1

Appendix 6C NHS BUDGET AND QUALITY OF CARE (FRANCIS REPORT) FOLLOW UP SCRUTINY KEY QUESTIONS Group 3-

Hertfordshire Community Trust (HCT) Theme 1 Question 1 The Trust aims to ensure the sustainability of the workforce through a range of measures to improve recruitment and retention, and reduce the use of temporary staff, as outlined below. Agency Staff The Trust has a long term aim to reduce agency usage, although challenges with this include national staff shortages leading to higher vacancy levels, the increased acuity of patients requiring additional support, new service developments needing to be staffed quickly and work pressure making agency working an attractive option. We plan to achieve the reduction by improving recruitment and retention to reduce vacancies, seeking funding for additional staff to support patients with higher acuity, further rolling out e-roster to ensure efficient utilisation of staff, and reducing sickness absence through effective management and support. Our short term priority is to work with Herts Procurement and other partners to implement the recently introduced national agency controls, ensuring that workers are obtained only through framework agencies which comply with the national caps on hourly rates. Our breaches are small in number, but these are nevertheless monitored and investigated, and we are working with our temporary staffing provider, NHSP, to replace agency workers with bank staff where possible. Attracting New Staff: We have a comprehensive Resourcing Plan in place and have an active programme of work to improve permanent recruitment, including:

Streamlining processes and reducing time to hire through our new e-recruitment system

Running co-ordinated recruitment campaigns, such as our successful back of bus/tube station campaign and cinema advert, plus open days and attendance at career fairs etc.

Expanding our use of social media (Facebook, Twitter and LinkedIn) for recruitment.

Overseas recruitment, resulting in 14 European nurses being recruited into vacancies in our Community Hospitals last year.

2

Introducing financial incentives, with recruitment and retention premia, Refer a Friend and Golden Hello schemes for difficult to recruit to posts

Working to attract newly qualified staff, encourage returners to work and make best use of retirement flexibilities.

Introducing new roles to attract and retain, such as assistant practitioners, apprenticeships and rotational posts.

Retention: Staff retention is recognised as a major challenge, with the Trust’s voluntary turnover rate rising from 11.65% to 13.73% over the last year. One of the main reasons is work-life balance/work pressure, due to constrained NHS budgets coupled with increasing demand, but the higher rates of pay in London are another factor. In addition our on-going monitoring of turnover and investigation of ‘hot spots’, the Trust aims to improve the retention of its workforce through its:

Active programme of staff engagement, including regular communications, Board/Executive visits, staff events/workshops on key issues, staff forums, annual recognition event and self-managed team project.

Programme to support staff health and wellbeing, including providing a comprehensive Employee Assistance Programme, staff resilience training, access to the Workplace Challenge and a range of information resources.

Support for flexible working, with around half of our workforce on less than full time contracts.

Wide range of leadership development opportunities, including development programmes, action learning sets, quarterly Leaders Forums at two levels, new leaders afternoon tea and annual Leadership Conference.

Range of training and development opportunities for staff, delivered through an internal training programme, plus access to university and online resources.

Training and Development Funding The Trust maximises the sustainability of the training and development it offers through using Trust subject matter experts, national and local bespoke e-learning, Train the Trainer cascade systems and collaborative working with other organisations to deliver its range of programmes. Programmes at the University of Hertfordshire are supported by Health Education England (HEE), with funds based on staff capitation. These have been maintained during 15/16, but are under pressure due the cost of essential full time specialist practice courses. HEE funding also supports apprenticeship and assistant practitioner programmes, along with fast track programmes into nursing. In addition, Workforce Partnership funds have been provided for specialist education. Whilst training levels and funds have largely been maintained to date, over the next year or two they are likely to be impacted by the reductions to HEE funding indicated within the Budget Spending Review and the imposition of the

3

Apprenticeship Levy at 0.5% of the workforce pay bill from April 2017. The full impact of these on training delivery is not yet known. Integrated Working The Trust works with partners at a range of levels to ensure sustainability, for example:

Strategic system wide working through the Partnership Boards looking at future service provision to make best use of limited resources.

Joint working in relation to new models of integrated service delivery, such as HomeFirst and Rapid Response, with health, mental health and social care staff working together around the needs of patients.

Partnership working of workforce leads to implement agency controls, plan for winter pressures, avoid the escalation of pay rates and share learning.

Sharing of resources in areas such as IT support, estate, joint training delivery, outsourced Payroll and Occupational Health etc.

Theme 1 Question 2 In Children’s services, Health Visiting and School Nursing have a key role in prevention and early intervention for all children through delivering the Healthy Child Programme. This is done in conjunction with children’s centres, schools, GPs and other health providers. For many other services in the Trust the focus is on early intervention to support patients with an identified health need and secondary prevention of further health needs. We do this through delivery of services such as HomeFirst and Rapid Response both of which are rapid intervention models to prevent patients requiring admission to hospital or to enable discharge from hospital and longer term case management of patients with more complex needs as well as support through our integrated community teams. Many services are focused on supporting patients with long term conditions to manage their health, maintain their wellbeing and prevent complications eg. Diabetes, stroke services and heart failure. The Trust is increasingly moving towards enabling patients to develop a self-management approach and a work stream to develop this across the organisation is currently being scoped The Trust is also working closely in partnership with other health and social care partners as part of the Integrated Care Programme Boards in both East and North Herts and Herts Valleys. Theme 1 Question 3

The Trust is committed to capturing feedback from patients and carers and has in place a variety of methods including: “Friends and Family Test” (FFT), The

4

Patient Advice and Liaison Service (PALS), direct staff feedback, Comment cards, Complaints/Compliments, NHS Choices, Patient Opinion. All feedback is reported to the Trust Board including actions taken to improve services for our patients and carers.

Over the past year the Trust has invested funding in patient and carer engagement by developing new ways to capture patient and carer feedback including: a revised Trust website that allows direct feedback, an organisational twitter account, a programme of patient surveys across all services and the development of a carers strategy.

In order to capture the views of patients and carers who are less able to provide feedback, the Trust has worked with Healthwatch to develop a model of individual interviews. This has enabled staff and Healthwatch representatives to offer home and clinic visits to capture real time feedback from patients or carers.

In November 2016 the Trust held an Equality and Diversity workshop which included representatives from diverse groups across Hertfordshire. The event facilitated healthy discussion on the Trusts delivery and access to services for disadvantaged groups. The group identified recommendations and improvements that can be made to improve access such as improved signage for HCT units and clear patient information leaflets for those with Learning Disabilities. All improvements are being addressed by the Trust. This workshop will now be a regular occurrence to continue engagement with disadvantaged groups and a further workshop will take place on 26th Feb 2016.

The Trust Board ensures that a patient or carer “story” is presented before each meeting to give the Board direct visibility about areas of the service. These tend to combine both positive and critical feedback. The Board may make recommendations on improving patient and carer experience as a result.

Examples of improvements that have taken place as result of patient and carer feedback include:

The development of a ‘Carers Guide’ that provides comprehensive information on HCT services for carers. This will also be available on the Trust website.

To ensure organisation wide engagement, HCT has added a ‘Carers in Herts’ icon on computer desk tops so that all staff can do an immediate and very quick referral of any Carers to Carers in Herts, where they will be able to access further information and support.

HCT provided additional administrative support to the Paediatric Audiology Service following patient feedback that staffing at the Principal Health Centre was inadequate

HCT improved the Community Hospital Discharge Checklist to include confirmation that family and carers have been fully informed following carer feedback

Access to a private room at baby clinics has been put in place following feedback from parents experiencing a lack of privacy when discussing sensitive and confidential issues.

The Trust monitors patient feedback monthly and current data indicates FFT scores being at 96.3%, which is above the national average of 95%

5

Theme 1 Question 4 The Trust’s NHS contracts have historically included funding for a demographic uplift to take account of increasing numbers of older people across Hertfordshire. Other funding changes have been on the basis of business cases / pilots for specific services, eg Home First in particular localities. As part of the Trust’s internal business planning and budget-setting process, services identify pressures such as increased demand. This is then escalated to commissioners to fund. Any increase in demand that is not funded cannot be met within existing budgets, therefore commissioners are asked to identify how they will limit or manage referrals, thus having an impact on access to some services.

The Trust works closely with other providers across Hertfordshire on the Improving Health Outcomes agenda for people with Learning Disabilities. Part of this work includes sharing the Trust action plan to improve services for patients with LD. Key achievements this year include:

St Albans Specialist Dental Care Service and Podiatry services were

awarded the Purple Star for delivery of high quality care to learning

disability service users

An audit of the quality of care provided to patients with learning disabilities was completed for the first time in 2015. 86.7% of respondents stated they are able to record details of any reasonable adjustments on their healthcare record system

Learning disability champions for adult services identified to raise

awareness across the Trust

Training on reasonable adjustments delivered by learning disability

Expert by Experience as part of corporate induction for HCT staff

Special Dental Care Service finalist in Health Education East of

England’s 2015 Leadership Recognition Awards for its work on learning

disabilities

Easy read Friends and Family Test comment cards produced

The Trust implemented the new NHS mandatory Equality Delivery System2 (EDS2) in partnership with a diverse range of local community and voluntary groups including people with learning disabilities to access how well people from protected groups fare. The Trust has produced the report findings and has an action plan in place to improve services for people from protected groups. The Trust will continue to engage with the local community group and a follow up meeting is planned for 26 February 2016 to review the EDS2 report and action plan. The Trust has invested in engaging with carers as part of the Commissioning for Quality and Innovation (CQUIN) scheme for 15/16. Progress to date includes:

Development of a training package with Carers in Herts for roll out to

HCT staff

6

HCT carer champions identified within each Integrated Care Team (ICT)

and Children’s Specialist Team.

Developed SystmOne electronic system to record carers. Theme 1 Question 5 Efficiency savings are identified by services. Internal and external benchmarking has identified opportunities for productivity gains and in addition services use best practice guidance from within their specialty to improve service delivery through efficiency gains. Cost Improvement Plans (CIPs) are monitored monthly and reported as part of the Trust’s regular financial reporting to the Board. Where schemes are deviating from plan this is investigated with the project manager and alternative savings identified if an initial plan is identified as not delivering in full. The Trust uses external benchmarking information, such as reference costs and NHS benchmarking data to compare its services. CIP scheme ideas are also shared between organisations by the Trust Development Authority and across NHS Community Trusts, enabling the Trust to identify good practice. The quality aspect of CIPs is measured via monthly Business Unit Performance Reviews to ensure there is no impact on service delivery as a result of the financial saving. The Trust can only invest in services if there are savings elsewhere to generate funding or through investment by commissioners. Theme 1 Question 6 HCT has seen some impact of the BCF in 2015/16, eg for the roll out of Rapid Response Teams. We work with commissioners and partners to manage demand but services subject to cuts will not be able to meet demand. HCT has a reference cost of 88 (where 100 is the average and being at 88 says HCT provides services 12% cheaper than its peers) and therefore opportunities for further efficiencies are extremely limited.

7

Hertfordshire Partnership Foundation Trust (HPFT) Theme 1 Question 1 Recruitment to nursing posts is becoming increasingly difficult due to: a national shortage of qualified nurse professionals, an increasing demand based on the introduction of safe staffing levels and a trend towards individuals choosing to work with agencies. Over the last year work has been undertaken to try and encourage agency staff to take up positions on the staff bank bureau or permanent positions with the Trust. The introduction of the agency price cap with effect from 23rd November 2015 to reduce agency pay rates and entice agency staff back into permanent positions should encourage this further. HPFT is working with Trusts throughout Hertfordshire and Bedfordshire to renegotiate agency rates in line with the price caps. The Trust is also about to embark on a communication process to encourage agency staff to return to the NHS on a permanent basis. In hard to fill specialist posts enhanced bank rates are being considered. The Trust has an in- house temporary staffing function which continues to recruit temporary staff. Over the last year bank incentives have been introduced for hard to fill posts and in areas where specialist skills are needed to try and increase the nursing fill rates and encourage staff to join the bank. Substantive members of staff are now enrolled onto the staff bank automatically. The Trust has also introduced recruitment incentives. This includes the ‘Refer a Friend’ scheme in which a member of staff can receive a £500 payment if they refer a friend who is recruited into a role. Another incentive introduced was the ‘Golden Hello’ scheme to encourage permanent recruitment into hard to fill nursing and social worker posts, which proved successful with 58 eligible candidates. Incentive payments were also introduced in specialist and hard to fill posts for bank staff to encourage more staff to work bank.

Retention activities that have been undertaken over the last year or have just been launched are as follows:

Promotion of flexible working

Promotion of flexible retirement

Writing to all staff who could retire over the next 5 years to promote the flexible retirement options and encourage staff to return on a flexible basis to retain skills and knowledge.

The launch of a new exit interview process which will give more in depth information as to why staff are leaving

Undertaking a new employee survey with candidates that have been appointed

Undertaking a survey with new employees after they have been with the Trust for 90 days

Establishing career pathways and succession planning Key recruitment activities that have already been undertaken are as follows:

8

Recruitment fairs in February and June 2015

Targeted recruitment campaigns in Norfolk, and within Community, Older People’s, the CATT team and CAMHS.

Offering 30 student nurses permanent posts with the Trust in 2015 with a further 18 student nurses being offered posts with HPFT so far in 2016.

Bands 1-4 apprenticeships were launched in clinical and non-clinical areas to further support the vacancy situations

Planning for overseas recruitment This work has been successful in reducing the financial strain incurred due to the agency ‘premium’. However, for specialist and shortage skills and also for professional groups with transferable skills which are not confined to the NHS or health sector, ongoing financial pressure remains. Theme 1 Question 2 Within our community based teams we have provided early intervention services for First Episode Psychosis, aligned to previous National Service Frameworks. There is significant regulator focus in relation to national access performance and we have continued to achieve this in relation to both the number of individuals accessing services and the response to new referrals. We are currently working with commissioners on plans to further develop this service in relation to NICE guidance on interventions and potential enhancements. Commissioners have responded positively to the requirement for further investment in this area and discussions are continuing in relation to the development of both service and budget plans. Working with partners in HCT and HCS we are implementing rapid response teams across all localities in the East and North of the county that in addition to the existing Home First Teams are delivering demonstrable reductions in A&E attendances and the improved care and support of the frail elderly and adults with long term conditions. It is expected that full roll out of Home First will be completed by the end of 2016/17. Feedback from those using the servicer and providing care has been very positive. On the West of the county, building on the extensive work on Your Care, Your Future led by the CCG – HPFT are working with HCS and HCT to align our current pathways of care. This approach has been tested in Watford developing a Multi-Speciality Team approach which brings teams together to work with individual complex needs to reduce duplication of service delivery for the individual and their families.

Theme 1 Question 3

9

Following our update last year, we have seen further developments in our ways of gathering feedback in the past year.

During our CQC inspection, which rated our organisation as “good” the following remarks were made as part of the Inspection Report:

We rated Hertfordshire Partnership University NHS Foundation Trust

as good for responsive because:

• Patients felt listened to and were confident that if they had a

complaint it would be acted upon.

• We saw staff changing their approach to patients and carers

when they received feedback.

Following the completion of our last major review of Having your Say (our primary method of feedback) in December 2014, we launched the Friends & Family Test on 1st January 2015. This has seen a steady increase in satisfaction ratings throughout the year resulting in a yearly high score of 90% of people saying they would recommend HPFT services to Friends & Family in November 2015.

As reported last year, the FFT question is the first question in all HPFT surveys. However in those services not using standard surveys (CAMHS, Wellbeing Services, IAPT (Essex)) the Trust has developed postcards to gather feedback from people. In CAMHS clinics this has been particularly successful and a high proportion of young people provide their feedback each month. Additionally we have developed easy read versions of these postcards that are used in our Learning Disability Services. There is currently a project in place trialling this approach in our Dementia services to see if it increases the level of feedback we receive.

Within our Single Point of Access service we have this year launched a new telephone survey that all operators can transfer someone through to after they have spoken to someone. This has seen some success and resulted in those responsible for its development nominated for a staff award in 2015.

We have continued to use the Membership Engagement Services (MES) online survey system to analyse all feedback which we are continually customising to our own needs. All survey data is available to services in real-time and we have system users in all services who are able to access data to see what is being said about the service at a local level.

We have a volunteer team who support service users and carers to give their feedback independent of any staff intervention. This allows service users and carers access to an impartial listening ear and means that answers to questions can be explored for more qualitative feedback. This innovative approach has increased the amount of feedback received.

In addition to the MES systems and general ‘Having your Say’ feedback mechanisms the Trust also has continues to implement our Peer Experience

10

Listening (PEL) service. PELs are service users or carers with lived experience of mental health services who have been trained to support someone in a similar situation and get their feedback on services. Over the past year we have seen increased work with gathering qualitative feedback from carers and also beginning to look at the experience of people’s safety within our inpatient environments.

We find that Peer Experience Listening is a great way to capture feedback from people less readily accessing services as it does not rely on people within service completing surveys. Services users and carers are actively contacted to participate in providing feedback. We have begun 2016 by looking at new ways we can gather feedback from people including trialling the use of ipads, SMS and QR codes to engage more people than ever in providing their feedback. Feedback received feeds into the discussions within service units and within the Board around the budget setting process and the use of finances to develop and improve quality in-year. Theme 1 Question 4 See response above Theme 1 Question 5 We have a well-developed process for the development, planning, implementation and monitoring of efficiency schemes which is built from best practice and guidance from Monitor. As part of this process we require the concurrent and related development of Quality Impact Assessments for each efficiency scheme. Schemes are tested for their robustness and to mitigate risk of slippage or non-delivery early planning seeks to include schemes in excess of the in-year requirement.

In developing schemes we engaged Capita-Res in 2015, a joint team with

clinical expertise and leadership combined with programme management

experience.Our programme is based on clinically appropriate, evidence based

opportunities to provide improved care at reduced cost, with a focus on the

following six principles:

• clinically sensible and achievable

• integration of quality and efficiency – encouraging clinicians to

take ownership of efficiency

• Delivering long term sustainability rather than short term survival

• not about major reconfiguration or transformation

• not about significant redundancies

• Delivering cash release without destabilising existing services

11

To manage this comprehensive programme a governance structure and

approach, reflecting best practice in programme management, has been

developed and agreed by the Board. Further work to refine this has been

undertaken with key workstreams being populated and project leads identified.

The key elements of work commenced in 2015/16 and are already well

underway.

A key element of our programme is to drive improved value through the

effective review and management of placements of service users outside the

Trust. ‘Placements’ here refers to all transfer of service users to external units

or accommodation. Placements can be defined in three categories as:

• Healthcare

• Residential

• Supported living

The trigger for placements usually depends on one or more of the following: 1)

Lack of internal facility to care for particular service user groups; and 2)

Temporary lack of capacity within one or more local services.

To progress this significant programme we are working in partnership with

Central North West London NHS Foundation Trust through an established

‘Placement Efficiency Programme’, with shared learning and ownership. To

ensure placements are clinically appropriate, safe and of high quality, no

placement is agreed until a full risk assessment has been completed and signed

off clinically.

For 2016/17 we have developed an innovation fund derived from efficiencies

and available for recycling to ‘pump-prime’ innovation. This is a key aspect of

our approach to driving continuous improvement.

Theme 1 Question 6 Working with CCG specific and county-wide partners, HPFT are providing leadership and support for the development of a range of system priorities aligned to the BCF. On the East and North of the county our Chief Executive holds the Chair for the Integrated Care Programme Board which is overseeing a range of service initiatives across providers to improve outcomes through integrated service delivery. Working with partners in HCT and HCS we are implementing rapid response teams across all localities in the East and North of the county that in addition to the existing Home First Teams are delivering demonstrable reductions in A&E attendances and the improved care and support of the frail elderly and adults with long term conditions. It is

12

expected that full roll out of Home First will be completed by the end of 2016/17. Feedback from those using the servicer and providing care has been very positive. On the West of the county, building on the extensive work on Your Care, Your Future led by the CCG – HPFT are working with HCS and HCT to align our current pathways of care. This approach has been tested in Watford developing a Multi-Speciality Team approach which brings teams together to work with individual complex needs to reduce duplication of service delivery for the individual and their families.

Response

13

Hertfordshire Community Trust (HCT)

Theme 2 Question 1 The Trust undertakes a Training Needs Analysis (TNA) every year which is sent to each service manager to complete. This is based on service specifications, PDPs, Trust strategies and policies, quality priorities and cquin requirements as well as previous training needs; managers may also added locally identified requirements. This includes all development areas such as clinical skills, leaders, apprenticeships and key skills training; as well as specialist practice to assure the supply of Health Visitors, School Nurses, District Nurses and Community Children’s Nurses The Training Needs Analysis then forms the basis of the Training Plan for the following year. Development is a mixture of internal training programmes – mandatory, clinical, leadership and key skills; commissioned short courses and modules at the University of Hertfordshire and smaller amounts of purchased external training, or use of external trainers to deliver internal programmes.

Formal training programmes are supplemented with coaching and mentoring of individual staff members, reflective supervision and action learning sets, as well as in-service CPD programmes and access to NHS library facilities to support self-directed learning.

With specific regard to patient safety and learning from events, The Trust set up a Serious Incident panel to review all incidents where patients have received harm in order to implement improvements in safer care for our patients. Examples of improvements include-

holistic assessment of new patients to ensure Pressure Areas are recorded and actions taken

Escalation process to ensure patients receive pressure prevention equipment in a timely manner

Provision of cameras for staff to monitor pressure ulcers.

Training of staff in Route Cause Analysis to ensure availability of skilled investigators to carry out in depth review of incidents.

The Trust is committed to sharing improvements in practice with staff and ensures this happens via:

Clinical Matters - a bi-monthly information magazine to ensure all clinical staff learn about the latest changes to clinical practice and innovations in the Trust.

Sharing Lessons In Practice- cascaded to all staff identifying lessons learnt and improvements in practice

Team brief, Trust newsletter also contain information for all staff on changes that improve patient care

Other initiatives that the Trust has put in place over the last year to improve patient safety include:

Training of all Health Visitors and School Nurses in Graded Care Profile Assessment as a result of a Serious Case Review

14

Training Community Hospital staff to use the National Early Warning

System to recognise deteriorating patients

Enrolment in the national Sign Up to Safety Campaign to improve the culture of safety across the Trust

Within the wider leadership development, the Trust has focused on clinical leadership as the key driver of excellent clinical care. A Professional Clinical Leaders Forum has been initiated to bring together clinical (rather than operational) leaders across the organisation, and Clinical Quality Leads are in place within each of the Business Units.

Evaluation of all programmes is based on the Trust priorities to enable the Trust to demonstrate how every training session supports the implementation of good practice. The Trust has been using an impact evaluation questionnaire for some clinical programmes –sent 6 weeks after the training.

The End of Life programme pilot of a confidence questionnaire before/after training is demonstrating increasing confidence of staff with an average score 1.0 increasing to 2.0 (out of 3) across confidence measures for Advanced Care Planning

Leadership programmes which run over a number of months include pre-course and post-course questionnaires to enable individual to identify the impact on their practice. Managers’ feedback is also sought for these programmes

Performance Management – The Appraisal system includes a performance management system based on the Trust values, identifying the behaviours expected of staff. This is also used to identify individual personal development needs. These may also be set to enable individuals to deliver their objectives.

New programmes

A new Clinical Corporate Induction programme began in January 2015. Evaluation of each session shows a confidence rating above 80% to put in practice what has been learnt

The Self-managed Teams programme has continued to roll out across the organisations, working with front line teams to identify issues and processes which impact on the working of the team. Local initiatives have improved the morale and cohesiveness of teams.

Bespoke Induction programmes have been provided to Homefirst and Rapid Response teams in conjunction with Herts County Council to upskill staff members and reinforce cross organisational team working

Following on from the Annual Trust Leaders Conference and quarterly Senior Leaders Forum; a Leaders Forum for Team managers and Clinical Leads has been implemented to increase staff visibility of the wider Trust agendas and provide informal Leadership development

The 2 day Health Coaching programme has been offered to staff to support patients with self-management. Evaluation of programmes identifies an 80% confidence rating to put the techniques into practice and a 90% rating for the quality of the programmes. CPD updates for trained staff are planned for 2016 to support User Self-Management.

15

The Trust captures uses and shares information to inform current and future workforce developments as follows:

Monitoring of workforce KPIs against targets at Business Unit and Trust level:

Staff Surveys – national staff survey

Action to address issues identified in the survey at Trust level are incorporated into the action plan to support the Workforce and OD Strategy, whilst each Business Unit develops a local action plan to address areas of concern specific to its own

Between the annual surveys, the views of staff are gathered through a quarterly ‘pulse’ survey, incorporating the staff Friend and Family Test. The results of these shorter surveys are used to monitor the impact of the actions that have been taken, as well as helping to identify new areas of concern

Qualitative intelligence -Staff and patients feedback is also gathered through our range of engagement activities, such the CEO Strategy events, Director of HR Listening events, Board member visits to services etc Workforce Planning

Workforce planning - The Trust carries out an annual process of workforce planning to inform developments in the workforce numbers, skills requirements and education commissioning needs. Information is gathered from the services on their transformation, service development and CIP plans and this is consolidated into a Trust workforce plan with associated narrative.

Partnership working with other agencies - The Trust works closely with a range of partners (primary care, acute, mental health, social care, education, Health Education England, etc.) and uses feedback and information from meetings and discussions with these partners to inform various workforce developments, for example in relation to training needs, organisational development requirements and changes to working practices.

External developments - The Trust keeps abreast of changes in national policy, professional requirements, employment legislation etc., acting on any developments as appropriate and ensuring that managers and staff are informed of the changes that relate to them. This encompasses a wide range of areas from the Francis Report, 5 Year Forward View, Cater Report, etc., to changes in employment legislation. The Trust also uses external benchmarking information, for example Workforce Information shared between aspirant Community NHS Foundation Trusts. Theme 2 Question 2 Not applicable to HCT. Theme 2 Question 3

16

The Board receives the following standing reports which address quality and performance. Each of these is also considered by a Board Committee, as identified below;

Integrated Business Performance report (IBPR) Strategy and resources Committee

Quarterly quality report - Healthcare Governance Committee

Complaints Report – Healthcare Governance Committee

Serious Incident Report – Healthcare Governance Committee

Safe Staffing report – Healthcare Governance Committee

Finance Report – Strategy and Resources Committee

Workforce Report – Strategy and Resources Committee All of the above are considered in Part 1 of a Board meeting (Meeting in Public) although (a) serious incidents which may involve patient information which may identify a patient/members of staff and (b) new incidents arising, are reported in Part 2 (meeting in private). In addition:

Business Unit Performance Reviews by the Executive team are held monthly for each of the three Trust’s business units – Adult Core Services, East and North Herts; Adult Core Services, Herts valleys and Children’s Services

Any achievements and risks to quality are included in individual Directors’ reports to the Board.

There is a Board Escalation process whereby any significant quality or performance issues which arise between Board/Committee meetings are shared with the Board.

The Non-Executive Director Chairs of each Board Committee provide a ‘Committee Chairs Report’ to each meeting of the Board.

Periodic ‘ad hoc’ reports may be submitted to the Board – e.g Saville Assurance, nurse and medical revalidation, PSED.

The Board has requested a review of the Integrated Business Performance Report so that it better reports and triangulates quality, workforce and finance. The trust will be implementing a revised report from April 2016. The Board has reviewed its Board governance framework and is currently completing a self-assessment of the Well led Framework. The outcome of this will enable us to further improve accountability and governance from frontline to the Board. Responding to Serious Incidents

We are working to embed learning from incidents across the Trust and have made good progress, although there is more for us to do. Incidents and the learning from them are raised regularly in our Clinical Matters newsletter. Teams have been asked to review incidents, not just in their own area, and draw learning from them in their team meetings.

17

There is a regular communication, Sharing Lessons in Practice which highlight areas of learning for discussion in team meetings. The need to do this is reinforced through our Clinical Matters newsletter and through other communication routes. Drug errors generally relate to the administration of insulin and warfarin.

Challenges The Trust had a full CQC Inspection in February 2015, and received a rating of ‘Requires Improvement’. The Lead Inspector described the Trust as being ‘a short walk to good’. Over the last year we have tackled the compliance actions and concentrated on improvements to address safety, and to ensure that clinical practice improvements are fully embedded. We are preparing for re-inspection this Spring. In February HMP The Mount was re-inspected by the CQC and all compliance actions have now been met. Theme 2 Question 4 The Trust values and behaviours are promoted at every opportunity to ensure staff are familiar with the standard of care expected within the organisation. This includes regular information provided via the Trust website, newsletter, Clinical Matters and the CEO updates that are sent to all staff. Trust values are displayed on posters across the Trust for staff, patients and their families. HCT recruitment process includes information on the Trust’s values available to all candidates in advertisements and on job descriptions. Recruiting managers are provided with example behaviours against the values to incorporate appropriately into the person specification. Recruiting managers are expected to assess the candidates’ fit with Trust values and behaviours during the course of the interview. The Trust has recently introduced a new electronic recruitment process (TRAC) to improve efficiency of the recruitment process and increase involvement of the recruiting manager. On commencement with the Trust all new staff must undertake the 2 day induction training which includes information on the Trust values and behaviours delivered by the CEO. Agency staff are provided with this information at local level by the line manager on initial commencement with the Trust. The Trust continues to use the Trust values as the basis of Appraisal Performance Management. The current behaviour standards have been in place for 2 years and are currently under review to confirm they still reflect the key requirements for the Trust. Staff who fail to demonstrate Trust values and behaviours will be supported initially with additional training before instigation of the Trust disciplinary process. Last year the Trust identified a Quality Priority on care and compassion to drive up the quality of care provided by staff. The quality Priority focuses on a number of actions including, staff attitude and behaviour, complaints regarding standard

18

of care as well as compliments. The outcomes are monitored monthly with actions identified to achieve improvements. Monitoring of quality metrics within the organisation is in place across all areas including monthly board reports, individual monthly business unit reports, and strategic groups such as the Workforce and OD committee. Quality metrics include: complaints regarding standards and staff attitudes, induction training attendance of all new staff, currently at 97%, Staff appraisal 87%. Theme 2 Question 5 All formal complaints are reported at service level in a weekly complaints SITREP and shared with the General Managers and Service managers across the Trust. The exec team are made aware of all complaints at the monthly Business Unit Review meetings as well as immediate escalation of high level complaints. The Trust produces a quarterly complaints report for the Trust Board and commissioners. Trends in complaints are noted with actions agreed or requested by the Board. Informal complaints to staff that can be resolved at the point of contact are recorded at service level and shared with the Trust Complaints department. All services are required to report on actions taken as a result of complaints and service changes implemented. Improvements made as a result of complaints are shared with all HCT staff via the complaints report, Noticeboard, Clinical Matters and Business Unit Bulletins Examples of service improvements as a result of complaints include:

Changes to patient access to physiotherapy appointments.

Parking information added to patient letters

Improvements in the quality of patient meals served in Community Hospital

Feedback regarding waiting times for apt in west Herts supported a business case for increased resources to reduce the waiting time.

Current and future improvements include:

Working with West Herts Hospital Trust (WHHT) to improve the patient discharge process

Review of Physiotherapy services to improve access and patient expectations

Capturing complaint data from those in the 9 characteristic groups to ensure equal access

Development of and End of Life Strategy to improve Care for those at the end of their life

To encourage openness and transparency the Trust offers all complainants and their families the opportunity to meet with Trust staff to discuss their concerns in more detail and agree a mutual resolution to their complaint. The Trust meets its Statutory Duty of Candour by being open and transparent in the investigation of complaints and providing apologies to those harmed or affected where it is appropriate to do so. Last year the Trust responded to 99.6% of complaints within the agreed timescales of 25 days.

19

HCT are active members of the regional complaints managers forum and work to the Hertfordshire’s joint complaints protocol, which includes health and social care partners. This enables HCT to work jointly to investigate complaints regarding a patients pathway of care delivered by several agencies. HCT has fostered good working relationships with complaints managers in other organisations to ensure that the process runs smoothly and enables and timely responses to complainants.

HCT participated in the complaints mapping exercise undertaken by Healthwatch Hertfordshire as well as a workshop regarding young people and complaints. Staff complaints are dealt with in the first instance by the manager with escalation to Human Resources if the matter cannot be resolved. The Trust has in place a Whistle Blowing Policy for staff who feel they need to alert the executive members of serious concerns. All matter raised are dealt with in strict confidence to protect the staff member. Theme 2 Question 6 The Trust works with other providers as part of the Integrated Care Programme Board to ensure alignment of physical and mental health in care delivery. The Trust has also developed Rapid Response and HomeFirst teams which provide physical and mental health services in integrated teams. In Herts Valleys work has also commenced on the MST model of integrated working in localities. A challenges has been to provide the right framework and governance arrangements for staff to work in integrated teams on the ground and “work-arounds” for IT as don’t yet have shared records. Step 2 / PALMs – child and adolescent mental health services provided by HCT is fully integrated with physical health services. Step 2 also works very closely with school nursing and health visiting particularly and PALMS liaises with specialists in physical health eg community paediatricians, therapists and nurses. Health visiting and FNP programme are delivering the Healthy Child Programme which encompasses both the physical and emotional health of the child and mother. Theme 2 Question 7 Adult services have undertaken a wide range of work to improve the patient experience when they have multiple providers delivering their care. Roll out of HomeFirst in the east and north of the county is an integrated health and social care model of delivery. Staff are co-located and work together to deliver a co-ordinated personalised service.

20

In Watford a pilot for multi specialist team approach has been undertaken, where staff work together to deliver a co-ordinated approach to service delivery based on what the patient wants. There has been the roll out of rapid response service in the west of the county- which now covers three of the four localities. A pilot of employing health care assistants to undertake home care where there are shortages of level home care provision has also been used in Herts valley, supporting large number of patients to stay in their homes. The Better Care fund has been used for a wide range of the above developments, and all have evaluated well for a good patient experience. The challenges being faced in delivering person centred care are:

Recruitment to particular professions and in particular geographical areas

e.g. Hertsmere where there is the attraction of London weighting payments.

The lack of IT systems linking to create a single record

Capacity to plan effectively across agencies, change practice and at the

same time maintain existing services.

Theme 2 Question 8 During 2015, HCT has started the final phase of deploying a full electronic clinical record (ECR) across all community services. This programme began in 2011 and is now in the final stages meaning all HCT community services will have fully integrated electronic clinical records that can be shared across services and into GP practices. The programme is due to finish in November 2016. Part of the implementation includes ‘connect-disconnect’ tools that facilitate access to records when there is no mobile signal. Our experience has shown that mobile phone signal coverage in Hertfordshire can be patchy. This means staff cannot rely solely on the mobile networks. Connect-disconnect allows us to update clinical records whenever there is a signal because the software automatically connects – without the need for staff to intervene. In addition, HCT has also introduced ‘mi-fi’ signal boosters for use in problem areas. It is expected that these technologies along with 4G will put an end to signal problems. This means a true, remote access records for all community staff. Significant investment has been made during 2015 to implement electronic clinical records in community hospitals. HCT received criticism from the Care Quality Commission (CQC) about the consistency and quality of records in hospitals. This implementation will fully digitise those units. It gives us access to a full electronic bed board, patient notes, handover

21

documentation and discharge summaries. The deployment started in January 2016 and is expected to finish in November 2016. Later in 2016, HCT will migrate email services to NHSMail2. This is a significant change that opens up enormous possibilities for telehealth. NHSMail2 includes Skype for Business. It is linked to all other NHS staff using the system (expected 80% of the entire NHS). This means that a secure communications channel will be available for all NHS Staff to video conference one another e.g. Nurse to GP but also clinician to patient. This is not local to Herts. So a clinician here could Skype a colleague anywhere in the country. A number of trials are currently underway with HCT services that have shown positive results. Our target implementation date is December 2016. In November 2015, HCT re-launched its website. The new site makes it much easier to access information about our services. This includes contact details and opening hours as well as key information about how to prepare for clinical visits and appointments. HCT is rapidly expanding its social media presence through use of Twitter, Facebook and YouTube. Over the next year we will create more content to aid patient self-management. This includes instructional videos and signposting for services. HCT is an active member of the Hertfordshire Health and Social Care Data Integration Programme Board. Through this group HCT is pursuing interoperability standards and overcoming integration issues. By autumn 2016, HCT will have fully implemented Wi-Fi in all our buildings. A key aim for 2017 is to implement a corporate Wi-Fi across the Hertfordshire Health and Social Care estate enabling seamless access for all health and social care staff to the trusted networks in every building in the county. Theme 2 Question 9

Quality Improvement over the last year has been driven by the ongoing delivery of the Trust’s Quality Strategy and the actions we have set out in the Quality Improvement Plan, developed following our full CQC Inspection. This has focused on addressing all the ‘must do’s’ and ‘should do’s’ identified within the report. The Trust continues to deliver Commissioning for Quality and Innovation (CQUIN) schemes agreed with its commissioners and the programme of Quality Priorities which drive quality improvement across key areas agreed by the Board. The Trust acknowledges the role of effective leadership in driving innovation and a programme of leadership development continues. We have strengthened the professional clinical leadership within our services which drives quality improvement at frontline level and have established a Professional Clinical Leaders Group which brings these leads together to share innovations and best practice and to ensure its delivery.

22

The Trust has agreed a change methodology – Plan, Do, Study, Assess – and is rolling this out systematically. This helps us implement change more successfully. The Trust has a transformation team to drive forward service redesign n and quality improvement linked to the Clinical Strategy. There has been a lack of continuity of the team and recruitment to the Head of Transformation role has been a challenge, although we have now recruited and go into 2016 with a resourced team.

23

Hertfordshire Partnership Foundation Trust (HPFT) Theme 2 Question 1 The Trust undertakes a strategic training needs analysis process which commences in Q3 each year. A template is forwarded to all of the business units and professional leads so that they can put forward priority training needs in line with their operational plans and service developments for the year ahead. Once collated, a review of the needs analysis is undertaken by the strategic workforce development group to ensure that the investment in training is aligned to meet the service needs. Alongside of this each business unit has a workforce plan looking at the future establishment requirements. As an organisation we have under taken a talent mapping exercise to highlight critical posts and develop a plan for succession into these. This process has identified development needs and targeted programmes of development.

Some of the new programmes in the last two years have included our leadership academy which is delivered through the University and develops two levels of leader. In addition in 2015 we have developed and are running multiple cohorts of a managing service excellence programme which a pragmatic programme is focusing on service performance and people management.

The Trust is part of the streamlining programme of work to improve the efficiency of statutory and mandatory training (without compromising on safety). We keep a record on compliance rates as well as DNA rates and undertake evaluations of our internal and externally commissioned courses.

As a member of the East of England Region, the organisation has a programme of activity within the ‘Talent for Care’ programme of work, which includes our apprenticeship offering and in 2015 we recruited a cohort of apprentices. Within this, we are working to clarify a clear route into nursing looking at career pathway options to fill a pipeline of talent for the future.

The organisation is a pilot for the think ahead programme (social workers) and continues to provide education and training for students and trainee health professionals Theme 2 Question 2 and Theme 2 Question 3 Quality Assurance As a Foundation Trust we abide by the quality governance standards set by Monitor. After publishing our initial response to Francis and related national reports in February 2014 we shared our review of progress last November. We are confident that our quality assurance processes are robust.

24

Our integrated governance structure has clear lines of accountability to the Board and full support of Non-Executive Directors. It is complemented by the practice governance structure in the three Strategic Business Units, with practice governance leads being members of each SBU’s senior management team. The Executive Team hold regular performance review meetings with the SBUs in turn, where these senior management teams are closely questioned on details of their quarterly performance. In April 2015 we were subject to a comprehensive inspection by the CQC. The Trust were rated as Good overall which places us in the top quartile of providers in England. The CQC rated us as Good for the well-led domain and commented on the way the executive team demonstrated cohesion and a determination to improve and enhance the quality of care provided to those who use services within the Trust. Serious Incidents Our numbers of Serious Incidents remain similar to previous years. The rate of suicide remains below the national rate and we continue to work on projects such as the Spot the Signs campaign. During the last year the Trust has seen significant improvements in the management of falls and pressure ulcers. There has been an overall reduction in falls of 28% and the Trust has not reported any grade 3 or 4 pressure ulcers. We have aspired to have no suicides by those under our care. Whilst this remains a very challenging aim for us all, we believe that it ensures no complacency from practitioners who each day prevent suicides through their expertise in clinical risk assessment and management. Key Challenges and Actions

a. As in many parts of the NHS, recruitment and retention of staff continues

to be a major issue for us. Following Francis we now report openly our

inpatient staffing levels. Our Workforce and Organisational Strategy

(2014 to 2017) lays out the ways we are addressing such challenges.

b. We continue to work to achieve our ambition of zero suicide. Whilst our

rate of suicide is below the national rate we continue to strive to reduce

the number of suicides. Each case is reviewed and investigated fully to

determine areas of learning which are shared across the organisation.

c. The Trust is committed to our Making our Services Safer (MOSS)

strategy focussed on reducing violence and aggression in our services

and the impact this has on both service users and staff. Our Deputy CEO

leads the Trust wide group which oversees the implementation of Trust

wide plans.

d. The Trust has committed to the national Sign up to Safety Campaign with

3 key areas of falls reduction, MOSS and leadership in patient safety.

In addition the CQC Inspection report detailed that we were “good” under the Well-Led criteria and they said in their final report:

• Managers had both the support and autonomy to do their jobs

effectively and were confident they could raise issues of

concern with senior colleagues.

25

• Managers proactively attempted to engage staff in regular

briefings and meetings. • Staff felt that poor performance was not tolerated and

managers dealt effectively with performance issues. • Staff said they felt confident to raise concerns to senior

colleagues or to use the whistleblowing procedure and felt their

concerns would be taken seriously. • Well-developed audits were in place to monitor service quality.

For example, peer led assessments took place to improve the

quality of the service provided such as from the Royal College of

Psychiatrists’ quality networks. Theme 2 Question 4 We have introduced a Managing Service Excellence Programme which is focussed on middle managers. The programme is pragmatic and focuses on real scenarios and how to use Trust policy to improve the workplace culture and take collective ownership. Over 90% of staff have attended values focussed workshops to embed the Trusts values which support our Customer Care Strategy. We have also introduced values based recruitment and delivered training to managers involved in recruitment on how to use the scenarios and behavioural questions. Staff are encouraged to challenge each other in a professional manner over the quality of care their team provides. Managers through experience and training develop skills in giving their team members the confidence to approach their work in this way. Occasionally, staff may feel they need anonymity and access to an external organisation over their issue. In such situations they use our well established Whistleblowing Policy and Procedures. Through quality visits we make sure staff are fully aware of this option. Issues raised through this channel are dealt with individually and themes are also discreetly considered at the Integrated Governance Committee. Theme 2 Question 5 All comments, compliments and complaints from Trust services are directed to the Complaints and Service Experience department to ensure they are logged and that the complainant receives an acknowledgement within 3 working days. The department also includes the Patient Advice and Liaison Service (PALS) and provides service user, carer and staff literature to all services to ensure that service users and carers have easy access to making a complaint or raising a concern. To help to diffuse concerns/complaints at an early stage there are dedicated PALS and Complaints email addresses which help to provide choice to service users, carers and their families around how they would like their concerns to be

26

raised. There is also an accessible web form on our website that can be used to raise any concerns or complaints. HPFT provides Having Your Say patient/carer experience questionnaires to all service users and carers and the questionnaires also include the option to state whether the service user or carer wishes their comments to be viewed as a complaint.

Learning from complaints The Complaints & Service Experience Department prepare monthly and quarterly reports which show how the Trust is learning from complaints. As a matter of course quarterly and annual reports are shared with the Service User and Carer Engagement Committee (SUCEG) who in turn escalate any issues higher up the governance chain as well as ensuring that good practice is spread throughout the Trust as a matter of course. This group includes representatives from HPFT services, third sector services as well as HPFT service user and carer council representatives to ensure added scrutiny from those with lived experience. The Executive and Trust Board also receive all reports. Where there is significant learning from a complaint, this is shared across HPFT through the practice governance network using practice learning notes. These help to ensure that clinical practice responds to evidence of changes needed within frontline services. Theme 2 Question 6 Working with CCG specific and county-wide partners, HPFT are providing leadership and support for the development of a range of system priorities aligned to the BCF.

On the East and North of the county our Chief Executive holds the Chair for the Integrated Care Programme Board which is overseeing a range of service initiatives across providers to improve outcomes through integrated service delivery.

Working with partners in HCT and HCS we are implementing rapid response teams across all localities in the East and North of the county that in addition to the existing Home First Teams are delivering demonstrable reductions in A&E attendances and the improved care and support of the frail elderly and adults with long term conditions. It is expected that full roll out of Home First will be completed by the end of 2016/17.

Feedback from those using the servicer and providing care has been very positive.

On the West of the county, building on the extensive work on Your Care, Your Future led by the CCG – HPFT are working with HCS and HCT to align our current pathways of care. This approach has been tested in

27

Watford developing a Multi-Speciality Team approach which brings teams together to work with individual complex needs to reduce duplication of service delivery for the individual and their families.

During 2016/17 having tested this model it is planned to implement this within the remaining 3 localities alongside maintaining the momentum set by Your Care, Your Future. Theme 2 Question 7 See response above Theme 2 Question 8 See response above Theme 2 Question 9 Over the past 12 months we have begun to explore the opportunities, barriers and enablers to delivering change and improvement in a ‘continuous quality improvement’ mode. We have started to develop an informal network of ‘Quality Improvement (QI) enthusiasts’ and have helped them to understand the principles, techniques and required behaviours to help drive improvement and in turn they are helping to shape our emergent Quality Improvement approach. This network is truly diverse, comprised of a range of disciplines (medical, nursing, corporate support staff etc.) and people at differing levels of seniority in the organisation. Latterly we have begun to extend this network into service user and carer representatives. A milestone on this journey was the hugely successful HPFT Futures event held on 13th November 2015. This event both showcased the Quality Improvement activity that is already ongoing in the organisation and also empowered and inspired colleagues to take their own first steps towards continuously improving quality. Some examples of the quality improvements achieved in the year include:

Improved service user medication management in our rehabilitation services

Using Audit to drive quality improvement

Delivering nutrition through Ice Cream in a dementia unit

Intervening earlier in crisis (Older People services)

Reducing administrative tasks in SPA to increase available time to deliver the core service

Reduction in psychotropic medication prescription for management of behavioural conditions in Learning Disability services

28

As we move into 2016, we are strengthening our culture and organisational strategy centred around the theme of quality and delivering ‘Great Care, Great Outcomes’ and supported by a Collective Leadership approach. The combination of our Collective Leadership and Quality Improvement approaches and the organisational refocus on quality that we achieve through our revised strategy will further encourage and enable innovation and quality improvement at all levels of the organisation.