recorded the patients’ preferred place of death in
51% of cases. The trust had issues with current data due to an amended template on the
electronic system which had provided inaccurate data. A process of manual data validation had
been completed with a senior clinician for each service to review each set of patient’s records.
A total of 975 patient records had been manually reviewed, which showed that assessment taken
place but not recorded in a place but the electronic data system had not pulled the relevant
information on to the dashboard.
191
Portfolio
Appropriate
assessment taken
place but not
recorded in a place
that pulls through
to the end of life
dashboard
Patient identified
in last year of life
but identified by
the service that
ACP discussions
not appropriate
Planned date in place
for review of end of
life and ACP for
those patients where
no appropriate
assessments are
recorded.
Number of
patients who
had been
discharged
from the
service
Community
Hospitals 129 / 180 (72%) 11 (neuro) 0 40
Herts
Valleys
CAHS
105 / 151 (70%) 0 15 30
East and
North ICTs 296 / 389 (76%) 31 33 31
Specialist
Services
including
SPC
156 / 255 (61%) 22 55 21
TOTAL 686 / 975(70%) 64 / 975 (6%) 103 / 975 (11%) 122/975 (12%)
(Source – manual data validation of the end of life September 2018)
Further information proved by the trust for the period October 2017 to September 2018 had
identified the 1544 patients recognised as at the end of their life had died in the last 12 months of
these 209 had cancer and 1335 non- cancer. Of these 81% had a preferred place of death
recorded and 28% of patients achieved their preferred place of death. No information was
provided on the number of patients achieving a rapid discharge.
Referrals
The trust has identified the below services in the table as measured on ‘referral to initial
assessment’ and ‘assessment to treatment’.
The trust met the referral to assessment target in the target listed.
Name of in-patient ward or unit
Days from referral to initial assessment Comments, clarification
National / Local Target Actual (median)
Specialist Palliative Care
126 1 Onset of treatment occurs at
initial assessment
(Source: CHS Routine Provider Information Request – Referrals)
The data below shows that in the localities in Hertfordshire where HCT provide specialist palliative
care (Watford, Hertsmere, North Herts and Stevenage) on average 45% of patients identified as
being at or near end of their lives were referred to the SPC team in 2017/18.
192
(DR53-Percenatge of patients referred to the Specialist Care Team)
Learning from complaints and concerns
Complaints and concerns were treated seriously. They were investigated, but there was no
system in place to ensure lessons were learnt from the results. Outcomes from complaints
and concerns were generally shared with inpatient and community staff through monthly
reports.
Complaint reports were produced every month and discussed within the CLIPSS monthly meeting.
The reports produced information relating to specific community localities. During our inspection
the operational lead for end of life care stated that any specific complaints relating to end of life
care were not individually disseminated to senior community trust staff. Following our inspection,
the operational lead for end of life reflected on the need for specific reviews to be made in relation
to detailed end of life incidents, rather than being grouped with all the inpatient or community
service complaints.
Information about how to make a complaint or raise a concern was available to patients and staff
within community localities.
The trust received feedback from relatives regarding the length of time some community patients
had waited for their daily care. However, on investigation the outcome of the complaint showed
that the care had been delayed due to emergency care being prioritised.
Complaints
From April 2017 to March 2018 there had been no complaints about community health services for
end of life care.
(Source: Routine Provider Information Request (RPIR) – Complaints)
Compliments
From April 2017 to March 2018, the trust told us that they have received over 12,000 compliments;
however, they did not provide the data by core service so we are unable to identify how many
compliments were received specifically for community health services for end of life care.
(Source: Universal Routine Provider Information Request (RPIR) – P53 Compliments)
End of Life Readcode recorded
2017 Apr
2017 May
2017 Jun
2017 Jul
2017 Aug
2017 Sep
2017 Oct
2017 Nov
2017 Dec
2018 Jan
2018 Feb
2018 Mar
Grand Total
Herts Specialist Palliative Care Referral 115 111 82 90 62 68 71 69 55 80 66 64 933
No Herts Specialist Palliative Care recorded 39 85 72 63 56 54 88 82 85 149 184 178 1135
Grand Total 154 196 154 153 118 122 159 151 140 229 250 242 2068
74.68% 56.63% 53.25% 58.82% 52.54% 55.74% 44.65% 45.70% 39.29% 34.93% 26.40% 26.45% 45.12%
193
Is the service well-led?
Leadership
Leaders had the skills, knowledge and experience required to run a service providing
sustainable care.
The service was managed by an operational lead for end of life care and a consultant in palliative
medicine. Senior managers had the knowledge and experience required and understood the
challenges needed to embed a quality and sustainable service. The end of life team spoke
passionately about the care provided by all staff.
SPC nurses were integrated within the locality community nursing teams. They were line managed
by the locality manager with support from the trust palliative care consultant. Where there were no
locality SPC nurses, the locality managers met regularly with hospice teams to sustain, improve
relationships and working practices.
Leaders were visible and approachable. Staff told us their locality managers operated an open-
door policy and they could discuss any concerns with them. Staff were well connected to other
teams across the trust. Community nurses spoke with the SPC staff regularly. We observed that
the specialist nurses were available to answer telephone queries from community nurses and
supported them on visits when necessary.
There was a clinical competency package for end of life care which supported staff to develop
their skills. This had been developed by the Macmillan clinical education managers, to ensure that
clinical development and training was provided within the community trust. Staff within the trust
complimented the Macmillan team on the support and dedication they had provided to promote
end of life care within the localities.
Vision and strategy
The trust had a vision for what it wanted to achieve and workable plans to turn it into
action.
It was clear that there had been some progress with end of life care in the trust since our last
inspection. A strategy that included partnership working between the trust and the local clinical
commissioning group had been developed, staff had received enhanced training to provide a more
robust service and senior leadership had been addressed to provide a standardised approach to
patient care.
The trusts vision for end of life care was to:
“Ensure health and wellbeing is maximised in the last year of life and that patients and carers are
supported to access appropriate services and jointly plan treatment and a preferred place of
death.”
(Source – End of Life Care Strategy July 2017)
The trust realised that the end of life service required an increased visibility with a robust
participation in order to establish their vision and strategy across all the localities. During our
inspection in March 2016 the trust had not embedded the end of life policy. At this inspection an
updated policy dated June 2017 was in evidence within all the inpatient and community settings.
We saw notice boards dedicated to end of life care which included the community trust vision and
strategy.
The end of life care strategy was underpinned by the national ambitions for palliative and end of
life care (2015) the outcomes for the strategy were:
194
• The number of patients identified to be in the last year of life increases.
• All patients at the end of their life receive high quality, personalised care.
• Patients and carers are supported in identifying and living the life they wish at the end of
their life and planning for a good death.
• All end of life and palliative care services are coordinated effectively.
Delivery of the strategy was overseen by the specialist palliative and end of life care strategic
implementation group chaired by the operations manager.
(Source – End of Life Care Strategy July 2017)
Culture
Managers across the trust promoted a positive culture that supported and valued staff,
creating a sense of common purpose based on shared values.
Across all areas staff said they were committed and passionate about the care they provided to
patients. They reported feeling proud to work within their community settings and were positive
about the job they did.
End of life champions were present within each locality, they spoke of a strong desire to improve
the service and how to cascade information to other staff. However, they told us that it was difficult
to encourage all the community staff to complete the essential objectives for example, some staff
found it difficult to discuss preference of death with patients, this frequently did not get completed
on the electronic system. New focus groups had been set up to improve the motivation and
commitment within the service.
There was an emphasis on the safety and wellbeing of staff. There was a lone working policy and
staff knew how to access it. Systems and processes were in place to ensure staff were safe when
lone-working and working in the community. If staff were deemed at risk, staff would be doubled
up during while attending patients in their homes.
There was a culture of group working within the inpatient and community settings. Staff we spoke
with felt that they were listened to by the management locality teams and could openly raise
concerns. Staff of all levels within the community trust felt they could raise concerns without any
reprisal.
Openness and honesty were encouraged at all levels of the trust and staff felt able to report
incidents and raise concerns. Staff we spoke with had not been involved in failings of care that
would have led to responsibilities to implement duty of candour, but had an awareness of the
policy and where to find it.
We saw cooperative, supportive and appreciative relationships among staff groups. They worked
collaboratively which meant staff were enabled work with and to meet the needs of patients
requiring end of life care.
Governance
There was an effective governance structure in place. Processes and systems of
accountability supported the delivery of the end of life care strategy.
All staff at all levels working within the SPC were clear about who they reported to. There were
clear lines of accountability, and the responsibility for cascading information upwards to senior
managers and downwards to staff in the community was understood by all staff we spoke with.
195
There was a non-executive director on the trust board who had a responsibility for end of life care.
The business performance review presented to the executive board every month. This meant
there was representation at board level of the end of life services offered by the trust.
The end of life steering group addressed the need for quality, improvement, engagement and how
to implement this within the service. This was clear from discussions with them and from minutes
of meetings. This group fed information directly into the assurance report which ensured that end
of life was then discussed at the health care governance committee. The health care governance
committee was attended by the executive and non-executive board members. The purpose of the
meetings was to share information related to each end of life team within the localities and trust
wide issues. The trust had recently implemented an end of life care dashboard which highlighted
areas including pain control, preferred place of death and advanced care planning. Due to the
recent implementation of the dashboard the trust could not provide us with current data regarding
the dashboard standards. The meetings were minuted and circulated to attendees.
Each locality held governance and development meetings which were attended by community
senior sisters, SPC leads and the community hospitals’ locality managers. Shared learning,
incidents and deaths were discussed at each meeting.
Staff groups had regular team meetings and there were plenty of opportunities for staff to speak to
their managers. Staff told us they could raise concerns and ideas and these would be listened to
and taken seriously. The staff received relevant and up-to-date information, for example, feedback
from incidents, during staff meetings.
Management of risk, issues and performance
The trust had effective systems for identifying risks, planning to eliminate or reduce them,
and coping with both the expected and unexpected. However, end of life care was not
always included.
A strategic end of life steering group had been organised to ensure risks within the service were
addressed. However, this was a recent initiative and its effectiveness had not been ascertained.
A task and finish operational group chaired by an executive team member had been developed in
line with the steering group to ensure the service improved and that this was sustained.
During our inspection we requested up to date information about the risk register. We were told
that the risks had been recorded in a locality report. However, incidents and risks, pertaining to the
end of life service, had not been individually identified and reported on. The operational manager
commented on this lack of oversight during our inspection and realised this was an area that
needed to be developed.
All community localities had a specific action plan relating to risks, but not specific to end of life
care. We were told at our inspection that an enhanced training plan had been developed and that
further training on the electronic data system, where risks were recorded, had been rolled out.
The trusts board papers dated July 2017, stated that the mode of communication had been
reflected upon and that it had been identified that specific localities required further training in this
area. The Macmillan clinical education manager discussed with us the importance of ensuring
effective communication with patients, relatives and between staff. Training assistance and
support had then been arranged at different localities ensuring the risk had been addressed and
actioned appropriately.
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Information management
The service had collected, analysed, managed and used information to support its
activities, using secure electronic systems with security safeguards.
The trust had an information governance policy which described how information was managed
and controlled through the trust’s policies and protocols. The policy identified measures that
ensured the security of information that was held about patients and staff. In addition, the policy
identified measures to be implemented in the event of an information governance breach. There
had been no breaches in information governance reported within the community hospitals or the
community, within the past year.
The trust had a data protection policy in place, which incorporated the Data Protection Act 1998;
staff received training on information governance as part of their mandatory training. Information
provided by the trust showed that from April 2017 to March 2018 compliance with information
governance training within the end of life team was at 100%.
The electronic data system had been implemented however some information recorded
electronically was additionally recorded on paper. This led to duplication of work. Some
information recorded on paper was different to that recorded electronically, for example DNACPR
forms.
A clinical dashboard assimilated information such as patients’ preferred place of care, preferred
place of death, advanced care plan and end of life assessment. However, due to recent changes
within the electronic record framework we were unable to gather sufficient information to ascertain
how thoroughly the dashboard had been completed, or how up to date the information was. Senior
staff informed us the end of life dashboard information had shown an improvement in the
compliance regarding patient requested place of care and place of death. Further data provided
confirmed this.
Staff had their own trust email account and received regular updates on, for example, available
training courses they could attend. Staff could also see when their mandatory training was due or
had expired. Staff showed us how they accessed policies, practices and guidance using the
intranet while at locality bases and when out in the community. Staff who worked in the community
had their own laptops and had access to the trust’s network and patient records, providing there
was connectivity. Some staff told us there were network connectivity problems within some rural
areas, however, there were recognised areas staff drove to where connectivity was usually much
better.
Engagement
The trust engaged well with patients, staff, the public and local organisations to plan and
manage appropriate services.
The service consistently sought feedback from the relatives and carers of patients who received
end of life care. Feedback was collated and reported to the areas they related to. Both inpatient
and community settings received reports relating to patient experience. Improvements made as a
result of feedback, for example providing a more detailed list of emergency contact numbers within
the community were included in the reports.
Patients and members of the local community had opportunities to get involved in the
improvement of the services and were encouraged to become volunteers or members of
Hertfordshire Community Trust. We saw evidence of this in relation to the volunteer medicine
group service and the implementation to improve access to end of life care for the Gypsy and
Traveller community across the county.
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The trust ran a survey as part of its ongoing engagement with staff. This covered 16 core
questions and additionally, a small number of ‘hot topic’ questions in order to gain more detailed
feedback. We were not provided with individual results for the inpatient and community settings,
however we were told that generally, the trust had seen an overall trend of improvement,
particularly on staff recommending the trust as a place to work, staff health and wellbeing
questions and the quality of appraisals. The trust had actions for areas of the survey where staff
had reported concerns. For example, to improve staff morale within inpatient settings, which had
led to a health and wellbeing programme being introduced, along with resilience training and
improved use of technology.
Learning, continuous improvement and innovation
The trust was committed to improving services by learning from when things went well,
and when they went wrong, promoting training, research and innovation.
The trust had implemented a strategy, a new governance framework and a vision for the
development of end of life care. They had acted upon shortfalls found in the previous inspection
and were dedicated to improving the service through ongoing reviews. The community trust were
in the process of contributing towards the National Care of the Dying audit.
The Macmillan clinical education team within the trust's specialist palliative care team won a
finalist award in the 'Innovation Excellence' category at the national Macmillan professional awards
in November 2017. The team won the award for delivering innovative and tailored training for
individual clinical teams, introducing a network of champions, which had highlighted end of life
care across the whole of Hertfordshire.
The equality and community engagement forum had heard presentations from several groups
throughout the year, including HCT’s end of life and specialist palliative care team and carers in
Hertfordshire, this was to understand the needs of patients, their families and carers at different
stages in their life. In addition, discussions had been held with regards to collaborative working
had a positive impact on the local community.
The service had improved the care and treatment provided to those in the last 12 months of their
lives by being accessible, specialised and knowledgeable. Priorities for improving the quality of the
service were clear. They were also documented in the strategy. Progress made against the
delivery of priorities were monitored within the localities using action plans.
Accreditations
NHS trusts are able to participate in a number of accreditation schemes whereby the services they
provide are reviewed and a decision is made whether or not to award the service with an
accreditation. A service will be accredited if they are able to demonstrate that they meet a certain
standard of best practice in the given area. An accreditation usually carries an end date (or review
date) whereby the service will need to be re-assessed in order to continue to be accredited.
There were no services reported within inpatient and community services that have been awarded
an accreditation.
(Source: Universal Routine Provider Information Request (RPIR) – P66 Accreditations)