2020/21 - nhs

Quality Account2020/21

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Section 1:

Introduction

Statement on Quality from the Chief Executive

About Our Trust

Section 2:

Review of Quality Performance 2020/21

Theme 1 – Providing Safe and Effective Care and Improving Outcomes

Theme 2 – Ensuring Services are Caring and Responsive

Theme 3 – Building a Quality Culture

CQC Inspection

Priority 9: Improving our infrastructure

Quality Performance Indicators

Our Quality and Improvement Priorities for 2021/22

A Review of Our Services

CQC Registration

Inclusion and Diversity

Freedom to Speak Up

Participation in Clinical Audits and National Confidential Enquiries

Research

CQUIN Performance

Data Quality

NHS Number and General Medical Practice Code Validity

Information Governance

Clinical Coding Error Rate

Section 3:

Appendix 1: Quality Performance Indicators

Appendix 2: Our 2020/21 Quality Objectives

Appendix 3: Participation in Clinical Audits and National Confidential Enquiries

Appendix 4: National Confidential Enquiries for 2020/21

Appendix 5: National Clinical Audits Reviewed During 2020/21

Appendix 6: Local Clinical Audits Completed During 2020/21

Appendix 7: Participant Recruitment to Research

Appendix 8: Glossary

Section 4:

Annex 1: Statement of Directors’ Responsibilities in respect of the Quality Account

Annex 2: Statement from Healthwatch Hertfordshire

Annex 3: Herts Valley Clinical Commissioning Group’s response to the Quality Account of

West Hertfordshire Hospitals NHS Trust for 2020/21

Annex 4: Hertfordshire Health Scrutiny Committee

Contents

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Section 1. IntroductionThe Quality Account is an annual report which reviews the quality of services provided by an NHS healthcareorganisation. Quality Accounts aim to increase public accountability and drive quality improvements in the NHS. OurQuality Account looks back on how well we have done in the past year at achieving the goals which we set ourselves.It also looks to the year ahead and defines what our priorities for quality improvements will be and how we expect toachieve and monitor them. The quality of the services is measured by looking at patient safety, the effectiveness oftreatments patients receive and patient feedback about the care provided.

Statement on quality from the Chief ExecutiveOur 2020/21 Quality Account looks back at a year where we faced our greatest challenge from the COVID-19pandemic. Through our skilled and dedicated workforce, we responded to the pandemic’s challenges and strived toprovide safe and effective care to our patients.

We remain immensely proud of our response to the first and second wave of the pandemic. Our teams have shownincredible resilience and ingenuity and the support that we have received from our community has been overwhelming.Inevitably, the pandemic has impacted our staff wellbeing and we have put in place many sources of pastoral andpsychological support to assist with stress, anxiety and improve staff health and well-being.

As you would expect, our ability to deliver services and meet performance targets continued to be adversely affected bythe pandemic and is not reflective of our mission to provide the very best care possible.

Attendances at all our Urgent and Emergency Departments (ED) were lower in 2020/21 compared to 2019/20 becauseof the pandemic. We experienced the second highest ambulance conveyance rate in the region, and we were the onlyorganisation to experience over a 5% increase in conveyances. In 2020/21, 81% of our patients were seen within 4hours in our ED, which was a similar position to 2019/20, but below the national target of 95%.

Our planned care performance was severely affected because of the national suspension of elective care during the firstand second wave of the pandemic. Against the Referral to Treatment (RTT) standard, our 52-week breaches were 1702as of March 2021. Similarly, we were unable to sustain our previously consistent achievement in meeting diagnosticwaiting time standards and our performance fell below the 99% standard throughout the year.

Treatment for the most urgent, time critical patients including cancer continued during the pandemic with, just under4000 patients being treated by Trust teams at independent sector (ISP) facilities. This enabled us to improve andmaintain performance against the 62-day GP referral to treatment cancer waiting time standard.

During 2020/21, we implemented shadow reporting for the new 28-day faster diagnosis standard of 75% which weconsistently achieved throughout the year. This puts us in a good position for 2021/22 when this target goes live.The Trust’s overall performance against the 62-day referral to first definitive treatment standard was 82.2% in 2020/21,in comparison to 82% in 2019/20 and 82.6% in 2018/19. The target is 85%.

We were delighted to receive two Healthcare Financial Management Association (HFMA) Awards in 2020. We receivedthe Excellence in Organisational Development category which acknowledged the senior medics’ assessment and reviewtrial (SMART) initiative. We also received HFMA’s HR Team of the Year award.

In addition, our Chief Nurse Tracey Carter and respiratory consultant Dr Matthew Knight were appointed MBEs(Member of the Order of the British Empire) for services to the NHS in the Queen’s Birthday 2020 Honours List. Our partnership with the Royal Free London NHS Foundation Trust continued in 2020/21 which supports the Trust’scentral quality improvement (QI) hub. The hub uses a consistent QI methodology developed by the institute ofHealthcare Improvement (IHI) to facilitate service improvements and drive quality commitment throughout every area of

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the Trust. During the pandemic, work focused on harm free care reviews to keep our patients safe with the programmewidening its scope again at the end of the year as services restarted.

In February 2020, the Care Quality Commission (CQC) inspected urgent and emergency care, medical care (includingolder people), and surgery at Watford General Hospital. The minor injuries unit at St Albans City Hospital and theurgent treatment centre at Hemel Hempstead Hospital were also inspected. We achieved marked improvements inurgent and emergency care across our hospital sites. There was a review of our leadership under the CQC’s ‘well led’regime where we improved our rating to ‘good’.

Before the outbreak of COVID-19 , our integrated care partnership (ICP) work was well underway with goodengagement. It responded well to the test of the pandemic and worked together in the best interests of patients onchanges to support people in care homes, facilitate rapid discharges from hospital and manage people safely at homethrough our virtual hospital model. Locally, we are working with other health and care organisations to change the waywe care for children, people with diabetes, and frail people, to help them stay as healthy as possible and reduce theirneed to spend time in hospital. Our new clinical strategy for the next 5 years will focus on collaboration with ourstrategic partners to improve clinical outcomes for our patients.

Although the pandemic limited our services in many ways – we stopped accepting referrals except for urgent andcancer cases – it also accelerated new ways of digital working. We introduced a ‘virtual hospital’ where patients wereremotely monitored from home which prevented unnecessary admissions while keeping patient safe. This enabled us tomonitor and manage over 4000 patients by the end of the year. It is estimated that at least 1000 “bed days” havebeen saved since the pilot started. We have continued to implement changes to improve the experience of patientssuch as the opening of the new acute respiratory care unit, new secure rooms in the children’s emergency department,a new CT scanner in St Albans, which came into use in October 2020, a new outpatient digital call centre, neworthopaedic centre in St Albans and a new Urgent Treatment Centre in Watford.

We remain well prepared as a Trust for managing any further waves of COVID-19. We have learned new ways ofworking including testing and vaccinating our staff to manage the impact of the virus. We have developed differentways to treat the disease leading to better clinical outcomes for patients. Our continued innovation has also ensuredthe continuation of non-urgent appointments which is great news for our patients.

In closing, we would like to acknowledge the support from our community which has been overwhelming. We wouldlike to thank and pay tribute to our staff, volunteers and our health and social care partners who have worked soincredibly hard to provide the very best care for our patients in the most challenging of years.

Christine AllenChief Executive

About Our TrustWest Hertfordshire Hospitals NHS Trust provides acute healthcare services to a core catchment population ofapproximately half a million people living in West Hertfordshire and the surrounding area. The Trust also provides arange of more specialist services to a wider population, serving residents of North London, Bedfordshire,Buckinghamshire, and East Hertfordshire. Overall, the population served by the Trust is relatively affluent, but there aresome areas of deprivation.

With approximately 5,400 staff and 593 volunteers working across our three hospital sites in Watford, St Albans, andHemel Hempstead we are one of the largest employers locally. There are 674 inpatient beds (including surge capacity)throughout the Trust, the majority being at Watford General Hospital.

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Watford General Hospital • Inpatient emergency and intensive care• Elective care for higher risk patients• Outpatients and diagnostics services• 613 beds and nine theatres• Women's and children's services

Hemel Hempstead Hospital • UTC open seven days a week, 8am to 10pm• Diagnostic services, including MRI and pathology• Outpatient services• Endoscopy and bowel cancer screening

St Albans City Hospital • Elective care• Outpatient and diagnostic services• 40 beds and six theatres• Minor injuries unit (closed April 2020).

Section 2This section of our Quality Account looks back over the last year and reviews progress against the quality priorities weset ourselves for 2020/21. It also describes the areas for improvement in the quality of our services that we intend toprovide in 2021/22.

The Trust is a member of the Partnership Board for the Integrated Care System (ICS) and of the place-based partnershipSouth and West Herts Health and Care Partnership, known as ‘the Partnership’. Christine Allen, CEO of the Trust, chairsthe Board of the Partnership.

There is a programme of work to support the integration work in West Herts and staff from the Trust are well-represented across all workstreams. The programme has two main elements – the establishment of the partnership andthe transformation required to implement integrated working.

The Trust is involved in all of the system transformation projects which include:• Implementation of more virtual hospital pathways (adding to the COVID virtual hospital)• System transformation of respiratory care• The Herts Integrated Diabetes Service• Transforming care and services for Children and Young People• Frailty

The key focus for the Partnership over the coming months is finalising the Health and Care Strategy and agreeing thegovernance framework for the Partnership, as well as progressing the key service transformation priorities set outabove.

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Review of Quality Performance 2020/21

Our quality priorities for 2020/21 were agreed to ensure we continued to deliver on our Trust Strategy and our QualityCommitment of ‘The West Herts Way’, to embed a culture of quality and service improvement.

The Quality Commitment

We identified three core themes which set the basis for our 2020/21 quality priorities:

Theme 1 – Providing safe and effective care and improving outcomes

Theme 2 – Ensuring our services are caring and responsive

Theme 3 – Building a quality culture

Underlying the three themes are nine priorities for improvement. Each priority has key areas for us to focus on.

Our themes and priorities consider our Trust Quality Strategy, national targets, feedback from staff, patients, ourcommissioners and partners and the findings of CQC inspections.


Priority 1: Providing Safe Care and Improving Outcomes

Mortality and learning from deaths

Harm free care

Hand hygiene compliance

Maintaining effective infection prevention and control standards

Medicine storage compliance

Seven-day services

Priority 2: Implementing Best Practice and Reducing Clinical Variation

Care pathway redesign

Getting it right first time (GIRFT)

Executive Leads: Chief Medical Officer and Chief Nurse

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Theme 2 – Ensuring our Services are Caring and Responsive

Priority 3: Improving Patient Experience

Discharge

Booking processes

Volunteers

Priority 4: Improving Care for Patients with Additional Needs

Physical and sensory disabilities

Mental health and learning disabilities

Safeguarding

Priority 5: Improving Access

Time to first assessment and early discharge in the Emergency Department

Referral to treatment (RTT) performance and choice at 26 weeks

Performance against the 62-day standard for challenged pathways

Executive Leads: Chief Operating Officer and Chief Nurse


Priority 6: Happy, Healthy Well Supported Staff

Recruitment and retention

Staff engagement

Learning and development

Priority 7: Quality Improvement and Clinical Leadership

Quality Hub and Quality Improvement Framework

Clinical Leader Development Programme

Priority 8: Quality Governance with Risk Management and Learning

Action plans and organisation wide learning

Duty of Candour for moderate harms and above

Priority 9: Improving our Infrastructure

Improving the Quality of our Estates, IT Systems and Facilities.

Executive Leads: Chief People Officer, Chief Medical Officer and Chief Nurse

During this reporting period we saw the impact of the COVID-19 global pandemic. How this affected our performanceand ability to achieve our targets is reflected throughout the document.

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In 2020, the Trust committed to ensuring that our patients received the highest quality of care and the best possibleoutcomes.


In order to achieve this priority, we focussed on six key areas: • Mortality and Learning from Deaths• Harm Free Care• Hand Hygiene Compliance• Infection Prevention and Control Standards• Medicine Storage Compliance• Seven Day Services.

Mortality and Learning from DeathsMortality rates are one of the most important indicators of how safe our care is. Our aim for 2020/21 was to improveour ‘as expected’ position for mortality indicators and to further develop and embed robust governance for learningfrom deaths.

Whilst we did not improve on our position in 2020/21 in the face of the COVID-19 pandemic, we did maintain asatisfactory performance against the mortality metrics of Hospital Standardised Mortality Ratio (HSMR) and SummaryHospital Mortality Indicator (SHMI) with an ‘as expected’ performance reported throughout the year. It should be notedhowever, that the data period is approximately 3-4 months behind the reporting period and early reports for the year2021/22, which refer to 2020/21 data, show a switch from ‘as expected’ to ‘above expected’ starting in January 2021.This coincides with the second wave of the pandemic. The majority of excess deaths are attributable to COVID-19.

HSMR compares observed deaths to expected deaths. Ratios under 100 mean there are fewer in-hospital deaths thanexpected. For the 12-months between 1 January 2020 and 31 December 2020, the Trust’s HSMR was 101.4 andtherefore rated ‘as expected’. The Trust was one of two within the regional peer group of 12 trusts within the ‘asexpected’ range. Seven trusts were worse, 2 were better and 1 remained the same.

SHMI performance between 1 January 2020 and 31 December 2020 was 98.81 and ‘as expected’.

Perinatal mortality for 2020/21 was 0.7 cases per 1000 live births, significantly lower than the national average.

Since 2019, acute trusts in England have been required to establish a Medical Examiner Service to focus on thecertification of all deaths occurring in their own organisation.

The purpose of the medical examiner system is to:• provide greater safeguards for the public by ensuring proper scrutiny of all non-coronial deaths• ensure the appropriate direction of deaths to the coroner• provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased• improve the quality of death certification• improve the quality of mortality data

Medical Examiners are senior medical doctors who are contracted for a number of sessions a week to undertakemedical examiner duties, outside of their usual clinical duties. They are trained in the legal and clinical elements ofdeath certification processes. The Trust’s Medical Examiner Service operates five days a week, with eight MedicalExaminers and two Medical Examiner Officers.

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During 2020/21, there were 2037 inpatient deaths:• 581 in the first quarter (Q1 April – June)• 320 in the second quarter (Q2 July – September)• 487 in the third quarter (Q3 October – December)• 649 in the fourth quarter (Q4 January – March)

Inpatient deaths in the reporting period can be broken down as follows:

Sum of deaths quarter Status Total

Q1 Deaths 572

LD deaths 7

Still births 2

Q1 total 581

Q2 Deaths 313

LD deaths 4

Still births 1

Deaths age <29 days 2

Q2 total 320

Q3 Deaths 474

LD deaths 7

Still births 2


Q3 total 487

Q4 Deaths 627

LD deaths 14

Still births 7


Q4 total 649

Fiscal year type 2020/21 (All)

Sum of deaths (whole year) Total

Deaths 1986

LD deaths 32

Still births 12


Grand total 2037

Mental health from SJR forms*

Sum of deaths quarter Total

Q3 1

Q4 1

Total 2

Our Medical Examiners scrutinised 1044 of these deaths (51%). 336 deaths were referred to HM Coroner (16%) and ofthese, 69% were reviewed by the Medical Examiners before referral.

The Trust uses the Royal College of Physicians Structured Judgement Review (SJR) methodology, led by trainedconsultant reviewers, to scrutinise deaths for avoidability, the quality of care given and the themes emerging forlearning and improvement.

Deaths falling into the following categories are referred for SJR:• Suspected suboptimal care• Unexpected death• Death declared and investigated as a Serious Incident • Concern or complaint raised by family about care or treatment• Patient with learning disabilities• Patient with mental health problems• Perinatal or maternal death• Neonatal and paediatric death• Death following elective surgical procedure• Referral to HM Coroner• Issue of ‘Regulation 28 Report - Action to Prevent Future Deaths’ by HM Coroner

Fiscal year type 2020/21 (All)

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There are two stages (tiers) to the SJR process. A Tier 1 review is carried out by front-line reviewers, using a metricscoring system between 1 (the poorest) to 5 (excellent care). A case is escalated to a Tier 2 panel review when the Tier1 review finds that overall care was very poor, poor or adequate (SJR score 1-3).

Of the 2037 deaths, 74 (3.6%) were selected for SJR. Eighty-six Tier 1 reviews were carried out in 2020/21, but 35 ofthose were cases referred during 2019/20. Therefore, 51 of the 74 cases (69%) referred for SJR in 2020/21, received aTier 1 review.

Twenty-three cases from 2020/21 were escalated and received a Tier 2 review. Of those, the SJR panel found that fivedeaths were more likely than not to have been due to problems in the care provided. Ten cases from 2019/20 wereescalated to Tier 2 review during 2020/21 (0.6% of all 2019/20 deaths) and one was found more likely than not tohave been due to problems in the care provided.

The five cases from 2020/21 represented 0.24% of all deaths in 2020/21, and are broken down as follows:• 0% of deaths in the first quarter (Q1 April – June) • 0.3% of deaths in the second quarter (Q2 July – September) • 0.6% of deaths in the third quarter (Q3 October – December)• 0.15% of deaths in the fourth quarter (Q4 January – March)

These numbers have been estimated using SJR methodology.

Quarter

Numbercasesreviewed(Tier 1)

% of cases whichwere referred forSJR in that Qtr

% of totaldeaths inQtr

% of alldeaths in2020/21

Number casesreviewed by Tier2 SJR panel

No cases judged tohave care servicedelivery issues

Q1 2 17% 0.3% 0.09% 0 0

Q2 19 119% 5.9% 0.93% 13 2

Q3 13 72% 2.6% 0.63% 12 3

Q4 17 61% 2.6% 0.83% 6 1

Total 51 31 6

Number of Cases Subject to Structured Judgement Review (Tier 1 and Tier 2)

Thirty-five deaths referred in the previous reporting year (2019/20) were reviewed during the 2020/21 period. Thisrepresented 2% of all deaths in 2019/20, 25% of SJR referrals made in 2019/20 and 41% of all Tier 1 SJR reviewsconducted in 2020/21. Of the 35 deaths, 10 were reviewed by the Tier 2 panel in 2020/21 and one was judged to bemore likely than not to have been due to problems in the care received.

Quarter 1 of 2020/21 spanned the first wave of the COVID-19 pandemic. During this time, some mortality reviewworkstreams were temporarily suspended due to the significant impact of COVID-19 on the availability of consultantreviewers. Quarter 4 was also subject to service suspension during the second wave of the pandemic.

A number of positive themes emerged from our mortality reviews including:• good communication with patients and relatives which is well documented• compassionate care• timely palliative care service with excellent documentation• prompt consultant review of all acute inpatients, often adding value to junior doctor management of the patient• good interaction between specialties• escalation by nursing to medical staff of a deteriorating patient• good symptom control• specific SJR of patients who died from COVID-19 and who had learning difficulties was conducted and found to be positive with good to excellent overall care provided in the majority of patients.

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A number of themes emerged, which require improvement:• Overall standard of record keeping, particularly: o Documentation of decision making o Documentation of fluid balance• Timely review of diagnostic test results• Medication errors• Anticoagulation management.

Learning Disabilities Mortality Review (LeDeR)All patients with a learning disability who die within the Trust are reported to LeDeR and have a Structured JudgementReview. This year, these have primarily been undertaken by the named consultant for adult safeguarding. The reviewsare shared with the LeDeR Local Area Contact who uploads them to the LeDeR observatory for shared learning. Therewas a significant increase in the deaths of patients with learning disabilities, a direct result of the COVID-19 pandemic.During the reporting period between 1 April 2020 to 1 May 2021, there were 32 deaths of patients with a learningdisability.

The Trust has an established Learning Disability Partnership, which is chaired by the named nurse for safeguardingadults. This forum is used to share learning and take actions form LeDeR reviews, LeDeR annual report, SafeguardingAdult Reviews (SAR) and local learning. There is an associated work plan, which is updated monthly and discussed ateach meeting. Minutes from the meetings are shared at the Trust’s safeguarding panel, which has executive oversight.

The named consultant for safeguarding adults attends the Trust mortality review meetings to discuss and share learningfrom SJR and LeDeR reports. The named nurse for safeguarding adults attends the Hertfordshire LeDeR steering groupwhich is a strategic multiagency meeting to drive improvements and reduce inequalities in health.

A review of patient deaths and SJRs was undertaken during March 2021 to provide assurance to the Quality SafetyCommittee and the wider health partnership that patients who were admitted to the Trust during the COVID-19pandemic received the appropriate standards of care and treatment.

The outcomes of both reviews and data analysis were reassuring. They both concluded that the Trust provided good toexcellent care to patients with a learning disability during the peak of the pandemic.

Perinatal DeathsDuring 2020/21 we reported 19 stillbirths and neonatal deaths:• 2 deaths in the first quarter (Q1 April – June) • 3 deaths in the second quarter (Q2 July – September)• 6 deaths in the third quarter (Q3 October – December)• 8 deaths in the fourth quarter (Q4 January – March)

Learning from the delivery of 22-week gestation infants has led to discussions on the implementation of the BritishAssociation of Perinatal Medicine (BAPM) guidelines on preterm birth, published in 2019. As a result, the Trust’s labourguidelines have been re-written to include the use of evidence-based bedside toolkits to facilitate early transfer ofpregnant women between 22 and 27 weeks gestation to centres with a tertiary neonatal unit, improving their long-term outlook. All patients in preterm labour are provided counselling by a senior paediatrician to help them understandthe short and long-term implications of prematurity, as well as explaining the need for hospital transfer (if applicable).The neonatal consultant workforce has also been arranged so at least two consultants are available onsite duringworking hours to support unexpected peaks in clinical activity.

Harm Free CareOne of our priorities in 2020/21 was to ensure that our patients were cared for safely and without harm. Harm freecare is defined by the absence of pressure ulcers, harm from a fall, urine infection (in patients with a catheter), newvenous thromboembolisms (VTEs) and harm from medication errors. The National Safety thermometer tool whichcollected information on ‘Harm Free Care’ was discontinued in 2020 however; the Trust still routinely collects this dataand sets its own targets as part of our commitment to our quality targets.

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HarmSuccess measures for2020/21

2020/21 resultsTargetmet?

New Harms

Better than national average fornew harms, as capturedthrough the SafetyThermometer

Data collection discontinued in March 2020 N/A

Hospital-acquiredpressure ulcers

Zero Category 4 hospital-acquired pressure ulcers (HAPU)

1 Category 4 HAPU reported in 2020/21 Not met

60% reduction in Category 3hospital-acquired pressureulcers

2 Category 3 HAPU reported in 2020/21 reducedfrom 18 in 2019/20. 88.9% reduction in Category3 pressure ulcers (60% target achieved)

Met

40% reduction in Category 2hospital-acquired pressureulcers

223 Category 2 HAPU reported in 2020/21 reducedfrom 248 in 2019/20. 10.1% reduction in Category2 pressure ulcers (40% target not achieved)

Not met

Falls5% reduction in the number offalls resulting in harm

217 total falls with harm reported in 2020/21reduced from 281 in 2019/20. 22.8% reduction infalls with harm (5% target achieved)

Met

VTEAchieve zero preventabledeaths from VTE

Zero preventable deaths from VTE in 2020/21. Met

Urinary cathetersand catheter UTIs

10% reduction in patientsdischarged out of the Trust withan indwelling urinary catheter

779 discharges in 2020/21 reduced from 933 in2019/20. 16.5% reduction in discharges with anindwelling urinary catheter (10% target achieved)

Met

Medication errors

Reduction in harmful incidentsrelating to medication errors

9 medication errors in 2020/21 that causedmoderate harm or above compared to 7 in2019/20

Not met

% of omitted medications to bebelow 5% (annual average)

Q1 4.6% Q2 5%Q3 4.97%Q4 4.73

Met

A decrease in the number ofomitted doses of medicines inthe ‘administrative box leftblank’ category i.e. poor recordkeeping

Q1 15 (an increase from 9 in Q4 2019/20)Q2 20Q3 11Q4 18

Not met

A further on-going priority for the NHS is to reduce avoidable harm that leads to full term babies (babies born after 37 weeks of pregnancy) being admitted to a neonatal unit. The number of unexpected admissions to neonatal units isseen as a proxy indicator that preventable harm may have been caused at some point in the maternity or neonatalpathway.

Our achievements against our priorities and aims for ensuring continued improvement to the safety of care received byour patients in 2020/21 can be seen in the table below. Of the nine targets set for Harm Free Care, five were met, andfour were not met. Of these, three saw an improvement on the 2019/20 position.

Hand Hygiene ComplianceHands are the main pathways of germ transmission during health care. Hand hygiene is therefore the most importantmeasure to avoid the transmission of harmful germs and prevent health care-associated infections.

Through increased training in clinical areas by the Infection Prevention Control (IPC) Team, our hand hygienecompliance target of 95% was maintained throughout 2020/21.

Our continued compliance rates reflect the efforts our staff have made to ensure the highest possible standards aremet, in order to protect our patients from unnecessary infections during their visit or stay.

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Maintaining Effective Infection Prevention and Control StandardsThe Trust met its objective of a 25% reduction in Gram Negative Blood Stream Infections (GNBSI) in particular E Colib,for post 48 hours samples. Other organisms in particular C. difficile and gram-negative organisms with antibioticsresistance, such as carbapenemase producing enterobacteriaceae (CPE) have seen a rise in rates. In Q4, a continued risefrom Q3 in the number of cases of CPE and Vancomycin Resistant Enterococcus (RE) was identified. These are Gramnegative organisms that have built a resistance to some antibiotics. It should be noted these are not blood streaminfections, but samples taken as screens. We are working to reduce this number, including carrying out a recent peerreview.

For 2020/21, the Trust set a new target of attributable cases of C. difficile of no more than 34 cases. The Trustexceeded this target, reporting 45 cases. Changes to the criteria for C. difficile were made in 2019/20 so in order tocompare our cases; the table below enables comparisons to be made. The majority of cases (later cases Root CauseAnalysis (RCA) to be completed) have now been reviewed by the CCG to identify any underlying lapse in care in linewith the local quality contract. To date, 10 cases have been identified with no lapses attributed to the Trust. Thosecases with no identified lapse in care (a lapse is defined in accordance with the CDI objectives NHSE) will not besubjected to any associated financial penalty.

The reported rates for C. difficile infection has risen for the East of England, when compared to the previous years,however, the Trust’s rate of 21.24 is below the regional rate of 24.38.

In response to the increased C. difficile, the Trust carried out a thematic review of cases and several areas ofimprovement have been identified and actions and interventions have been taken to address the areas of concern.Examples include:• A focus on reduction of patient movement both around the Trust and within ward areas.• Monitoring of staff rooms for compliance as part of IPC audit.• Implementation of an algorithm to evidence patient mask wearing.

Antibiotic usage, which is known to contribute to C. difficile infections, rose during 2020/21, which can becontributed, in part, to the rise in rates of COVID-19 infections.

Total Antibiotic Consumption

Indicator (DDD/1000 admissions)

2018/19 (PHE data)

Target 2019/20 4304.44

(1% reduction from 2018/19 baseline)

Target 2020/21 4261.40

(1% reduction from 2019/20 baseline)

Total antibioticconsumption

4347.92(The Trust’s DDD/1000 was 3447.29

based on the calculation doneinternally) reduction achieved

(The Trust’s DDD/1000 was 3949.59based on the calculation doneinternally) reduction achieved

With antibiotic consumption rising across the Integrated Care Systems (ICS), the CCG have developed an antibioticstewardship group with members from across the ICS. Within the Trust, the data relating to prescribing and actions toensure improvements are made specifically relating to duration, review of duration and antibiotic choice (in line withWHHT policy), and have been shared with divisions. Further support and education are available from the antimicrobialpharmacist and microbiology lead for stewardship.

Whilst there was no formal trajectory for MRSA and MSSA bacteraemia in 2020/21, the Trust continued to have a zerotolerance policy to these infections. In 2020/21, there were two apportioned MRSA and six MSSA bacteraemiainfections within the Trust. This was a significant improvement on last year’s MSSA bacteraemia rate, when there were22 cases. All cases of MRSA and MSSA bacteraemia underwent a review and the learning shared with clinical anddivisional management teams.

The rising number of hospital admissions since November 2020 due to the COVID-19 pandemic, has dominated thework of the IPC team.

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There has been a national focus on nosocomial COVID-19 from June 2020, with NHS England issuing guidance on thecategorisation of nosocomial acquired infection and associated screening regimes.

Mandatory reporting of all cases of COVID-19 was required, along with completion of thematic reviews with evidencelearning from outbreaks and individual cases. The IPC team, SI team and divisional quality governance facilitators,worked in collaboration to ensure patients were correctly categorised using the HCAI definitions provided by NHSEngland and NHS Improvement in order to ensure the correct investigative action was taken and Duty of Candourrequirements were fulfilled.

As the numbers of patients with COVID-19 requiring inpatient care increased in November 2020, the standards ofcleaning and decontamination across the organisation was reviewed. Enhanced cleaning regimes remained, and theimplementation of an enhanced cleaning audit and ATP testing was introduced for further assurance of standards. Thiswas complemented by informal monitoring arrangements undertaken by the IPC/DIPC during walk rounds withmembers of the facilities and estate team every month.

Regular infection prevention and control audits were undertaken by the IPC Team and results disseminated to heads ofdepartment, IPC Link Staff and Matrons. Action plans were produced and owned by the divisions whenever compliancerequired improvement.

Personal Protective Equipment (PPE) audits were undertaken on inpatient areas every month and added to the IPCdashboard for review at IPC panel. On-going support and training continue to be provided by the IPC team as well asspot checks by Matrons. Compliance for Q4 is generally between 50 to 100%, with only a few areas scoring below80%. PPE compliance also includes monthly hand hygiene audits undertaken by division.

Code of Practice (COP) audits have been adapted to align with the IPC Board Assurance Framework and areundertaken monthly. These have also been added to the IPC dashboard and reviewed at IPC panel. Themes from auditsare added to IPC divisional action plans. Spot check COP audits continued to be undertaken to ensure all areas arecovered and areas highlighted with issues (for example, higher than average infection rates) are completed weekly ormore regularly if indicated.

Throughout 2020/21, the IPC team have provided formal education via Teams/Zoom to staff, which has included anumber of clinical and non-clinical groups. In addition, the team has provided ad hoc ward and clinical area trainingaround PPE usage, including donning/doffing, and management of COVID-19 patients. The team has produced postersand films to promote good PPE practice, which have been updated in line with national guidance and changes. Theposters have been made available on the Trust intranet site and have also been shared via WhatsApp groups.

Other activity includes:• Ventilation Risk Assessments (RA) have been undertaken in areas where Aerosol Generating Procedures (AGPs) are undertaken i.e. ED, Endoscopy and theatres. Downtime post procedure calculated using number of air changes in the areas. In addition, High Efficiency Particulate Air (HEPA) filters have been used to increase air changes and minimise downtime. RAs have been completed on ward areas where ventilation does not meet recommended standards, HEPA filters have also been used in these areas to assist with air flow and advice to open windows where able has also been communicated. • Staff areas have been assessed by the COVID safe team and recommended numbers of staff to facilitate social distancing has been displayed, monitoring of compliance with social distancing is by IPC audit and Health and Safety team. • Testing protocols have been reviewed and in November 2020 frequency increased whereby patients are screened on admission, day 3 and day 5, and if they remain inpatients after that time, screening is undertaken every seven days. For patients who have had contact with positive cases, screening every 72 hours is undertaken, and prior to any patient movement. Staff screening is undertaken on symptomatic staff, as part of point prevalence or if there is an outbreak on area. Staff that work on green pathways are screened twice weekly. Lateral Flow Testing is now rolled out to all staff and required twice weekly.

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The Trust met its objective for mandatory and statutory training for infection prevention and control, reporting 90%compliance.

There has been a delay in the updating of some of the IPC policies due to the Trust’s COVID-19 response. A review ofthe policies has been undertaken to ensure advice and guidance remains in line with national policies, and practices areevidenced based. Extension requests have been submitted on 14 policies until June 2021. The Trust plans to review andupdate all IPC policies in 2021/22.

Medicine Storage ComplianceThroughout 2020/21, the Trust conducted quarterly audits of the storage of medicines. The medicine storagecompliance reports in Q1 and Q2 show similar results to the previous audits.

In Q2, there was an increase in compliance in areas such as air-conditioning units fitted and in working order in drugtreatment rooms, opened insulin vials were stored in locked medicine cupboard and insulin pens in Patient own drugs(POD) lockers.

However, there was a reduction in compliance in areas such as medicine trolleys not locked and attached to the wall,on a few occasions patient’s own medicines were left on the bedside cabinet and not locked up, medication storageroom not always locked and temperature in intravenous (IV) fluids room and fridge temperatures were not alwaysmonitored.

These areas of non-compliance were addressed, and spot audits carried out to ensure on-going compliance and toincrease staff awareness.

This action had a positive impact and increased staff awareness of the importance of compliance with secure storage ofmedicines according to the storage policy. An audit in Q3 showed an increase in compliance in areas such as lockingthe medication storage room, the Controlled Drug keys were kept separate from other keys, storing opened insulinpens in POD lockers, completing the date opened stickers on insulin vials/pens, ensuring IV fluids were in original boxesand/or clearly labelled and increased staff awareness on actions to take if fridge temperature is out of range.

It is important to note, however that there was a decrease in compliance not always locking the fridge where medicinesare stored.

The Trust has a robust governance structure in place, and the safety of medicines is monitored through the MedicinesSafety Committee, which receives and reviews the quarterly audits results. It is a priority for 2021/22, to ensure theTrust’s management of medicines is of the required standard and in line with our Medicines Management Policy.

Seven Day ServiceFor the Trust to uphold its commitment to deliver quality of care and service, we needed to make sure that our patientsreceived the same standard of care throughout the week. In 2013, the NHS launched its Seven Day Services initiative totarget and reduce the increased mortality rates being seen at weekends. As part of this, 10 standards were launched ofwhich four, were made into national priority targets against which Trusts were required to conduct bi-annual self-assessments.

The four priority national standards were:• Time to first consultant review (within 14 hours of admission) (Standard 2) • Access to diagnostics (within 1 hour for critical patients, 12 hours for urgent patients and 24 hours for non-urgent patients) (Standard 5)• Access to consultant directed interventions (weekday and weekend access either on site or via formal network arrangements) (Standard 6) • Ongoing consultant review (weekdays and weekends for patients requiring once daily and twice daily reviews) (Standard 8).

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Under national instruction, work on Seven Day Services progress monitoring and reporting was suspended in February2020 at the start of the pandemic. It has yet to be resumed and currently no national guidance has been received as towhen this will recommence. We are therefore unable to provide updates for the period between 1 April 2020 to 31March 2021.

The Trust continues to strive to maintain our 100% compliance rate against Standard 5 and 6, and for Standards 2 and8, we will be seeking to improve our position as reported in 2019. We will also take steps to maintain the clinicalstandards outside of the priority standards.

In addition to the national programme of monitoring and reporting, the Trust aims to conduct an audit of the fourpriority national standards in the summer of 2021, to determine current compliance rates. The report is expected in lateautumn and the findings will be included in our 2021/22 Quality Account.


In 2020/21, the Trust aimed to provide the best care to every patient, every day. At the heart of this vision was thedesire to keep learning and ensure that our care was in line with best practice.

A patient’s experience and clinical outcome should not be driven by differences in who they are treated by. Weestablished a single common view of best practice across our clinical pathways, which could be shared and learnedfrom, used to drive a reduction in variation and ensure the best care was received by every patient every day.

Care Pathway RedesignCare Pathways, also known as Clinical Pathways, aim for greater standardisation of care and treatment, as well asimproved outcomes, from both a quality and a clinical outcomes perspective.

Using our clinical partnership with the Royal Free London NHS Foundation Trust, we worked closely with their ClinicalPathway Groups (CPGs) and their clinicians, to collectively identify and implement best practice across these pathways.

During 2020/21, work continued on the eight care pathways which had previously been identified, resulting in thecompletion of data collection and analysis of improvements and patient benefits realisation was completed.

A summary of our progress with our CPG programme in 2020/21 is as follows:• The Pneumonia Pathway was redeveloped to include COVID-19 and diagnostics, with the aim to reduce avoidable admissions and unnecessary antibiotics. • The Frailty Pathway and the Right Upper Quadrant pathways were both paused as a result of the pandemic. • A Chest Pain Pathway was added to the programme in July 2020.• Co-design work, involving staff, patients and their families began on the Wheezy Child pathway. This involved understanding and developing the Personal Asthma Plan, asking for patient feedback on three possible spacer devices and preparing a patient panel workshop to take place in October 2021, to gain insight of the whole pathway from admission to discharge and follow up.• The Induction of Labour ‘Introduction of non-pharmacological method of induction’, co-design workshop is planned to be held in Q1 2021.• An evaluation was completed of all Royal Free London digitalised pathways to identify those which would be applicable for adoption or adaptation by the Trust. Twelve pathways were identified which would be suitable and work has commenced to identify clinical leads to lead on their implementation.

A business case has been completed and submitted for approval to support the expansion of the programme to a totalof 40 pathways over a three-year period.

A CPG workshop is to be held at the end of June 2021 to showcase the progress the Trust has made on the variouspathways.

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Theme 2 – Ensuring Services are Caring and Responsive

In 2020/21, the Trust’s priorities were to improve patient experience with a particular focus on discharge, the bookingprocess, and our use of volunteers. Additionally, we wanted to ensure our patients with additional needs also receivedindividualised, compassionate care with reasonable adjustments made whenever necessary.

It is important that our patients are treated with compassion, kindness, dignity and respect and that our services areorganised to meet their needs. It is essential that we listen, respond, and use patient feedback to make improvements.


A number of initiatives were put in place during 2020/21, to help relieve some of the challenges faced by patients,carers and staff. These were:• A family liaison line service was established to promote a regular communication stream between relatives and the hospital, specifically where a clinical and holistic update was provided to relatives over the phone when visitation restrictions were imposed due to COVID-19. • Digital solutions such as iPads were introduced to enhance the surrogacy service.• The “letters to loved ones” scheme was introduced to promote communication between inpatients and their families whereby a direct correspondence service was provided so messages could be sent to one another. • The Carers and Patient Experience team (CAPE) had a strong social media presence and promoted resolution of any queries and removed barriers as they arose. • We extended hours of the Patient Affairs service to ensure we met added service needs, in particular the delivery of fast track funeral arrangements to meet religious needs of our service users. • A new role was developed for the considerate management of property of deceased patients and provision of information on safe management of belongings during a pandemic. • In response to the emotional turmoil of the pandemic, we extended the hours of service and increased our Pastoral team by two members to meet the additional need. In addition, we initiated counselling sessions for staff, which had a direct impact on patient interactions and thus patient experience, created staff and service user therapeutic environments for reflection in our pastoral care rooms and religion was facilitated through virtual platforms which provided access to funeral services. • A triumvirate approach to compassion was initiated by the Trust, the Red Cross and Watford Football Club, and provided regular contact with patients and relatives to support wellbeing and mental health. The initiatives were independent until recently, when the Trust pulled together the data and learning to create a social contract report on “End to end pathways to compassion”.• A carer group was established, which gave carers a direct line of support and a chance to talk. Our carers lead has established regular contacts with carers in the community and our hospital carers. Multiple virtual roundtable meetings took place and these discussions will inform the carers strategy for the Trust. • Service users were able to express their gratitude for our staff during the pandemic through a dedicated “Thank You” email. Emails received were cascaded to the appropriate wards through the Assistant Divisional Managers and Matrons.• A new framework was developed that allows our patients and the community to have an integral part in shaping pathways and service delivery.

DischargeAn overarching reason for not achieving some of the set measures of success for discharge was and remains theCOVID-19 pandemic, during which the Trust closed to all but urgent and emergency care, and previous establishedpathways were modified to comply with new guidelines. The patient lounge closure resulted in lower absolute numbersflowing through. However, the measure on the reduction of longer stay patients (21+ days) was achieved due to earlydischarges whilst getting prepared for COVID-19.

The team continued with the SAFER patient flow bundle (Red2Green) initiative, which ensures our patients are not inhospital any longer than they need to be. With the impact of staff shortages and changing restrictions and guidance,

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the team persevered and piloted changes to the initiative, bringing in the Therapies team to support nursing staff withdata capture requirements. This has led to small improvements and ultimately improving the patients care.

The ‘Fresh Eyes’ initiative has been embedded within the Trust, which offers additional support to speed up thetreatment and discharge process and therefore reducing the length of stay for patients on a case by case basis. A multi-disciplinary team works with ward staff to review patients ready to be discharged, identify internal or external delaysand solve any problems. The ‘Fresh Eyes’ rounds continue and due to its positive impact on patient discharge numbers,the team will re-launch it with a special focus around Bank holidays, to help flow into the hospital during these ‘peakperiods’.

The target to reduce long stay patients by 26% compared to 2019/20 was achieved in all quarters 2020/21, except forQ4 where there was a slight deviation of 1.5%. This is a significant improvement over the previous year, where thetrajectory was not achieved in Q2 and Q3 by deviations of 6% and 13% respectively.

Table of achievementsDespite the closure of the patient lounge on weekdays between 30 December 2020 and 8 February 2021, 26.5% ofdischarges went through the patient lounge against a target of 35%. In Q2, the target was almost met at 34.5%. In

2020/21 Indicator Q1 Q2 Q3 Q4 Total

Achieve 30% ofDischarges beforemidday

13.0%

NotAchieved

16.5%

NotAchieved

17.8%

NotAchieved

14.6%

Not Achieved

15.7%

Not Achieved

Reduction in long staypatients (26%reduction in bed days)

MeetingTrajectory

MeetingTrajectory

MeetingTrajectory

Not MeetingTrajectory

(1.5% deviation)

Meeting Trajectory,Reduction of 25.9% from

2019/2020 to 2020/21

35% of discharges togo through the Patientlounge on weekdays

19.7%

NotAchieved

34.5%

NotAchieved

27.8%

NotAchieved

21.6%

Not Achieved

26.5%

Not Achieved

2019/20, 40.7% of discharges went through the lounge on weekdays; the Trust expressed confidence in reaching thislevel in the next year by an increased target of 40%.

The impact of COVID-19 was not as devastating on discharges before midday as expected. During Q2 and Q3, after aninitial drop, percentages recovered to levels of the previous year. The Trust is determined, however, to improve thismeasure from the current performance of around 16%, to be in line with the national level target of 33%, a revisionfrom 30%.

We have continued to embed Red2Green (R2G) days and the safer bundle to monitor and report the daily updates ofR2G delays by wards. Since the reporting started in June 2020, the number of wards recording reasons increased from14 to around 21 (out of 25) in March 2021. Initially, no ward achieved 90% daily updates, but by March 2021, sixwards achieved 90% daily updates.

As the pandemic stabilised, the Trust has started a new programme of work with the mission To Improve our PatientsJourney and Experience; by ensuring the safe and timely discharge of care. This programme will reinvigorate the Nurseled Discharge and SaferFlow/Red2Green scheme, now commonly referred to as Criteria to Reside.

Additionally, the Internal Discharge Team will be restructured to support patients having a well-planned, informed, andtimely discharge.

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Booking ProcessDuring 2020/21, the Trust had a reduced number of calls, which has made it difficult to ascertain the level ofimprovement in patient experience of the outpatient booking process. Over the last 18 months the Trust has completedthe first stage of digitising the call centre, which has made it easier to handle calls and has improved the call quality,improving patient experience.

For the last quarter of this year, abandonment rates were 26%, compared to approximately 60% previously. However,the Trust recognises this is still higher than we would hope to achieve, when fully digitised and on lower call volumesthan previous years.

We believe the average time to answer (due to the digitisation and the reduced volumes) will have improvedsignificantly and await the full year report on average call times to confirm this.

The entire Outpatient Booking Team has been trained on the new system, and further training will be provided tosupport the next stage of digitisation and re-start.

VolunteersOur volunteers help make a huge difference to our patients. They provide a welcoming environment and lend a helpinghand to complement the work of Trust staff. Throughout 2020/21, the Trust increased the numbers of volunteers tocreate a great experience for our patients and their carers through well run, well-evidenced volunteering services.

During 2020/21 we achieved the following:• An increase in our volunteer service cover to support our 7/7-week service. • The further development of bespoke voluntary services to address specific service user needs. • The coordination of deliveries for patients during a time when visiting was restricted. • The provision of a surrogacy service to patients on an end-of-life pathway to ensure a companion was by their side. • A scheme where young people aged 16 to 18 years old who are feeling isolated whilst in hospital are visited by volunteers their own age to provide support.• Weekend cover of all bespoke services.

Improving Patient Experience-Volunteers

Measure of Success Q1 and Q2 Q3 Q4

Maintain minimum 90%volunteers reporting their timespent volunteering wasbeneficial to staff and patients.

95% of volunteerssurveyed felt their timespent volunteering wasbeneficial to patients



Increase volunteeringsupporting patients (10%increase in patient supporthours volunteered).

Avg: 743 per month Avg: 797 per month923 per month

Target met for 2020/21

Increase volunteer supportwith mealtimes (10% increasein mealtime support hoursvolunteered).

Avg: 96.5 per month Avg: 107 per monthAvg: 209 per month

Target met for 2020/21

Maintain minimum 95%compliance on statutorymandatory training renewalsand DBS renewal.

100% compliant 100% compliant 100% compliant

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We aim to provide the highest quality of care for every patient, every day, and we acknowledge that some patients mayrequire additional or modified care, to achieve this.

Mental Health and Learning DisabilitiesDuring 2020/21, we saw a significant increase in the number of patients presenting in mental health crisis that requireda multi-agency or multi-disciplinary approach to manage their acute admissions. Many of these patients have complexneeds and required a collaborative approach.

To meet the needs of these patients, a clinical nurse specialist was seconded into a role dedicated to mental health andcomplex needs. The individual works closely with the mental health liaison team to improve patient outcomes andreduce overall risks. The mental health liaison team are available on site 24 hours a day and the hospital provide amental health suite available to support section 136 admissions and patients in mental health crisis.

We identified the monitoring of mental health sections required improvement, so the safeguarding team have beenworking in conjunction with the emergency division to improve the quality of reporting through Datix and a standardoperating procedure is in development to support reporting of section 5(2).

The missing persons pathway was reviewed with Hertfordshire Constabulary to develop a simplified process to guidestaff in reporting missing persons. This has been promoted across the Trust and forms part of the Safeguarding AuditStrategy.

The Safeguarding Team work collaboratively with the Acute Health Liaison Team to ensure there is a strong focus onpromoting reasonable adjustments and equality in care provision. There is an established learning disability partnershipwith associated work plan to ensure local and national recommendations are achieved.

Patients with learning disabilities were particularly vulnerable to COVID-19. Work to support patients admitted duringthe pandemic included: • Joint ward rounds between the safeguarding nurses and the Acute Health Liaison Team (AHLT). Every day, the teams visited every patient who had a learning disability to provide support with reasonable adjustments, complex care and discharge planning and ensuring appropriate documentation was completed in regards of MCA/DNACPR.• Staff were supported to provide daily updates to families and carers whilst visiting was restricted.• Electronic devices were used to support patients undergoing clinical procedures. Families and carers were able to access Face Time to reassure the patients who were experiencing anxiety. • Easy read material and COVID-19 passports were made accessible electronically to support patients and staff.• The safeguarding team reviewed and audited every patient with a learning disability who tested positive for COVID- 19 and had a DNACPR in place to provide assurance that each patient was assessed individually and not on the basis they had a learning disability. The audits were reviewed and analysed in conjunction with a review of the SJR, which demonstrated that patients with a learning disability received a good level of care during the pandemic.• The safeguarding team and AHLT participated in discussions, to ensure the frailty score was not used to assess patients with a learning disability. This was to ensure health equality when reviewing processes in ethical decision making.• National specialist guidance on managing patients with learning disabilities during COVID-19 was reviewed, summarised and shared with staff across the Trust. Information was provided to staff in clinical areas regarding reasonable adjustments, diagnostic overshadowing, and expression of pain.• Visiting guidance for parents/carers of patients with learning disabilities was developed in line with national guidance.• The AHLT co-located with the safeguarding team to improve communication and joint working.

SafeguardingMoving forward, plans are in place for the implementation of the Liberty Protection Safeguards (LPS), which will replacethe Deprivation of Liberty Safeguards. These are due to be released in October 2021 and the new Code of Practice isalso awaited.

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We applied for 937 Urgent Deprivation of Liberty Safeguards (DoLS) between 1 April 2020 and 31 March 2021. We

continued to maintain robust processes to track our patients who were under DoLS.

During 2020/21, whilst staff continued to undertake training, the mandatory compliance rate for training was

suspended between 20 April 2020 and 31 August 2020. This was re-commenced on 1 September 2020. The

compliance rates for Mental Capacity and Deprivation of Liberty Safeguards as of 31 March was 93%.

Safeguarding level 3 children training was affected during the pandemic due to the cessation of face-to-face training

and an issue with targeting on the online learning management system (Acorn) training system. An action plan and

trajectory were developed to increase compliance. The risk of low compliance was placed on the risk register.

To facilitate increased uptake and compliance, an E-learning package was added to Acorn and virtual training sessions

were held – one of these was filmed and added to Acorn. Staff were targeted and encouraged to book on sessions and

as of 31 March 2021, these additional initiatives resulted in an increase in training compliance to 90%, which is above

the Trust’s target.

Safeguarding level 3 adults face to face training was introduced in the Trust in the Autumn of 2020, following the

publication of the intercollegiate document (Royal College of Nursing 2018). Training was targeted at all clinical facing

nursing staff band 6, 7 and 8 and medical staff in emergency medicine and elderly care at registrar and above.

Although face to face training was suspended during 2020/21 due to the COVID-19 pandemic, training was amended

to incorporate E-learning. By the end of March 2021, training compliance for level 3 was 73%. The Trust is working

towards the achievement of a 90% target by the end of September 2021.

Monitoring of training compliance has resumed monthly from September 2020 for all staff and is presented to the trust

safeguarding panel which has executive oversight.

No adult assurance visits took place in 2020/21; however the Trust has implemented recommendations from the

previous visit. These include:

• The named consultant for adult safeguarding has continued to support medical colleagues in the training and the

application of MCA and DoLS. Medical training compliance is monitored via the safeguarding panel and now meets

the expected target.

• The named nurse for adult safeguarding delivered a joint presentation with the Strategic Liaison nurse for the AHLT

to Hertfordshire Safeguarding Adults Board, which showcased the initiatives and good practice that have been

implemented to support people with learning disabilities within the Trust.

• The Safeguarding Team continue to support the application of DNACPR and MCA in practice, with a specific focus

on patients with learning disabilities and having difficult conversations. Monthly dip dive audits are undertaken with

an annual audit forming part of the safeguarding audit strategy.

• The Trust continues to incorporate any learning from published Safeguarding Adult Reviews (SAR) at the Learning

Disability Partnership meeting, Champions day and safeguarding training. Furthermore, a summary of the case and

learning is shared via the safeguarding newsletter.

• The safeguarding team has included adult safeguarding supervision into the existing supervision policy. Informal

supervision is provided at champions days, following safeguarding investigations and complex case management.

Safeguarding Mental Capacity Act trainingThe MCA training package was re-designed until face-to-face training could re-commence. There has been additional

face to face training sessions delivered in preparation to the implementation of LPS. The training includes the practical

completion of documentation in addition to the theoretic aspect. Materials have been developed to support learning.

Safeguarding referralsThe safeguarding team has adopted and successfully utilised the Local Authority online reporting portal of raising

safeguarding referrals. These have been triaged by the safeguarding team allowing for improved quality of referrals to

Adult Care Services.

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Operation Tropic

The safeguarding team continue to work with Hertfordshire constabulary to provide safe and well checks for individuals

who are either being exploited or have been trafficked into working in the sex industry. A Standard Operation

Procedure is being adapted to use nationally as a best practice model for partnership working.

Missing patients

The safeguarding team has continued to work collaboratively with CP Plus (on-site security) and the Hertfordshire

Constabulary to promote the pathway for patients who are reported missing. The pathway is aimed to assist staff when

reporting patients missing to establish a clear escalation process and avoid inappropriate reporting to the police.

Multiagency working

The safeguarding team continues to work collaboratively with Hertfordshire Safeguarding Adults Board (HSAB).

Services for young people

The Trust has a virtual ward in place for 16 and 17 year olds who are admitted across the organisation. These young

people are visited at least once during their admission by the safeguarding nurses and they are overseen by the senior

paediatric nursing team.

A new record card in CED/ED was launched in Q4 for 13 to 18 year olds incorporating a HEADSSS assessment

framework – a nationally recognised framework for identifying psychosocial and safeguarding issues. The record card

was well received by clinicians and will be fully audited six months following implementation in the autumn 2021.

We are also pleased to report the Trust was successful in our joint bid with Hertfordshire Youth Services to run a

hospital youth worker project. A youth worker joined the team in Q4 to support 11 to 18 year olds. Paediatric staff

continue to be offered mental health awareness training from a variety of sources including national e-Learning and in-

house training led by CCATT.

Improving Access for Wider Community Groups

In response to the disproportionate impact COVID-19 has had on women from Black, Asian and minority ethnic groups,

the Trust’s maternity service created a small notepad with information in various languages to assist women where

English is not their first language.

The notepad was sent as a link for women to refer to as often as required and it contained information on healthy

eating, Vitamin D supplement and breastfeeding.

The UK Obstetric Surveillance System (UKOSS) carried out a study in 2020, which revealed 55% of pregnant women

admitted to hospital with COVID-19 were from Black, Asian and minority ethnic groups and further analysis found

black pregnant women were eight times more likely to be admitted to hospital with COVID-19 while Asian women are

four times likely. With this data in mind, our community midwifery teams offered additional contacts for women from

those ethnic groups to provide extra support and information.

The maternity service also offered women personalised care plans as per the Better Births report (2016), which were

built on decisions made by the woman and her service provider/healthcare professional. The care plans all differed in

nature according to the woman's individual needs. For example, a woman with a disability may need the birthing

environment to be adapted to suit her needs or a woman with certain risk factors will have a birthing care plan to

accommodate the risk/s involved. The woman will have an honest, open, and unbiased dialogue with the health

professional and will have evidence-based information available about their choices with sufficient time to have a

dialogue and make an informed choice.

Additionally, for women with a hearing impairment the Trust offered continuity of care by providing the same midwife

and the same British Sign Language (BSL) interpreter at every appointment.

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The Trust is committed to ensuring that we continue to improve access for both those attending as a planned patient,and for those attending for urgent or emergency care. In line with being a safe, responsive, and caring organisation wetake the nationally mandated access targets very seriously and are committed to improving our performance againstthese standards.

The impact of COVID-19 can be seen across all of the access standards and measures. The pandemic has affected ourworkforce, with significant sickness absence. This, combined with the need to focus resources on the most unwellpatients, had a substantial effect on our ability to provide routine elective care.

Pressure on critical care services required the redeployment of anaesthetic and theatre staff to ensure we were able tomanage demand. The redeployment of medical, nursing and allied health professionals to other wards and areasenabled us to care for our acute, urgent and emergency pathway patients.

Pathways from the Emergency Department through to the wards and out of hospital, were affected enormously by theloss of capacity resulting from segregating pathways, COVID-19 testing and access to the right bed. The combinationof factors caused flow to slow significantly and the backlog of patients in the department resulted in a reduction incapacity creating ambulance offload delays.

This segregation of pathways has been maintained throughout the year and although there was some improvement inQ2, the onset of the pandemic’s second wave saw a much greater demand, and our performance thereforedeteriorated in Q3.

Comparatively in the first wave (Q1) the number of ED attendances dropped significantly in comparison to the sameperiod the previous year. This drop in attendances enabled ED to manage the separate streams of patients moreeffectively. However, the second wave did not see the same level of reduced attendances. Together with an increase inCOVID-19 numbers this impacted on flow throughout the organisation resulting in multiple streams of patients,impacting on ED performance.

There has been an increase in ambulance conveyances throughout 2020/21 and the Trust experienced the secondhighest ambulance conveyance rate in the region and was the only organisation to experience over a 5% increase inconveyances. In order to manage the increase in demand, the Trust and East of England Ambulance Service Trust(EEAST) signed a formal memorandum of understanding which committed both services to a clinical partnership. TheAmbulance Service allocated a number of staff to work with the Trust in a planned and structured way to support co-horting, corridor care and manage off load delays. This clinical partnership allowed both services to respond in astructured way to ensure the safety of patients already in hospital and those being brought to the Trust and improvedtimely off loads enabling crews to continue to answer community 999 calls.

Referral to Treatment (RTT) Performance In response to the first wave of COVID-19, all non-urgent elective care was paused at the start of the financial year toenable the redeployment of staff and resources to care for the sickest patients. This meant that elective outpatientclinics and theatre lists were suspended and only the most urgent, time critical and cancer care was maintained.

As a result, waiting times for routine care increased and the number of patients waiting more than 52 weeks grewexponentially. This also affected RTT open pathway performance due largely to the very significant reduction in newreferrals during the first wave. When services resumed in July and August 2020, there was good improvement inperformance, although 52-week waits were relatively unaffected because these patients are waiting for routinetreatments. The second wave saw another and more prolonged suspension of routine elective care, which delayedroutine treatment, extending waiting times further. Unfortunately, a very large number of patients experienced delaysof 52 weeks or longer.

During the first and second wave, treatment for the most urgent, time critical patients has continued, many beingtreated by Trust teams using independent sector (ISP) facilities. Over the year, just fewer than 4000 patients were

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treated in this way, enabling the Trust to improve and maintain performance against the 62-day GP referral totreatment cancer waiting time standard.

The Division of Surgery has put in place a number of measures to ensure patient safety through the pandemic. Forexample, harm reviews are conducted at various times according to speciality and clinical need. These are clinicallyvalidated and the patient’s priority grade (P value) status is reviewed. Where it is felt clinically needed P value is adjustedto ensure patients receive surgery according to clinical need.

The Division continues to review the methods to ensure this process becomes as seamless as possible.

In discussion with the issues faced by the ICS, and following discussion, the Trust established a Harm ReviewsCommittee, which meets on a monthly basis to support individual directorates in their approach to Harm Reviews anddelivery.

The use of a software system - Pathpoint- is being reviewed in Orthopaedics. This allows automatic alerts direct to theclinician as and when harm reviews are due. The harm review period can also be set at different times according tospeciality requirements

During 2020/21, the Trust implemented shadow reporting for the new 28-day faster diagnosis standard, whichmeasures the number of patients who receive a definitive cancer/no cancer diagnosis within 28 days of referral againsta target of 75%. We have consistently achieved the standard throughout the year which puts us in a good position for2021/22 when this target goes live.

Improving Access

Measure of Success Q1 and Q2 Update Q3 Update Q4 Update

A reduction in breaches of the4 hour ED standard

Q1: 83.9%Q2: 84.4%

78.2% Q4: 77%

Improving our ED ambulancehandover delays

Q1: 86 > 60 minutesQ2: 347 > 60 minutes

761 > 60 minutes Q4: 494 > 60 minutes

A reduction in the number ofpatients waiting more than 52weeks

June 2020: 302September 2020: 855

December 2020: 1131 March 2021: 1702

Improved performance againstthe 18-week open pathwaystandard for RTT

June 2020: 47.7%September 2020: 69.7%

December 2020: 78.8% March 2021: 72.2%

Improved performance againstthe 62-day standard

Q1: 78.8%Q2: 83.8%

82.2% Q4: 82.2%

Fewer 104 day waitsJune 2020: 101

September 2020: 30December 2020: 17 March 2021: 26

Successful transition andimplementation of any newstandards.

Shadow reporting of the new 28 day faster diagnosis standard was implementedsuccessfully and with compliance against the 75% target (threshold to beconfirmed)

Emergency Department (ED) – Time to First Assessment and Early Discharges Attendances at all our Urgent and Emergency Departments were lower in 2020/21 compared to 2019/20 as a result ofthe COVID-19 pandemic.

The Watford Urgent Treatment Centre opened in July 2020.

The St Albans Minor Injuries Unit was closed to enable the redeployment of staff to Watford General Hospital duringthe pandemic.

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In 2020/21, 81% of patients were seen within 4 hours in our ED, which was a similar position to 2019/20, but belowthe national target of 95%.

Nearly all patients (99%) attending the Urgent Treatment Centres at our Hemel Hempstead and Watford sites wereseen within 4 hours.

Our performance in the Children’s Department improved from 91.7% in 2019/20 to 94.1% in 2020/21.

A&E Performance 2020/21

In 2020/21 we saw the number of patients admitted from ED (including ambulatory admissions) decrease by 21.6%when compared with 2019/20.

Our 4-hour performance of admitted patients deteriorated from 56.5% in 2019/20 to 50.9% in 2020/21.

However, there was a 5.7% reduction (improvement) in the average time from Decision to Admit to Admissioncompared to 2019/20.

In 2020/21 we developed our Emergency Care Improvement Programme to deliver on the following agreed set ofquality improvements:• Ensure that the emergency medicine workforce was appropriate in supporting the delivery of quality and timely care in the ED and resources aligned to demand.• Improve patient experience and outcomes by achieving quicker and more effective ambulance hand-overs.• Reduce admissions through the use of non-admitted pathways including assessment areas, ambulatory care, hot clinics and the SMART pilot which enabled specialty consultants working at the ‘front door’. • Ensure timely specialist input.• Improve time to clinical assessment for patients in ED.• Ensure consistent patient flow 24 hours a day in ED.• Redevelop the ED. • Develop and implement the UTC model at Watford.• Improve same day emergency care services through the development and expansion of the assessment unit model and the service provided within ambulatory care.• Work with system partners on the model of care for urgent and emergency services at Hemel and St Albans.

The senior team assessment and rapid response (STARRING) process was reviewed, and subsequently the STARR scopeof practice was revised. The new process was embedded by staff to aid patient flow within the Emergency Department.

Recruitment and retention work was also undertaken for the Consultant workforce within ED.

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Referral to Treament (RTT) Performance and Choice at 26 WeeksThe Trust’s planned care performance was severely affected as a result of the national suspension of elective care duringthe first and second wave of the COVID-19 pandemic. Against the Referral to Treatment (RTT) standard, our 52-weekbreaches were 1702 at year end.

The Trust was unable to sustain our previously consistent achievement in meeting diagnostic waiting time standards asa result of the impact of COVID-19. Our performance fell below the 99% standard throughout the year.

Month End 52 Week Breaches 2020/21

Performance Against the 62-Day First Definitive Treatment StandardPerformance overall against the 62-day referral to first definitive treatment standard in 2020/21 was 80.2%, incomparison to 80% in 2019/20 and 84.4% in 2018/19.

There were 1097 treatments overall, including shared pathways, which accounted for 1010 activity against WestHertfordshire Hospital Trust for the year. This is an 8.12% drop in the number of overall treatments accountingagainst West Hertfordshire Hospital Trust in comparison to 2019/20. There were 214 breaches overall, includingshared pathways, which accounted for 200 breaches against West Hertfordshire Hospital Trust for the year.

Please note that only those shared pathways which have been allocated against West Hertfordshire Hospital Trust asan activity and breach, whole or partial (under the 6 Scenarios Inter-Provider Transfer rules for shared pathways) areincluded in the final performance data.

The majority of specialties did not achieve the target for 62-day first performance in 20/21, and several of thespecialties which saw significant activity have not met the target for the last three reporting years (except for UpperGI, which was in target in 2018/19).

Tumour Type 2018/19 2019/20 2020/21

Haematology 79.1 56.0 48.1

Head and Neck 48.8 71.1 25.0

Lower Gastrointestinal 67.5 71.1 53.1

Lung 75.3 39.3 58.1

Upper Gastrointestinal 86.3 73.7 63.7

Urology 77.0 60.5 75.9

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However, not all the under-performance can be put down to an increase in demand within the service.

Tumour Type 2019/20 2020/21

Treatments % Change Treatments % Change

Breast 206 7.29 178 -13.59

Gynaecological 132 14.78 119 -9.85

Haematology 50 11.11 57 14.00

Head and Neck 32 -25.58 28 -12.50

Lower Gastrointestinal 103 10.75 99 -3.88

Lung 55 -26.67 38 -30.91

Skin 277 35.78 281 1.44

Upper Gastrointestinal 68 -15.00 56 -17.65

Urology 246 -18.00 221 -10.16

Cancer Waiting Times StandardsOverall the Trust did not meet all of the national cancer standards in 2020/21, however, our improvement workcontinues, and we are committed to recovering performance to be in line with waiting time standards. The Trust hasrefreshed and re-launched a number of cancer service action plans to boost performance, which include: • Adding capacity to ensure patients were offered appointments in the first week of the two-week wait. The Trust recognises that there is more work to do to achieve this consistently across all specialities. • The cancer pathways were enhanced to ensure patients were seen and investigated in a timely way. • The Trust continued to work collaboratively with tertiary cancer centres to improve systems and communication, allowing patients who are referred to, or from, another centre to receive care as quickly as possible.

Cancer Waiting Times Standards and Performance (WHHT) 2020/21

Standards Target (%) Performance (%)

2 week wait – Urgent GP 93 95

2 week wait – Breast Symptomatic 93 86.9

31 Day – Decision to treat to first definitive treatment 96 97.1

31 day – Subsequent surgery treatment 94 89.2

31 day – Subsequent drug treatment 98 99.3

31 day – Subsequent radiotherapy treatment 94 100

62 day – Urgent GP referral to treatment 85 80.2

62 day – NHS screening referral to treatment 90 72.2

Faster diagnosis – 2 week wait urgent GP 75 81

Faster diagnosis – 2 week wait breast symptomatic 75 94.7

Faster diagnosis – NHS screening referral 75 67.4

Our RTT performance is monitored through divisional meetings and a weekly cross-divisional Access meeting. TheElective Care Programme Board continues to have oversight of cancer and elective care performance. The Finance andPerformance Committee and the Trust Management Committee receive performance reports from here.

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What will success look like? How did we perform against our success criteria?

Reduction in the overall Trustvacancy rate by 1%

The vacancy rate at year end has reduced to 6.3%; a small amount of thereduction is due to testing staff employed temporarily. The change from Q419/20 has been a reduction of 2.6% points, from 8.9% to 6.3%

Further reduction in the turnoverrate for Band 5 nurses by 1%

In March 2021 turnover rate for B5 Nursing was 13.4%, a reduction of 3.9%points over the year (17.3% at Q4 19/20)

Overall Trust turnover rate toreduce by 1% to 14%

The overall turnover rate has reduced to 12.8% from 14.5% as at Q4 19/20, areduction of 1.7% points

Reduction in agency spend to£12.8m

The Trust finished the year with an agency spend of £12.02m. This was withinthe agency target of £12.8m for the year. Whilst temporary staffing controlsremain strong, a major driver behind the decreased costs was the operationalchanges made to deal with the pandemic. A fall in the number of patientstreated during this period also had an impact on our use of Agency staff


Evidence shows there is a very strong link between workforce engagement and patient outcomes and experience. TheTrust has made significant improvements over recent years and ensuring our staff are happy, healthy and wellsupported staff is an absolute priority for this year.

Our ‘Quality Commitment’ sets out our approach to building a culture that enables all staff to help us continuouslyimprove the care we deliver to our patients.

Priority 6 – Happy, Healthy, Well Supported Staff

This priority sought to uphold the Trust’s side of the quality commitment: to recruit, retain and care for our workforceand in so doing make it easier for staff to deliver the best quality care for every patient, every day to ensure a positivepatient experience and best patient outcomes.

We are proud of our caring and skilled workforce and their genuine commitment to our patients. Over the past year,we have focused on making sure that we have the right number of well-supported, well trained, happy staff in theright jobs.

Recruitment and Retention

Branding has been in place now for a few years and has really taken off. We continue to recruit using NHS Jobs andtrack through our own Trust website, which automatically interfaces with LinkedIn, Indeed, Find-a-Job and Jora. TheTrust also regularly posts updates and vacancies via Facebook and Twitter.

2020/21 has been a difficult year due to COVID-19 and we have adapted our recruitment processes to incorporatesocial distancing and no visitors on site. We moved to some home working and all interviews, assessments, on-boarding checks via MS Teams. This will continue until it is safe to start lifting some of these restrictions.

We have attended two online job fairs during this time, and we are working as part of a wider ICS to promote jobs andcareers across Hertfordshire and West Essex.

During the peak of the first lockdown, our overseas nurse recruitment programme was suspended between March2020 and August 2020. As soon as we were able to, we safely deployed nurses mainly from India and the Philippines incohorts of 24 to 26 nurses every three weeks. All government guidance was followed in terms of quarantine andCOVID-19 testing at key points. This programme has been extremely successful and since August 2020, 189 overseasnurses have joined the Trust. These valuable staff members have built strong communities and the turnover for thisgroup is very low at 9% over four years, equating to just 55 leavers since 2017 or 2% a year.

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The Trust has successfully recruited over 100 Health Care Assistants (HCA) since October 2020. There are plans beingdeveloped to support career progression within this essential staff group to undertake Apprenticeship or NursingAssociate training. We are enhancing the onboarding process to extend this beyond their start date to supportretention. Due to the successful recruitment campaigns, we have seen a significant reduction in agency spend for thisstaff group.

We have successfully secured more than £1m funding from Health Education England (£321k of this is dedicated ICSfunding) and overall, our vacancy rates for Band 5 Nurses (adult inpatient) and Band 2 HCAs is 0%.

We are working closely with our Midwifery Team to develop a recruitment strategy to fill their Band 6 vacancies, whichare traditionally difficult to recruit to. We are looking into international recruitment of midwives as we are seeing moreand more highly skilled applicants from overseas candidates. This is being supported regionally and potential fundingwill be made available.

Our experienced and dedicated recruitment team work closely with our candidates and managers. We are currentlyrevisiting our Time to Hire KPIs to ensure they are fit for purpose and deliver the highest standard of recruitment for theTrust.

Nurse development courses which provide management and leadership training for Bands 6 and 7, have beenimplemented within the Trust, whilst management training courses for other staff groups have been reviewed andrebranded.

A new recruitment policy is being developed and will focus on inclusion as one of our top priorities. This will bringmore diversity within interview panels, Inclusion Champions, enhanced recruitment and selection training to promoteexcellent standards and an inclusive culture.

Staff EngagementThe NHS National Staff Survey took place between October and November 2020 and is measured across three sub-sections:• Advocacy – Would staff recommend this Trust as a place to work or receive treatment? • Motivation – How well are staff motivated at work? • Involvement – What ability does staff have to contribute towards improvements at work?

The 2020 survey saw our best ever response rate at 47%.

Key results include:• Our Overall Staff Engagement Score was 6.9 out of 10. The national average was 7.0 and our 2019 Result was 7.0.• Our response ratio of white to BAME colleagues was 61% to 39% respectively, which represents a 1% relative increase in BAME respondents from 2019 (where the ratio was 62% to 38%). However, this still represents significant under-representation of BAME colleagues as responders to the Staff Survey, as BAME colleagues make up 45% of the whole Trust. • Compared to national results eight out of 10 themes have average scores. Two out of 10 themes received significantly worse scores – these were in Equality, Diversity and Inclusion and Morale.

The 2020 survey was undertaken at a very challenging and difficult time in the NHS and it is fair to say organisationswere affected in different ways. The Trust asked for a comparison to be against five large London acute trusts in asimilar position, as opposed to comparison against acute trusts nationally.

Our results against the five London Acute trusts are as follows:• We are first place amongst the comparison trusts in five out of 10 themes• We are second place amongst the comparison trusts in two out of 10 themes• We are third place amongst the comparison trusts in one out of 10 themes• We are lower than third place amongst the comparison trusts in two out of 10 themes.

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Overall, the Trust has not seen significant changes to our results since 2019, despite the severe challenges faced in2020. It is positive and encouraging to see we have done better in most themes than our London trust comparatorsand we continue to do very well in themes of Immediate Managers, Quality of Care and Team Working, thoughour scores in all of these have declined since 2019.

The Trust recognises the need to improve in the Equality, Diversity and Inclusion and Morale themes, which werepoor in 2019 and have worsened as perceptions around flexible working and safety fell during the pandemic.

The below table gives more details about our staff engagement performance:

Staff Engagement Results from Staff Survey

What will success look like? Key targets we wanted toachieve in the 2020 staff survey

How did we perform against our successcriteria?

Be in the top 20 acute Trusts overall for staff engagementas measured via the annual NHS staff survey.

Best score across STP region (acute trusts) at 7.0

75% of our colleagues say that they look forward togoing to work.

2018 – 64.7%2019 – 62.2% - better than national average 2020 – 60.3%

85% of our colleagues say that their manager values theirwork.

2019 –76.2%2020 – 71.9%

85% of respondents agree that the organisation makeadequate reasonable adjustments.

2019 – 69%2020 – 67%

95% of our colleagues agree that we take positive actionon health and well being.

2019 – 36%2020 – 32.3%

Less than 20% of colleagues will have experiencedharassment, bullying or abuse at work frompatients/public.

Less than 15% will state they have experiencedharassment, bullying or abuse at work from colleagues.

2019 – 16%2020 – 13.8%

2019 – 2.2%2020 – 1.8%

Staff networks optimised and impacting the Trust:ensuring inclusion is wired into all decision makingmeasured through numbers participating and evidence ofimpact.

The Diversability network created and piloted areasonable adjustments plan, which will be availableto staff across the Trust from June 2021. Recentworkforce data suggests the network has increasedpsychological safety for disabled staff at the Trustfollowing the launch of the network in 2019. Thenumbers of staff who have shared they are disabledon ESR has increased to 2%. An LGBT+ network waslaunched in 2021.

An above national average response to the staff survey byBAME staff.

39% of all staff survey responses were completed byBAME staff.

The challenges of the pandemic have had a significant impact on the morale of our staff, and this may be acontributing factor in the lack of improvement seen in many of the key targets we had wanted to see improve in2020/21. The way staff engaged and interacted with each other was further impacted by the high proportion of staffengagement undertaken remotely and using digital devices. This may have had a particular effect on staff feelingvalued by their manager as the score for this question decreased by 4.3% compared to 2019.

The Trust continues to make changes to improve the support given to staff at all levels. Activities include: • Managers continue to work with occupational health in providing support and implementing adjustments to staff where reasonably possible. • The Diversability network has helped create and is piloting a Reasonable Adjustment's plan. This is due to be launched in June 2021 and will be accompanied by guidance and training in the use of and implementation of the plan.

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• To mitigate the hearing challenges faced due to wearing of masks during the pandemic, "Please communicate clearly" badges were distributed. • A full-time onsite counselling service has been established, with referral pathway and signposting to our EAP, Occupational Health, Pastoral Care and external resources across the ICS and region. • The Trust has recently trained mental health conversation (REACT) trainers and Mental Health Frist Aiders, which will be rolled out across the organisation for a peer-to-peer support model.

Due to the pandemic, many of the Trust’s annual health and wellbeing events were not able to take place. However,the following did take place on a reduced scale:• ‘We Value You’ Week in November 2020• Virtual Long Service Awards presentation in November 2020• Financial webinars in June 2020 and February 2021

The Trust’s LGBT+ network was launched in February 2021 and is currently developing a term of reference which will befinalised by June 2021. The on-going growth in the network’s membership and Electronic Staff Record (ESR) data willbe a key measure moving forwards.

Connect, the Trust’s multi-cultural staff network, continues to be strongly involved in a number of decision-makingprocesses in relation to our workforce agenda. A recent example of this is their work to ensure our policy in relation tocolleagues travelling abroad for bereavement during the pandemic was as inclusive as possible. They continue to attendand update PERC meetings on their monthly safe space sessions.

The Trust’s top five actions in relation to staff engagement for 2021 are:

• We Value You – Staff Morale– Assess leavers’ questionnaires to explore the issues around staff either wanting to leave the Trust, as soon as they can find another job or will look for another job in the next 12 months. – Provide training for leaders and managers in engaging staff and raising morale.

• We Value Everybody – Equality, Diversity and Inclusion– Launch a Reasonable Adjustments Passport to increase access and support.– Establish why BAME and disabled colleagues consider promotion/career progression not fair and put into place key actions to rectify this.

• We Want You - Staff Engagement– Establish why advocacy remains below the national average and develop suitable plans to address this.

• We Protect You - Safety Culture– Investigate further colleagues’ perception of feeling unfairly treated when involved in an incident, risk or error.

• We Support You - Health and Wellbeing– Establish causes for high incidence of musculoskeletal injuries at work and put in place interventions to minimise these risks.– Increase the opportunities for flexible working by looking at existing barriers to this and suitable resolution of them.

Learning and Development

Quality Priorities Measures of Success 2020/21


20% more of the apprenticeship levy spent at theend of 2020/21 compared to 2019/20, with plans inplace to fully realise a further 20% increase in2021/22.

This has been achieved with a total spend of £276,343 in2021 as compared to £227,266 in 2020.

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Delivery of the leadership and managementprogrammes being successfully phased back infollowing the interruption during COVID-19, withthe first complete cycles of Evolve and Transformhaving been run by the end of the 2020 calendaryear, and the first complete cycle of Rise having beenrun by the end of the 2021 calendar year.

The programmes are now running again with Evolve andTransform having been restarted. The first cycle of Evolvewas completed in September 2020; Transform wasdelayed by the January-March pandemic issues and willnow complete its first cycle by July 2021. Rise isscheduled to commence in July. New programmesGateway and Launchpad will also commence in 2021.

Increasing numbers attending (either virtually orface-to-face) development, leadership andmanagement programmes with good qualityevaluations.

All evaluations of L&D programmes are positive and ofgood quality. Due to the pandemic counting attendeesattending training programmes for 2020/21 would notbe considered a useful measure. We aim to monitor andreport on the number attending training at the end of Q22021/22 and compare attendance figures with 2019/20data.

Numbers accessing coaching and subsequentimprovements in morale and performance in thoseareas.

We have seen a significant increase in the demand foraccess to coaching during the pandemic. Introduction offormal service was delayed; this will now take place in2021/22.

A minimum of 20 coaches trained by March 2021. Delayed by the pandemic but to be completed by end ofQ1 2021/22.

Positive evaluation of the reverse mentoring schemeby mentors and mentees.

Nine Executive Directors participated in the programmeduring 2020/21. An evaluation of the scheme is currentlybeing undertaken. The outcomes of the evaluation will bereported in the 2021/22 Quality Account.

The number of staff accessing Careers Matters andthe number of those who report they found ithelpful with their career development.

A new career coaching service is to replace CareersMatters by Q2 2021/22.

Less than 15% of our staff say they will be lookingfor a job in a new organisation within 12 months.

2020 Staff Survey response for this question was 18%

An increase in our apprenticeship metrics and levyspend and the number of new professionals eitherdirectly or incrementally created through theseprograms.

See apprenticeships section above.

The Staff Survey told us that career development was a key factor in staff retention. In the face of recruitmentchallenges and national staff shortages, we took a ‘grow our own’ approach to improve development opportunitiesand staff education where possible.

Priority 7 – Quality Improvement and Clinical Leadership

Our quality commitment set out a clear vision for the ‘West Herts Way’, placing a commitment to improving the servicewe deliver to our patients, at the heart of everything we do.

This service delivery and improvement mind-set required a deliberate effort to train our staff and to support them inworking in new ways.

Establish a Quality Hub and Roll Out Quality Improvement (QI)During 2020/21 the Trust’s quality improvement journey continued to gather pace and the following achievementshave been attained:• The falls prevention and Hospital Acquired Pressure Ulcers prevention QI project will be rolled out to other inpatient areas including the Granger Suite, Croxley and AAU L1.

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• Staff education in QI has continued with cohort 1 completing the course in September 2020 and it being incorporated into the Band 5 Nightingale programme. QI study days have also been facilitated. • Doctors have been receiving QI training as part of respiratory SPR training in Q1

Clinical Leaders Development Programme We know that to be a safe, effective, and caring organisation, it is crucial that we are clinically led. Healthcare haschanged substantially over the last decade and we need to ensure our current and aspiring clinical leaders have thetools to enable them to lead in a landscape where integration, technology and governance make increasing demands.

In 2019/20 we created Transform, a Clinical Leadership Programme, to ensure our clinical leaders have the tools toenable them to lead in the complex landscape of clinical or divisional directorship. The first programme commenced inOctober 2019 and the second was due to commence in April 2020, however the COVID-19 pandemic meant this wasdelayed until November 2020.

During the times developmental programmes were suspended, Clinical leaders (along with all leaders and managers inthe Trust) were supported through a programme of courses delivered remotely. These focused on supporting leadershipthrough crises, as well as providing an on-demand 1:1 and group coaching service. These were branded as “Are YouStill Managing?” and “Space to Think and Time to Reflect.”

Both Transform programmes have now restarted and the first will conclude in October 2021, with the secondconcluding in December 2021. The third and fourth programmes originally planned for September 2021 and April2022 respectively, will now commence in April 2022 and September 2022.

Despite the interruptions to the programmes, the parts that have been delivered have been very well received withuniversally excellent evaluations of all sessions.

Priority 8 – Quality Governance with Risk Management and Learning

Learning from incidents, complaints, claims and audits is essential for the Trust. The implementation of actions andchange following any investigation is pivotal to ensuring our organisation delivers harm free, quality care therebyensuring a positive patient outcome.

Organisational Wide Learning and Action PlansOver the last year, we continued to seek to improve the standard of our investigations and responses, aiming to informimprovement of care and services.

Learning from complaintsIn 2020/21, the COVID-19 pandemic impacted upon the planned actions of developing learning outcomes fromcomplaints, with planned reviews and work having to be paused as services and divisions focused on patient carepriorities. However, the Trust continued to seek to improve care by capturing learning effectively. Examples include:• The Medicine Division implemented a monthly presentation of a complaint, the themes, and outcomes by the senior sister for a ward within their Governance meetings to aid understanding and shared learning. The Surgical Division now creates and shares learning through a standardised template, which captures what went well, what didn’t and what lessons can be improved. • Following a review of the Trust’s Complaints policy, updates have been made to reflect a more streamlined process with the emphasis on early resolution and learning. • The Satisfaction Survey was one of the areas paused, however this has recommenced and in line with the new NHS Complaints Standard pilot, will be taken forward in 2021/22. • Complaints’ training as part of the induction process was to be developed, however due to induction being paused due to the pandemic; this will also be taken forward in 2021/22.

The Trust continues to work on improving overall response rate to complaints. In 2020/21, our response rate was 85%up from 71% in the previous year.

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Learning from Serious IncidentsThe Trust is committed to identifying, reporting and investigating serious incidents and ensuring that learning is shared

across the organisation and actions taken to reduce the risk of recurrence. During 2020/21 the following processes for

cross divisional and Trust-wide learning were further developed and embedded:

• Bi-monthly meetings of the Serious Incident Review Group (SIRG) to monitor actions and gain assurance that actions

arising from serious incidents had been implemented.

• Divisions took learning to the Quality and Safety Group to enable cross divisional learning.

• Serious Incidents, incidents, complaints, litigation, and PALS were monitored through the Quality Committee and

work has begun to develop corporate processes to allow triangulation of learning from these areas.

Learning from Never Events Never Events are defined as serious, largely preventable incidents that should not occur if the available preventative

measures have been implemented.

During 2020/21 the Trust has reported four Never Events, all of which have been or are currently being reviewed in line

with our serious incident investigation procedures. We have developed actions to make sure we are reducing the

likelihood of similar incidents occurring again including, revisions in local standard operating procedures, divisions have

reviewed and implemented Local and National Safety Standard for Invasive Procedures (LocSIPs/NatSIPs) and regular

compliance audits to monitor performance.

Learning from Claims The National Clinical Audit Office suggests clinical negligence claims are rising year or year. They are costly, both in

terms of harm and expense. An important part of the Trust’s claims process is the action taken in relation to learning.

This helps us to mitigate risk and reduce future harm to patients. In 2020/21:

• On receipt of a claim, if the incident had not already been the subject of an internal investigation, consideration was

given to whether it was appropriate to carry one out, thereby maximising our learning opportunities

• Divisions were kept informed of the expert evidence obtained during an investigation and at the completion of claim

as they were best placed to recognise what systems and practices could be changed to ensure similar incidents did

not happen again.

• Learning from claims was captured on our risk management system, Datix, and was shared with the Divisions, for

inclusion in their presentation slides for Quality and Safety group.

Duty of Candour for Moderate and Above HarmsThe Trust is committed to open and effective communication with patients, their families and/or carers throughout the

time spent under its care. When something goes wrong with the clinical care provided and a patient has or could have

suffered harm as a result, the Trust ensures full compliance with its statutory duty to be open and honest as outlined in

its duty of candour policy.

The pandemic saw an exponential increase in the number of patients requiring Duty of Candour to be undertaken,

which was mainly attributed to COVID-19 healthcare acquired infections reported, according to the national

classification.

In response, the Trust reviewed current processes and additional governance processes and resources were put in place

to support the Trust to achieve the required compliance.

In 2020/21 our Duty of Candour compliance for all Serious Incidents was 100%.

In March 2021 the Care Quality Commission (CQC) issued updated guidance to providers on meeting the requirements

of Regulation 20 Duty of Candour. Our Duty of Candour policy was updated to reflect the latest guidance.

To ensure our compliance with Duty of Candour within divisions is robust, embedded and sustained; we have again

made it one of our key priorities for 2021/22.

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CQC InspectionAs part of the Care Quality Commission (CQC) regulations, the Trust is required to register all sites and services.

The current registration status is registered without conditions and the Trust did not participate in any special reviewsundertaken by the CQC during the period of 2020/21.

The CQC inspected the Trust in February 2020 the focus of which was against the following core services:• Urgent and emergency care at Watford General Hospital, Hemel Hempstead General Hospital and St Albans City Hospital. • Medicine at Watford General Hospital and Hemel Hempstead General Hospital • Surgery at Watford General Hospital.

The outcome of the inspection was published in June 2020 and the Trust’s overall rating remains requires improvement.

However, despite remaining as requires improvement, the Trust is proud that the report highlighted significantimprovements. All services at Watford General Hospital and St Albans City Hospital (SACH) are now rated overall as‘good’ (eight and three services respectively) and two out of three services at Hemel Hempstead are rated overall as‘good’.

The Trust improved to a ‘good’ rating in two domains - effective and well led - and remained in ‘requires improvement’in two - safe and responsive. Ratings did not decrease in any domain.

Urgent and emergency care services on all three hospital sites are now rated ‘good’, which included the lifting ofrestrictions at the Minor Injuries Unit (MIU) at SACH which had been previously rated as inadequate with restrictions.

Overall, we have achieved a higher number of ‘good’ ratings than ratings for ‘requires improvement’, which is asignificant improvement on the Trust’s previous inspection in 2018, when we were rated as ‘requires Improvement’overall.

The report said inspectors saw how: “staff worked together as a team to benefit patients. Doctors, nurses and otherhealthcare professionals supported each other to provide good care.”

The report also said: “the service was inclusive and took account of patients’ individual needs and preferences,” and“staff cared for patients with compassion, kindness and respect. Feedback from patients and those close to them waspositive about the way staff treated them. Patients felt supported and cared for by staff.”

Inspectors said they saw evidence that: “Staff felt respected, supported and valued. They were focused on the needs ofpatients receiving care.”

Areas for improvement described in the report as ‘must dos’ and ‘should dos’ have been put in place and are part ofthe Trust’s on-going monitoring arrangements.

Rating for acute services/acute trust

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Priority 9: Improving our infrastructure

Sustainability

The complex challenges caused by the COVID-19 pandemic resulted in progression of the Trust’s sustainability agenda

being somewhat restricted during 2020/21. However, improved operation of plant and equipment has resulted in a

reduction in energy consumption, a significant portion of which was generated onsite at Watford.

The timely negotiation of energy contracts has resulted in a reduced energy spend of more than 20% compared to the

previous financial year. Looking ahead, the Trust remains focussed on decarbonising its estate and putting sustainability

at the heart of its operations. Work is to resume on the production of the Trust’s new Green Plan, which aims to

improve the health, wellbeing, quality of life, and quality of care experienced by patients, visitors and staff.

Energy infrastructure upgrades have continued throughout the year, with the vast majority of the Trust’s old-style

fluorescent lighting being replaced with contemporary LEDs, which has reduced energy consumption, costs and

maintenance requirements. Replacement of aged boilers and chiller plants have also supported improved energy

efficiency, reduced the risk of breakdown and helped address the Trust’s burden of backlog maintenance.

A number of efficiency projects are planned for the coming year which will bolster the Trust’s ambition to contribute to

a net-zero society. For example, the Trust will take part in the Green Ward Competition initiative, run by the Centre for

Sustainable Healthcare, Oxford. Comparable wards will be encouraged to make small changes in practice and adopt

sustainable approaches. Best practice will then be repeated across the Trust. Not only will this save energy, but it will

also produce savings in waste and the way in which medicines are dispensed. The most successful ward will be

crowned the winner.

Estates

COVID-19 has highlighted the significant challenges associated with the Trust’s estate and it has become clear that the

current estate does not meet the needs of 21st century healthcare.

Urgent upgrade and expansion works were carried out at speed throughout the year to create new or reconfigure

existing facilities and infrastructure to meet the needs of our clinical staff. A project team has been assessing and

improving our physical environment with a refurbishment of the outside food area and staff rest rooms. Works to

address critical infrastructure and life-saving systems risks has continued and significant investment was made in fire,

water hygiene, electrical infrastructure and heating systems across all sites.

A number of new service developments were completed including, the new Emergency Assessment unit at Watford

General Hospital, which has been designed to accommodate an additional 20 beds to support the ED clinical

workstream.

A significant number of diagnostic imaging schemes have been completed including the CT and MRI at SACH, a new

CT scanner adjacent to ED, two new digital imaging in PMOK, and works have commenced to deliver two new Cath

labs, and an additional CT scanner to replace the existing unit in AAU.

The Environment Division will continue to manage, monitor, and mitigate the risks associated with our estate. A further

six facet and condition surveys are due to be undertaken in 2021/22, which will allow for further refinement and

planning of investment of capital funding and establish baseline information for service delivery model optioneering,

which will be undertaken over the coming years.

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Environment

Our pastoral care and wellbeing rooms in the admin block at Watford General Hospital have been refurbished and

newly decorated and will allow staff to take time out, relax or reflect, either by themselves or with a colleague. There

are also dedicated multi-faith areas for prayer or spiritual reflection. These rooms have been made possible by the

Trust’s charity Raise.

Quality Performance Indicators

The Department of Health requires organisations delivering acute healthcare services to report against a mandated set

of quality indicators in their annual Quality Account. These were introduced so the local population could assess if an

organisations performance was good or poor when compared against other NHS organisations. Our performance

against the required indicators can be found in Appendix 1.

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Our Quality and Improvement Priorities for 2021/22

Theme 1 Providing Safe and Effective Care and Improving Outcomes

Quality Priority Achieve a target of zerocategory 4 hospitalacquired pressure ulcers,40% reduction in MedicalDevices Related PressureUlcers (MDRPU) and 40%reduction in hospitalacquired category 2pressure ulcers

% of omitted medicines tobe below the nationalaverage of 5%

Reduce the number ofpatients discharged fromthe Trust with anindwelling catheter

Rationale Taking key actions to reducehospital acquired pressureulcers will lead toimprovements in patientsafety and experience, areduction in length of stayand reduced treatment costs.

For some critical medicinesor conditions, such aspatients with sepsis or thosewith pulmonary embolisms,delays or omissions in theadministration of medicinescan cause serious harm ordeath.

Catheter associated urinarytract infections (CAUTI) arean increasingly importantissue with the identificationof multi-resistant bacteria.The risk of complicationsoccurring increases with theduration of catheter. Toreduce CAUTI and othercomplications, early catheterremoval is important.

Measuring Success • Sustained improvement in the number of hospital acquired pressure ulcers.

• Role of Skin Champions strengthened to promote best practice in clinical areas.

• Development of an e-learning package for pressure ulcer prevention.

• Test Your Care audit.

• Pharmacy led audit - % of omitted medicines to be below 5%.

• Decrease in the number of omitted doses of medicines in the ‘administrative box left blank’ category.


• Reduction in harmful incidents relating to medication errors.

• 10% reduction in patients discharged with an indwelling catheter.

• Monitor effectiveness of the nurse-led HOUDINI protocol in reducing the number of catheters remaining in situ longer than clinically required.


Monitoring Committee Quality Committee Quality Committee Quality Committee

Responsible Director Chief Nurse Chief Nurse Chief Nurse

We have carried forward our three themes from 2020/21, ‘Providing Safe and Effective Care and Improving Outcomes’,

‘Ensuring Services are Caring and Responsive’ and ‘Building a Quality Culture’.

Whilst we have selected a set of key priorities on which to focus our quality improvement activity for each theme in

2021/22, all our quality objectives (appendix 2) will be reported upon in the 2021/22 Quality Account.

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Theme 2 Ensuring Our Services Are Caring and Responsive

Quality Priority Improve patientexperience with thedischarge process

Improve patientexperience with thebooking process

Improve access

Rationale A safe and timely dischargegives patients the bestpossible chance of returningto their normal level ofactivity; evidence-basedstudies have shown that 10days in a hospital bed canlead to 10 years’ worth oflost muscle mass in peopleover the age of 80.Improving the timeliness ofdischarge reduces the timeother patients in our ED waitfor admission, therebyimproving patient experienceof care at the beginning oftheir hospital stay.

Patient feedback shows usthat our booking process forboth scheduling andrescheduling outpatientappointments is a source offrustration, and this hascontributed to a higher thannational average DNA rate.

The impact of COVID-19 hasresulted in the suspension ofmost routine elective carecausing very long waits.

The Trust was below thenational standard for the 62-daycancer pathway in 2019/20.

Measuring Success • Achieve 33% of discharges before midday.

• Maintain the reduction of Long Stay Patients (26% Reduction in bed days).

• Discharge 40% of patients through the patient lounge.

• Continue to Embed the Safer flow Red2Green Principles with the Criteria to Reside data to support patient flow.

• Significant reduction in the patient’s call wait time (currently 9-20 minutes).

• A reduction from 60% abandoned calls to 20% (when call volumes increase to pre-covid levels).

• Sustained improvement in the number of calls responded to each day (currently 350-400).

• Staff training and competency compliance.

• Improvement in performance against the ED 4 hour standard.

• Improving our ED ambulance handover delay times.

• Improving our IPS response times.

• Progress the development of E-FORM to enable patients to cancel appointments or request to reschedule.

• Implementation of a post COVID-19 long waits improvement programme.

• Reduce number of patients waiting more than 52-weeks and improve performance against 18-week waiting time standard for RTT.

• Improve (reduce) the number of 63-day and 104-day cancer waits.

• Successful transition and implementation of any new standards.

MonitoringCommittee

Quality CommitteeTrust ManagementCommittee

Trust Management CommitteeFinance / PerformanceCommittee

ResponsibleDirector

Chief Medical Officer Chief Information Officer Chief Operating Officer

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Theme 3 Building a Quality Culture

Quality Priority Roll out QualityImprovement Programme

Promote effective ClinicalLeaders

Improve Duty of CandourCompliance

Rationale Our Quality Commitmentsets out a clear vision forimproving the quality ofservice we deliver to ourpatients. A QualityImprovement programmewill help build capacity andcapability for sustainedimprovement.

In order to be a safe, caringand effective organisation,clinical leadership is essential.We created a ClinicalLeadership Programme,‘Transform’ to equip ourclinical leaders with the toolsto enable them to lead in thecomplex landscape of clinicalor divisional directorship. TheTransform programme wasinterrupted last year by theimpact of COVID-19 andwillbe resumed in 2021/22.

Duty of Candour is astatutory duty to be openand honest with patients ortheir families whensomething goes wrong withcare or treatment causingmoderate harm or worse.Whilst the Trust is compliantwith Duty of Candour forSerious Incidents,improvements are neededfor compliance at divisionallevel.

Measuring Success • Increase in number of new local projects undertaken as more staff are mentored.

• Falls Prevention and HAPU QI projects rolled out to other inpatient areas.

• Staff education in QI will continue to be rolled out as part of the education and training programme.

• Doctors will receive QI training at all stages of their training.

• Increase in divisional performance metrics due to better clinical leadership.

• Complete delivery of first Transform programme and evaluate it by June 2021, and the second programme by December 2021.

• Embed results of these evaluations to inform improvements for the third programme due in 2021/22.

• 100% compliance with the statutory Duty of Candour.

• To develop mandatory training in Duty of Candour for staff to complete online.

• All serious incidents will have an identified family liaison officer/Duty of Candour lead.

• Implementation of weekly harm review meetings to establish level of harm, and where Duty of Candour is applicable, actions are taken to fulfil DOC obligations.

• Development and implementation of Duty of Candour Policy, to ensure it is addressed and applied in all incidents.

Monitoring Committee Quality Committee Quality Committee Quality Committee

Responsible DirectorChief Nurse / Deputy ChiefExecutive

Chief Medical Officer / ChiefNurse

Chief Nurse

The successful delivery of our themes and priorities requires the continued commitment of all of our staff in the delivery

of quality care. We will support them in this journey in every way possible. We will continue to listen carefully to what

our patients and local residents tell us about how we can improve care and learn from our mistakes and we will use this

information positively to make improvements. Partnership working with our commissioners, (Herts Valley Clinical

Commissioning Group and NHS England/Improvement), local councils and other local NHS providers will remain a

priority for the Trust to make sure that we deliver joined up care for our patients.

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A Review of Our ServicesDuring 2020/21, West Hertfordshire Hospitals NHS Trust provided accident, emergency, outpatient, elective inpatient,non-elective inpatient, and critical care services across a wide range of around 40 different specialties. A detailed list isavailable on our website and services provided at our three sites are shown in Part One of this document.

West Hertfordshire Hospitals NHS Trust has reviewed the data available to it on the quality of care in all these services.

The expected income to be generated by the relevant health services reviewed in 2020/21 represented 92% of the totalincome generated from the provision of NHS services by the West Hertfordshire Hospitals NHS Trust for 2020/21.However, due to the COVID-19 pandemic, the actual revenue generated from patient-care activity reduced during theyear and block and COVID-19 top up income from NHSE/I made up for the difference.

The percentages of income planned by these services in 2020/21 in relation to the Trust total income are as follows:

% Income 2020/21

A&E 8%

Outpatients 24%

Elective inpatients 16%

Non-elective inpatients 40%

Critical Care 4%

Total 92%

CQC RegistrationWest Hertfordshire Hospitals NHS Trust is required to register its services with the Care Quality Commission. The Trust isregistered to provide:

Watford General Hospital:• Assessment or medical treatment for persons detained under the Mental Health Act 1983.• Diagnostic and screening procedures.• Family planning.• Management of supply of blood and blood derived products.• Maternity and midwifery services.• Surgical procedures.• Termination of pregnancies.• Treatment of disease, disorder, or injury.

St Albans City Hospital:• Assessment or medical treatment for persons detained under the Mental Health Act 1983.• Diagnostic and screening procedures.• Family planning.• Maternity and midwifery services.• Surgical procedures.• Treatment of disease, disorder, or injury.

Hemel Hempstead General Hospital:• Assessment or medical treatment for persons detained under the Mental Health Act 1983.• Diagnostic and screening procedures.• Maternity and midwifery services.• Treatment of disease, disorder, or injury.

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Inclusion and DiversityDiversity is a fact and West Hertfordshire Hospitals consists of people from multiple disabilities, ethnicities, genders,nationalities, religions, sexual orientations and many more different backgrounds.

Inclusion on the other hand, is an act. We are extremely proud of our varied workforce and are actively working toremove any barriers our staff may face because of their identify.

Our overarching workforce inclusion objectives are set out in our 2020-2025 People Strategy:1) Build an inclusive and diverse team2) Support and engage our team3) Develop our team4) Move forward by embracing new ways of working

In the last year we have made progress in relation to objective one, particularly in relation to understanding how diverseour team is via data. For example: twice as many colleagues have shared, they have a disability in the last 12 months.This is significant progress as it had previously remained stagnant for a number of years and reflects the work of ourDiversability staff network who have been sharing personal stories of invisible disabilities and also creatingpsychologically safe spaces.

Our governance structure for our work in relation to ethnicity are now significantly improved, particularly through ourBAME staff network Connect who re-launched with a new Terms of Reference with aims/deliverables and significantlyexpanded roles/steering committee.

The objectives of Connect are to:• support the Trust in its strategic objectives to provide the best care for every patient• help the Trust be a great place to work by utilising the skills and resources of BAME employees in order to add value • Ensure the Trust is inclusive with a focus on improving BAME staff experience.

There is also now a standing item for diversity and inclusion on our People, Research and Education Committee (PERC),which reports into Board. The Chair of Connect attends these meetings and our disabled staff network Diversability’sminutes are included in the meeting papers for information.

Our understanding of our religion/faith as well as sexual orientation also increased by 5% each, which reflects the workour Pastoral Care Team as well as newly launched LGBT+ staff network has been undertaking.

Our second equality objective of supporting and engaging our team has been a significant undertaking over the past12 months. Our work to mitigate the disproportionate impact of COVID-19 has included creating a diagnostic pathway,which provides staff with access to clinical support in managing symptoms and access to various pathways, includingthe COVID-19 Virtual Hospital. This ensured BAME staff that are symptomatic are automatically categorised as “highrisk” and placed in the Virtual Hospital. Additional protection was embedded in our risk assessments for staff that areBAME, pregnant, have co-morbidities and are 60 years old and over.

In the past year, we have also analysed our performance in relation to developing our staff in a much more in-depthway than before. The most notable example is through a diversity dashboard which shares overall as well as divisionaldata in relation to: access to Continuing Professional Development (CPD) courses, demographic of staff having their payband increased and evaluating the success of colleagues returning from maternity leave full-time, part-time or leaving.

One of the ways we are addressing the lack of ethnic diversity in our senior management teams is through our reversementoring programme, pairing Board members with BAME reverse mentors in order to educate leaders about diversityissues by exposing them to challenging and insightful conversations and experiences that they may otherwise neverencounter. Nine Executive Members participated in the reverse mentoring programme in 2020/21. The programme iscurrently being evaluated and findings will be reported through the agreed committees.

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While our gender ratio breakdown is broadly reflected in our pay quartiles, the exception is the upper pay quartile,which is a clear indication of our gender pay gap due to the over-representation of male consultants.

In August 2020, the Trust Board supported a major consultation exercise run by NHS Employers to gain input intoproposed reforms of the Clinical Excellence Awards scheme, which is how our Gender Bonus Gap is calculated. NHSEmployer’s view is that the local current clinical excellence award (LCEA) scheme is not working as it should. They see itas unfairly disadvantaging BAME doctors, women (exacerbating the gender pay gap) and those who work part-time.

The Department for Health and Social Care also report a lack of support for colleagues experiencing the menopause asanother factor which causes the gender pay gap. The Trust plans to roll out further training to boost menopauseawareness via in house training following the completion of “Train the Trainer” courses in June 2021.

Key to improving our performance in relation to the latter is our work in relation to our fourth Trust inclusion objective:moving forward by embracing new ways of working. The pandemic accelerated our work in relation to this, mostnotably via flexible working, which was embedded in our newly launched Agile Working policy.

In the longer term, the redevelopment of the Trust’s estate is the most significant opportunity to ensure we embracenew ways of working. This will improve the physical environment, will be more inclusive for our disabled staff as well ascreate more spaces aligned to the religious diversity of the area.

Our Inclusion and Diversity Team work closelywith the Chaplaincy team in order to activelypromote equality between the different faiths.Our Chaplaincy service now has dedicatedchaplains on each ward to support staff as wellpatients, and our sanctuary rooms also providespace for prayer, reflection, and religiousservice.

The Trust recognises there is no ‘one size fits all’ solution to promoting inclusion. Our new Inclusion and Diversity policywill include a new screening element for Equality Impact Assessments (EIA’s), which colleagues are required to completewhen implementing new policies, programmes, and procedures. This includes a specific section where inequality acrossthe protected characteristics is assessed and appropriate action identified.

All information here should be read in conjunction with our work on the Workforce Race as well as Disability EqualityStandards, Gender Pay Gap and Public Sector Equality Duty reports which can be accessed atwww.westhertshospitals.nhs.uk/about/equality.asp

Freedom to Speak UpThe Trust appointed a permanent, independent, Freedom to Speak Up Guardian (FTSUG) in July 2020, to enable staffto report concerns, worries or negative experiences.

FTSUGs were a recommendation from the 2015 Sir Robert Francis report The Freedom to Speak Up and help to supportworkers to speak up when they feel that they are unable to do so through other routes. The Trust’s current non-executive director with a responsibility for Freedom to Speak Up (FTSU) remains in post and offers support to the FTSUGas required.

In the past 12 months, 31 FTSU cases were reported with broad themes mainly relating to managerial behaviour andbullying and harassment. It is recognised that many of the concerns raised through FTSU are linked to conflicts thatshould have been addressed sooner and therefore supporting colleagues through informal resolution is a key priorityfor the FTSU programme of work. Concerns raised during the beginning of the response to the pandemic changed toreflect key national issues such as availability of appropriate Personal Protective Equipment (PPE).

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The Trust has also embedded FTSU Champions across the organisation through a positive, targeted recruitment process.Seven additional Champions have been recruited and trained, to give further coverage across the organisation,increasing their numbers and their diversity.

Through this activity, it has become clear that different people feel comfortable raising concerns to differentChampions. Therefore in 2021/22, the Trust will continue with targeted recruitment at different bands, job roles andprotected characteristic groups where Champions are currently underrepresented to ensure that as many people raisingconcerns as possible have a Champion they feel comfortable approaching.

Speaking up continues to be widely promoted throughout the Trust to ensure it is accessible to all colleagues, patients,governors, and students.

Freedom to Speak Up Cases April 2020 - March 2021

Full details of all the Freedom to speak Up Champions can be found on the Freedom to Speak Up page on the Trust’sintranet.

Participation in Clinical Audits and National Confidential EnquiriesThere are three types of clinical audit that the Trust participates in, which monitor our quality of care:• Quality Account National Clinical audits, which are produced at the beginning of each new financial year by the Health Quality Improvement partnership. These are mandated audits.

17

75

2

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• Local audits, which are carried out by the Trust and are informed by audits undertaken in previous years and those proposed by divisions each year.• National Confidential Enquiries into Patient Outcome and Death (NCEPOD) studies, which investigate an area of healthcare and recommend ways to improve it.

During 2020/21 47 Quality Account National clinical audits were produced of which the Trust was eligible to participatein 41 (87%). Details of these audits are in Appendices 3 and 5. The Trust completed 128 local audits, of which 106required additional actions to be taken. Details of these are in Appendix 6. Additionally, the Trust participated in twoNCEPOD studies and details are in Appendix 4.

ResearchClinical research is the bedrock of the care delivered to patients across the NHS. Research enables us to gatherinformation to help us better understand which the best treatments and procedures are for patients and allows newtreatments, medications and vaccines to be developed. The Trust is proud to take part in clinical research trials and tosupport the development of new ideas, products and clinical services for the benefit of our patients.

During 2020/21, the Trust recruited 4848 participants to research approved by the Health Research Authority [HRA].We recruited participants to 87 studies and were directly involved in 144 clinical research studies. Our research teamsused national systems to manage the studies in proportion to risk and the majority of the studies were established andmanaged under national model agreements. The National Institute for Health Research (NIHR) supported 125 of thesestudies through its research networks.

We are proud that in 2020/21, the Trust recruited more participants to NIHR studies (2389) than ever before, includingto the well-publicised Urgent Public Health COVID-19 clinical trials, which have contributed so much to the evidence oneffective treatments for patients with the disease.

Systems are in place within the Trust to ensure that the principles and requirements of research governance are appliedconsistently through a full set of policies and standard operating procedures which have been ratified by the Trust. Aresearch recruitment summary is shown in Appendix 7.

Furthermore, as a result of the pandemic and the change of emphasis and working practices in the Trust, our Researchand Development (R&D) Strategy 2020-23 is currently being reviewed and updated.

CQUIN PerformanceThe 2020/21 CQUIN scheme was suspended this year, due to the pandemic with no schemes being published. As partof the revised payments to Trusts, the guidance was to assume 100% achievement of the (non-existent) schemes.

Updated guidance to the NHS has now been published on the third phase of the NHS response to COVID-19. Theoperation of CQUIN (both CCG and specialised) will remain suspended for all providers until 31 March 2021; providersdo not need to implement CQUIN requirements, carry out CQUIN audits nor submit CQUIN performance data. ForTrusts, an allowance for CQUIN will continue to be built into nationally set block payments; for non-NHS providers,commissioners should continue to make CQUIN payments at the full applicable rate.

Data QualityData Quality can support the delivery of safe and high-quality patient care by ensuring that the information is used tounderpin decision making is accurate and complete. Information entered on the Trust’s Patient Administration System isused to communicate appointment and admission related information to patients and track waiting times againstconstitutional standards and other national and local indicators. The reporting of data quality is also a contractualrequirement with our commissioners.

To improve data quality at the point of entry, the Trust’s IT training team offers classroom and in situ training to clinicaland administrative staff. The Trust also has a range of data quality reports used in operational meetings to identify andcorrect any potential data quality issues.

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NHS Number and General Medical Practice Code ValidityIn 2020/21, the Trust submitted records to the Secondary Uses Service (SUS) for inclusion in the Hospital EpisodeStatistics which are included in the latest published data.

Trust performance in relation to the inclusion of the patient’s NHS number has been better than the national average, inevery area of care, for the third year in a row.

Source: Latest SUS Information to April 2020 - March 2021

Information Governance

Data Security and Protection (DSP) ToolkitIn April 2018, the Data Security and Protection Toolkit (DSP Toolkit) replaced the Information Governance Toolkit (IGToolkit) as the standard for cyber and data security for healthcare organisations and their partners. All organisationsthat have access to NHS patient information must provide assurances that they are practicing good informationgovernance and must use the DSP Toolkit to evidence this by the publication of annual assessments.

The toolkit forms part of a new framework for ensuring that organisations are implementing the ten data securitystandards recommended by the National Data Guardian and that they are meeting their statutory obligations on dataprotection and data security. To comply with the DSP Toolkit, organisations should demonstrate that they areconsistently and effectively incorporating the standards into their ways of working and that they are complying with therequirements of the General Data Protection Regulation (GDPR).

The Trust achieved ‘standards met’ status when it made its DSP Toolkit v2 2019-20 end of year submission on 30September 2020. The DSP Toolkit v3 2020-21 was later published in November 2020. Several assertions covering CyberEssentials, which were previously non-mandatory, were made mandatory for this year.

The deadline for the 2020/21 publication has been extended to the 30 June 2021. An action plan has been developedto address any areas of non-compliance against each of the mandatory assertions within the DSP Toolkit, whichincludes actions and recommendations provided by an internal audit undertaken in February 2021. The aim of the auditwas to identify any evidence that may not be applicable due to changes within the DSP Toolkit from the previousversion and to improve compliance in areas where partial or non-compliance was identified.

One Level 2 data breach was reported to the Information Commissioner during 2020/21. This involved a paper copy ofa ward handover sheet containing personal details of 11 patients on a ward which had inadvertently been given to apatient together with a copy of their own discharge summary.

Clinical Coding Error RateThe Clinical Coding Department’s core function is to translate medical terminology written by clinicians intoalphanumeric codes. This process underpins how the Trust is reimbursed for the activity it provides and supports arange of additional functions used to improve the quality and effectiveness of clinical care.

The Trust commissioned an external audit for the financial year 2020/21, to provide assurance on the quality of thecoded data. Other measures include benchmarking of various metrics from Dr Foster Intelligence.

Published data

WHHT percentage ofrecords which includedthe patient’s valid NHS

number

National average(NHS number)

WHHT percentage ofrecords which included

the patient’s validRegistered GP Practice

National average(Registered GP

Practice)

Admitted patientcare

99.8% 99.5% 99.9% 99.8%

Outpatient care 100% 99.7% 99.9% 99.7%

Accident andemergency care

99.2% 98.0% 99.9% 98.8%

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Palliative Care Coding Rate

For 2019/2020 the Palliative Care Coding Rate was 1.99% vs. a national average of 2.06%.

For 2020/21 the Palliative Care Coding Rate was 2.73% vs. a national rate of 2.23 % and a peer group rate of 2.27%.

Depth of Coding

The mean number of secondary diagnosis codes per finished provider spell (mean depth of coding) for non-elective

admissions from Jun 2019 to May 2020 is 5.1 vs. the national average of 5.3.

The mean depth of coding for elective admissions is 5.2 vs. the national average of 4.9.

Summary of Findings from External Audit:

The Trust achieved the mandatory requirements for data quality.

Primary Diagnosis Errors:

Of the 200 primary diagnoses that were audited, 191 (95.5%) were coded correctly. The nine inaccuracies were

attributed to coder error.

Secondary Diagnosis Errors:

Of the 1278 secondary diagnoses that were audited, 1257 (98.36%) were coded correctly.

Primary Procedural Errors:

Of the 113 primary procedures that were audited, 109 (96.46%) of these were coded correctly.

Secondary Procedural Errors:

Of the 271 secondary procedures that were audited, 257 (94.83%) were coded correctly.

The audit identified a number of areas of good practice, which included:

• The Trust has met the requirements by achieving advisory level of attainment for clinical coding analysis within

information quality assurance.

• The overall quality of coded data was good, and coders demonstrated good knowledge of clinical coding standards

and guidance.

• The Head of Coding has set up clear objectives for the department and the individual coders.

• The Department has allocated a budget for training and audits.

• Coders are encouraged to attend the NCCQ exam and the cost is covered by the Trust.

• Coders validate any ambiguous areas of clinical information with clinicians via emails and keep a record of them as

evidence.

• 100 % mortality review is carried out by dedicated clinical staff in consultation with the clinical coders.

• Palliative care reports, thrombolysis reports and COVID-19 data are available to Coders for validation.

• There is a Policy and Procedure document which is updated on a yearly basis and includes the coding and data

processes.

• Coding was up to date at the time of auditing.

• Pending biopsy results are updated by the coders on PAS as soon as they are available.

F/Y 2020/21 Mandatory Advisory

Primary diagnosis 93.5% >=85% >=90%

Secondary diagnosis 94.85% >=75% >=80%

Primary procedure 95.38% >=85% >=90%

Secondary procedures 93.09% >=75% >=80%

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There were a number of areas identified for improvement, which included:• Restructuring the department as per the previous audit recommendation and the adoption of Electronic Patient Records (EPR) by the Trust has been delayed due to the COVID-19 pandemic. However, EPR is likely to go live in November 2021. • National Clinical Coding Qualification (ACC) status for number of coders has been put on hold for over a year due to the pandemic.• Since the pandemic the Trust has not been using the full case notes in all areas for safety reasons; instead, there are temporary case notes created. These notes are often disorganised or missing information. Coders spend their valuable time navigating through the notes or chasing for missing information.• On a number of occasions, the coders failed to refer to the Coding Standards References.• There were some inconsistencies in coding, for example, coding of general anaesthetics in obstetrics, coronary artery disease and coding of symptoms when confirmed diagnosis is present.• On three occasions the coders failed to extract the right clinical information resulting in coding of incorrect procedures.• In some cases, coders omitted mandatory and relevant comorbidities.

Clinical Coding Audit Recommendations

R1:To provide audit findings and feedback to the coding team, and to discuss theconsistency of coding (i.e. coding of GA in obstetrics, coding of I25.1)

R2:Coders to have training on areas where audit found consistent errors (to be actionedimmediately)

ICD 10

Coding rules around symptom coding

External cause codes

Sequencing of hypertension with certain blocks (i.e. I20-I25)

Correct use of body system code with Y codes for multiple procedure on the same organ

Chapter W - Foot surgery (Akin, Scarf etc.)

Chapter Y – Approach codes and image control

OPCS

Coding rules around endoscopy coding

R3:Coders to routinely check the codes and apply the four-step coding process beforefinalising and saving the codes

R4:Coders to routinely check the codes and apply the four-step coding process beforefinalising and saving the codes

R5:Trust to continue with the annual audit programme

R6:Department to continue with the clinical engagement and validation process

R7:Clinical Coding management to organise an internal system to avoid inconsistencies incoding practice.

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Section 3. Appendices

Appendix 1: Quality Performance Indicators

National Required Data

NHS Digital Data

Indicator Measure From NHS Digital

Most recent results for trust

Time period for results

Result for trust for previous reporting year

Best performing trust

Worst performing trust

National average

SHMI rate n/a

Value = 0.9891

Banding = 2

2020

Value = 0.9974

Banding = 2 (2019)

0.6951 1.1869 1.000

% of patient deaths with palliative care coding

n/a 40% 2020 41% (2019) 59% 8.14% 36%

Groin hernia*

Adjusted average health

gain

EQ VAS -0.067 2017/18 -0.817 (16/17) 3.614 -9.201 -1.156

EQ-5D 0.085 2017/18 0.097 (16/17) 0.137 0.029 0.089

Hip replacement Total* Adjusted average health

gain

EQ VAS 15.329 2019/20 14.663 (18/19) 21.841 6.019 14.074

EQ-5D 0.443 2019/20 0.452 (18/19) 0.527 0.327 0.460

Oxford Hip Score 21.345 2019/20 21.633

(18/19) 25.484 17.825 22.449

Knee replacement Total* Adjusted average health

gain

EQ VAS 8.498 2019/20 9.445 (18/19) 12.895 0.872 7.916

EQ-5D 0.357 2019/20 0.327 (18/19) 0.409 0.245 0.341

Oxford Knee Score 17.246 2019/20 16.880

(18/19) 20.761 12.295 17.340

Varicose vein* Adjusted average health

gain

Aberdeen varicose vein questionnaire

-13.068 2017/18 -9.651 (16/17) -0.391 -14.068 -8.450

EQ VAS 1.043 2017/18 -0.309 (16/17) 5.350 -5.417 -0.086

EQ-5D 0.097 2017/18 0.095 (16/17) 0.134 0.035 0.096

30-Day emergency readmission rate1

0-15 years 13.5% 2019/20 9.4% (18/19) 2.2% 56.7% 12.6%

16+ years 12.7% 2019/20 12.1% (18/19) 1.9% 37.7% 11.9%

Staff recommendation of the trust as a place to work or receive treatment

n/a

Work – 52% Care - 59%

2019/20

Work – 60%

Care - 58% (2018)

Work – 97% Care -

100%

Work – 33% Care - 50%

Work – 66% Care - 81%

Patient recommendation of the trust as a place to receive treatment

Friends and Family Test (Mat = Q4 birth)

IP=95% OP=95%

A&E=92% Mat=98%

Feb 2020

IP=95% OP=93%

A&E=90% Mat=96% (March - 19)

IP=100% OP=100% A&E=99% Mat=100%

IP=73% OP=76%

A&E=40% Mat=57%

IP=96% OP=94%

A&E=85% Mat=98%

NHS Digital Data







National average

SHMI rate n/a

Value = 0.9891

Banding = 2

2020

Value = 0.9974

Banding = 2 (2019)

0.6951 1.1869 1.000

% of patient deaths with palliative care coding

n/a 40% 2020 41% (2019) 59% 8.14% 36%

Groin hernia*

Adjusted average health

gain

EQ VAS -0.067 2017/18 -0.817 (16/17) 3.614 -9.201 -1.156

EQ-5D 0.085 2017/18 0.097 (16/17) 0.137 0.029 0.089

Hip replacement Total* Adjusted average health

gain

EQ VAS 15.329 2019/20 14.663 (18/19) 21.841 6.019 14.074

EQ-5D 0.443 2019/20 0.452 (18/19) 0.527 0.327 0.460

Oxford Hip Score 21.345 2019/20 21.633

(18/19) 25.484 17.825 22.449

Knee replacement Total* Adjusted average health

gain

EQ VAS 8.498 2019/20 9.445 (18/19) 12.895 0.872 7.916

EQ-5D 0.357 2019/20 0.327 (18/19) 0.409 0.245 0.341

Oxford Knee Score 17.246 2019/20 16.880

(18/19) 20.761 12.295 17.340

Varicose vein* Adjusted average health

gain

Aberdeen varicose vein questionnaire

-13.068 2017/18 -9.651 (16/17) -0.391 -14.068 -8.450

EQ VAS 1.043 2017/18 -0.309 (16/17) 5.350 -5.417 -0.086

EQ-5D 0.097 2017/18 0.095 (16/17) 0.134 0.035 0.096

30-Day emergency readmission rate1

0-15 years 13.5% 2019/20 9.4% (18/19) 2.2% 56.7% 12.6%

16+ years 12.7% 2019/20 12.1% (18/19) 1.9% 37.7% 11.9%

Staff recommendation of the trust as a place to work or receive treatment

n/a

Work – 52% Care - 59%

2019/20

Work – 60%

Care - 58% (2018)

Work – 97% Care -

100%

Work – 33% Care - 50%

Work – 66% Care - 81%

Patient recommendation of the trust as a place to receive treatment

Friends and Family Test (Mat = Q4 birth)

IP=95% OP=95%

A&E=92% Mat=98%

Feb 2020

IP=95% OP=93%

A&E=90% Mat=96% (March - 19)

IP=100% OP=100% A&E=99% Mat=100%

IP=73% OP=76%

A&E=40% Mat=57%

IP=96% OP=94%

A&E=85% Mat=98%

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National Required Data

NHS Digital Data







National average

Rate of admissions assessed for VTE

n/a 94.38% Q3 2019/20 95.53%

(Q4 2018/19)

100% 74.03% 95.33%

C difficile infection rates1

Trust Apportioned Cases

28 2019/20 15 (2018/19) 0 145 32.2

Trust Apportioned Rate per 100,000 bed days

12.4 2019/20 6.5 (2018/19) 0 51.0 13.2

Patient safety incidents[1]

Number of incidents occurring

7,754 Oct 2019 - Mar 2020

7799 Apr 2019 - Sep 2019

1271+ 22,340+ 6,502+

Incidents resulting in severe harm or death

16 Oct 2019 - Mar 2020

31 Apr 2019 - Sep 2019

0+ 93+ 20+

Rate of severe harm or death as a percentage of all incidents

0.1% Oct 2019 - Mar 2020

0.27% Apr 2019 - Sep 2019

0.00%+ 0.52%+ 0.2%+

Responsive-ness to inpatients' personal needs

Average weighted score of 5 questions from in-patient survey relating to responsiveness to inpatients' personal needs (score out of 100)

62.5

Hospital stay:

01/07/2019 to

31/07/2019; Survey

collected 01/08/2019

to 31/01/2020

64.0 Hospital

stay: 01/07/2018

to 31/07/2018;

Survey collected

01/08/2018 to

31/01/2019

84.2 59.5 67.1

1 Latest published data available+ All England data could not be found in ONS data so ‘Provider: Acute (Non Specialist)’ has been used.* Patient reported outcome measures (PROMs).

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Appendix 2: Our 2021/22 Quality Objectives

Theme 1 – Providing Safe and Effective Care and Improving Outcomes Executive Leads: Chief Medical Officer and Chief Nurse


• Reducing Mortality and Improving our Learning from Deaths• Delivering ‘Harm Free Care’• Maintaining ‘Hand Hygiene’ Compliance Rates• Maintaining Effective Infection Prevention and Control Standards• Improving Medicine Storage Compliance• Providing Efficient Seven Day Services• Maternity and Neonatal

Theme 3 – Building a Quality CultureExecutive Leads: Chief People Officer, Chief Medical Officer and Chief Nurse

Priority 6: Happy, Healthy, Well Supported Staff

• Improving Recruitment and Retention• Improving Staff Engagement• Improving Learning and Development Opportunities

Priority 7: Quality Improvement and Clinical Leadership

• Optimising the Quality Hub with Continued Roll Out of QI• Delivering a Clinical Leaders Development Programme

Priority 8: Quality Governance with Risk Management and Learning

• Improving Organisational Wide Learning and Action Plan Implementation• Improving Compliance with Duty of Candour: Moderate and Above Harms

Priority 9: Improving Our Infrastructure

• Improving the Quality of our Estates, IT Systems and Facilities

Theme 2 – Ensuring Our Services are Caring and ResponsiveExecutive Leads: Chief Operating Officer and Chief Nurse


• Care Pathway Redesign• Getting It Right First Time (GIRFT)


• Improving Patient Experience of the Discharge Process • Improving Patient Experience of the Booking Process• Expanding our Volunteer Service to Provide Support to Patients and Their Relatives


• Improving the Experience of Patients with Mental Health and Learning Disabilities• Ensuring Robust Processes and Organisational Scrutiny of Safeguarding Procedures


• Improving Organisational Performance Against Access Standards

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Appendix 3: Participation in Clinical Audits and National Confidential Enquiries

Clinical Audit title Eligible to participate Participated Number of patients % data submitted

Division of Surgery Anaesthesia and Cancer National Oesophago-gastric Cancer (NAOGC)

YES YES N = 75 non validated data for 2019/20

Published cases submitted in 2019 report (data period April 2016 – March2018) N =156 with case ascertainment of 85-100%

National Emergency Laparotomy Audit (NELA)

YES YES Continuous audit

Published cases submitted in 2019 report (data period Dec 2017 to Nov 2018) N = 209 97.2%

Case Mix Programme (CMP) ICNARC

YES YES Continuous audit

Validated data N = 1056 admissions to critical care from 1 April 2019 – 31 March 2020

National Vascular Registry YES YES AAA: 157/131 (120%)

CEA: 113/113 (100%)

Angioplasty: 196/328 (60%)

Bypass: 80/123 (65%)

Amputation: 8/69 (12%)

National Prostate Cancer Audit

YES YES 2019/20 N = 291 non-validated (taken from our refreshed data file but which we did not use because the 2019/20 refresh was cancelled due to COVID ).

National Bowel Cancer (NBOCAP)

YES YES 2019/20 - 259 patients submitted non-validated

published validated data 2019 report based on data Apr 2017 – Mar 2018 N = 247 123%

UK Registry of Endocrine and Thyroid surgery

YES YES Data collection ongoing2019/20 validated data N = 56

National Audit of Breast Cancer in Older Patients (NABCOP)

YES YES NABCOP does not directly ‘collect’ patient data. Instead, they use existing sources of patient data collected by national organisations. (National Cancer Registration and Analysis Service (NCRAS) in England and the Cancer Network Information System Cymru (CANISC) in Wales). Therefore, there is no direct submission of data from WHHT

Elective Surgery (National PROMs Programme)

YES Partial Currently suspended due to Trust mandated work of additional frontline activity COVID-19 related but partial non validated data was submitted

2018/19 Validated data

Hip N = 360 Knee N = 491

BAUS Urology Audits - Female Stress Urinary Incontinence

YES NO No functional urology operations are currently being performed and is being nationally withdrawn and thus individual data will cease on 31/01/21.

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National Joint Registry (NJR)

YES YES Continuous audit – Data submitted 2020-2021 non validated data from Watford General Hospital N = 36 and from Saint Albans Hospital N = 194

Surgical Site Infection Surveillance Service

YES YES In 2019/20 validated data 100% data submission. WHHT has continued to participate in continuous SSI Surveillance in THR + TKR across both WGH + SACH, Spinal surgery (SACH only). SSI Surveillance was also undertaken on Breast Surgery (SACH, Oct-Dec 19) and Repair of #NOF (WGH, Jan – Mar 2020). All surgeries involving implantation or insertion of metalwork are monitored for 365 days post-operation for SSI.

British Spine Registry YES YES 2020/21 data submission ongoing and not yet validated

BAUS Cytoreductive Radical

Nephrectomy

YES YES On-going national audit (No cases so far)

BAUS Renal Colic YES YES 2020/21 data submission on-going and not yet validated

Opthalmology Database YES NO No data submissions as WHHT I.T. systems unable to interface with the cataract database

Division of Emergency Medicine

(TARN) Trauma Audit Research Network data

YES YES Continuous Audit 2020/21

Case Ascertainment: 89%

RCEM – Fracture neck of femur

YES YES Non-Validated data 2020/ 2021 N = 76

RCEM – Pain in children YES YES Non-Validated data 2020/ 2021 N = 71

RCEM – infection control YES YES Non-Validated data 2020/ 2021 N = 100

Division of Medicine

Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)

YES YES Continuous Audit 2020/ 2021 as at 21/3/2021 N = 290

Case Ascertainment: Not yet available

2019/20 N = 222

Case Ascertainment: Not yet available

Validated data in 2019 report for data collected April 2017 to March 2018 N = 485 (case ascertainment 113%)

Coronary Angioplasty/National Audit of Percutaneous Coronary Interventions (PCI)

YES YES Non-Validated data 2020/ 2021 N = 413

National Audit of Dementia

Cancelled Nationally

NO N/A

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Cardiac Rhythm Management (CRM)

YES YES Continuous Audit – Data unavailable as not yet validated

National Heart Failure Audit

YES YES Continuous audit data not yet validated 2020/21 as at 21/3/2021 N=119 2018/19 Validated data Case Submitted N = 679 Case Ascertainment = 96%

National Diabetes Foot Care Audit (NDFA)

YES YES Continuous Audit

2019/20 N = 275

NaDIA-Harms - reporting on diabetic inpatient harms in England

YES YES Non-Validated data

January 2020 – December 2020

Cases submitted N= 44

National Core Diabetes Audit -Insulin pump audit

YES NO Unable to participate IT issues on both our and HSCIC/NHSI side

Falls and Fragility Fractures Audit programme (FFFAP) Inpatient Falls

YES YES Continuous audit April 2020 – February 2021 N = 9 Data not yet validated

Falls and Fragility Fractures Audit programme (FFFAP) National Hip Fracture Database

YES YES Non validated data N = 273 cases submitted from April – December 2020

Validated data N = 437 in 2019 report for data submitted from January 2018 to December 2018 (case ascertainment 95%).

Inflammatory Bowel Disease (IBD) programme / IBD Registry

YES YES The cumulative total number of patients submitted: 763 (January 2018 – till present)

Continuous audit data not yet validated

April 2020 – March 2021

Case Submitted N = 16

(new) National Asthma and COPD Audit Programme (NACAP) -COPD

YES NO Currently suspended Due to Trust mandated work of additional frontline activity Covid-19 related

(new) National Asthma and COPD Audit Programme (NACAP) - Asthma

YES NO Currently suspended Due to Trust mandated work of additional frontline activity Covid-19 related

National Lung Cancer Audit (NLCA)

YES YES April 2020 – December 2020

Cases submitted N=151

Case Ascertainment 100%

National Early Inflammatory Arthritis Audit (NEIAA)

YES NO Due to Trust has not been able to continue Consultation in a way that allows submission of data

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Sentinel Stroke National Audit programme (SSNAP)

YES YES April 2020 – January 2021 Case Submitted N = 541 Case Ascertainment +90%

2019 – 2020 Validated data Case Submitted N = 598 Case Ascertainment +90%

Division of Clinical Support Services

SHOT Serious hazards of blood transfusion

YES YES N=24 (100%)

Division of Women and Children’s Services

National Audit of Seizures and Epilepsies in Children and Young People (Epilepsy12)

YES YES N = 30 data not yet validated

National Neonatal Audit Programme-Neonatal Intensive and Special care (NNAP)

YES YES 19 metrics monitored for 2020/21. Largest data set was for ‘parental consultation within 24 hours of admission’ for which the denominator was 512.

Maternal Mortality Surveillance (part of MBRRACE programme)

YES YES No maternal mortality for 2020/21

National Paediatric Diabetes Audit (NPDA)

YES YES Currently completing the Trust Data for 2020/21 for submission – Final number of cases submitted will be available by the end of May 2021

Maternal morbidity confidential enquiries (reports annually) Part of MBRRACE

YES YES Nationally 30-40 women with morbidity (older maternal age while pregnant or 6 weeks after) are sampled from UKOSS. WHHT reports to UKOSS and is compliant (no cases submitted directly to MBRRACE).

National Maternity and Perinatal Audit (NMPA)

YES YES NMPA are using solely routinely collected data – no data is required directly from the Trust.

National pregnancy in Diabetes audit

YES YES Continuous audit – data submitted March 2020 – Feb 2021 N = 40 non validated data.

Perinatal morbidity and mortality confidential enquiries (reports alternate years) Part of MBRRACE

YES YES April 2020 – February 2021

There were 9 neonatal deaths and 18 Stillbirths

Data not yet validated

Perinatal Mortality Surveillance (Part of MBRRACE Programme)

YES YES April 2020 to February 2021

There were 9 neonatal deaths and 18 Stillbirths

Data not yet validated

NACAP Children and young people asthma audit

YES NO NA

Antenatal and newborn National Audit protocol 2019-2022

YES YES N = 3 cases - non validated data

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Trust wide

National Cardiac Arrest Audit (NCAA)

YES YES Data from April 2020 – February 2021 N = 92 -100% submission

Mandatory Surveillance of HCAI

YES YES Data from April 2020 – December 2020

Clostridium Difficile N = 49

MRSA Bacteraemia N = 2

MSSA Bacteraemia N = 44

E.coli Bacteraemia N = 206

Klebsiella SPP N = 59

Pseudomonas Aeruginosa N = 18

Audits the Trust not legible to participate in

Cleft Registry and Audit Network (CRANE)

NO

Service not provided by WHHT

N/A N/A

National Audit of Depression and Anxiety

NO


N/A N/A

National Audit of Psychosis

NO


N/A N/A

National Audit of Cardiac rehabilitation

NO


N/A N/A

National Adult Cardiac Surgery Audit

NO


N/A N/A

National Congenital heart disease

NO


N/A N/A

National Diabetes Audit- Adults National Diabetes Transition and NDA Integrated Specialist Survey

NO


N/A N/A

Falls and Fragility Fractures Audit programme (FFFAP)-

Fracture Liaison Service Database and vertebral Fracture Sprint Audit

NO

WHHT

Do Not provide service

N/A N/A

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National Asthma and COPD Audit Programme (NACAP) Pulmonary Rehabilitation

NO

WHHT

Do Not provide service

N/A N/A

Paediatrics intensive care audit

NO

Service not provided by WHHT-Patients transferred to Great Ormond street

N/A N/A

2021 Audit of the perioperative management of anaemia in children undergoing elective surgery

NO

Criteria not met in the Trust

N/A N/A

Mental Health Clinical Outcome Review Programme.

Suicide by middle-aged men

NO


N/A N/A

Mental Health Clinical Outcome Review Programme.

The Management and risk of Patients with personality disorder prior to suicide and homicide

NO


N/A N/A

National Audit of Pulmonary Hypertension

NO

Information collected from 8 specialist Pulmonary Hypertension services in the UK –WHHT not one of them

N/A N/A

National Bariatric Surgery Registry (NBSR)

NO


N/A N/A

Neurosurgical National Audit Programme

NO


N/A N/A

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Paediatric Intensive Care (PICANet)

NO

Service not provided by WHHT. Referred to Great Ormond St.

N/A N/A

Prescribing Observatory for Mental Health (POMH-UK)

NO


N/A N/A

UK Cystic Fibrosis Registry NO

Collect information from all people diagnosed with Cystic Fibrosis.

N/A N/A

Inflammatory Bowel Disease (IBD) Biological Therapies Audit

NO


N/A N/A

UK Renal Registry National Acute Kidney Injury Programme

NO


N/A N/A

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In addition, West Hertfordshire Hospitals Trust participated in a further 11 national audits by submitting data in2020/2021 and these are listed below:1. Each Baby Counts

2. Prepectoral breast reconstruction evaluation (PRE-BRA)

3 National 7-day hospital services self-assessment survey

4 BAD 2020 National Clinical Audit (hidradenitis suppurativa)

5 CovidSurg

6 B-MAP-C

7 Organ Donation audit

8 Operative Management of Complex Distal Third Tibia and Ankle Fractures

9 The UK COVID Trauma Surge (UKCoTS) study

10 Pre-hospital medication with vitamin D protective from mortality from COVID-19 infections in a hip fracture population

11 Hologic LOCalizer arm of the IBRAnet localisation study

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National confidential enquiries into patient outcome and death (NCEPOD) Participating Participated (%)

Physical healthcare provided to inpatients in mental health hospitals.

Yes Initial data request completed (No Questionnaires required as we are an acute Hospital and hence waiting for report publication as per the update on 15/4/2021)

Alcohol Related Liver Disease Survey Yes In progress - Organisational Questionnaire to be completed by 30/06/21

Appendix 4: National Confidential Enquiries for 2020/21

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Appendix 5: National Clinical Audits Reviewed During 2020/21

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National Clinical Audit title Actions to improve quality for Patients

National Neonatal Audit Programme-Neonatal Intensive and Special care (NNAP)

National Neonatal Audit Programme (NNAP) supports professionals, families and commissioners to improve quality of care provided to new-borns. NNAP offers a platform through which units can appraise and benchmark their data against other units, neonatal networks and/or national average. This enables data driven/guided approach to clinical care improvements. Woodland Neonatal Unit, Watford General Hospital has been an active contributor to this programme since its inception in 2007. Several of our neonatal care standards have improved over this period by active monitoring, benchmarking and actioning of NNAP results.

In 2019/20 The neonatal unit performed above national average on; Antenatal steroids, Magnesium sulphate, Screening for retinopathy of prematurity, Mothers milk at time of discharge, follow up at 2 years of age, keeping mothers and Babies together (term and preterm babies. Bronchopulmonary Dysplasia rates (respiratory morbidity following preterm birth) for the unit was much lower at 15% when compared to national average of 37%.

Sustain the improvements and high performance [Leadership, Motivation,

Drive, Time, Resources] Achieved and continue to progress

Ensure data quality – Data administrator in post since April 2020

Hypothermia Improvement collaborative: Work programme, Project group with multi-specialty stakeholders, Diagnostic phase, Fishbone analysis, Brainstorming, change ideas Hypothermia QI – baseline diagnostic data and scoping done, fishbone, driver diagram complete. Currently on hold due to COVID. This is to improve Neonatal Hypothermia which was the only parameter that our unit fell short of the National Average.

Delayed cord clamping (new measure) Delayed cord clamping – poor compliance (only 10 % of eligible babies receiving it), QI started. Further to new guideline, staff training and trial (followed by purchase) of Life Start resuscitaire trolley cord clamping rates have improved to 32 % in CY 2020 Neonatal team are continuing to monitor this metric and embed teaching/training more regularly.

Early breastfeeding (new measure) Baseline data have been collected

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This section shows the National Clinical Audits we reviewed during 2020/21 and the actions we have taken to improvethe quality of patient care.

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National Paediatric Diabetes Audit (NPDA)

National Paediatric Diabetes Audit highlights the main findings on the quality of care for children and young people with diabetes mellitus in England and Wales.

A National Benchmarking was published by HQIP on 30/9/2020 showing that the Trust is a negative outlier when compared with Nationally case mix adjusted mean HbA1c (mmol/mol). The HbA1c test, also known as the haemoglobin A1c or glycated haemoglobin test, is an important blood test that gives a good indication of how well diabetes is being controlled.

The following actions were undertaken to rectify the results of the benchmarking

Under COVID-19 Virtual clinics were established for Clinical Consultation and walking in Clinic to measure HhA1C

Change in Practice with improvement in case loading with every patient seen by a named Diabetic Nurse and employment of another Paediatric Diabetic Consultant in the Trust which will allow more clinical interaction with patients

Quality improvement projects are in place with Target setting of blood glucose level of 4 to 7mmol /L over 24 hours. The speciality is constantly working to improve the HbA1 c level with east of England which have similar level. (Affected by COVID-19 – action completion date extended to 31/1/2022)

National Maternity and Perinatal Audit (NMPA)

The National Maternity and Perinatal Audit (NMPA) aims to improve the treatment of mothers and babies during their stay in a maternity unit by evaluating a range of care processes and outcomes in order to identify good practice and areas for improvement.

A National Benchmarking on our Trust results that was published on 9/9/2020 based on 2019 published report by the Health Quality Improvement Partnership showed that the Trust is within the expected range for:

•! Case-mix adjusted proportion of all babies at term who are <10th centile, who are born at or after 40+0 weeks

•! Case-mix adjusted proportion of single, term infants with a 5-minute Apgar score of less than 7

•! Case-mix adjusted proportion of vaginal births with a 3rd/4th degree perineal tear

•! Case-mix adjusted proportion of women with severe post-partum haemorrhage of greater than or equal to 1500 ml

•! Proportion of live born babies who received breast milk for the first feed

•! Case-mix adjusted overall caesarean section rate for single, term babies. The Trust was an outlier in previously published benchmarking. The C/S rate fell from 31% to 27.9% and the National aggregate is 25.5%. this improvement is the result of Daily Caesarean section reviews within 24hours with team involved in decision making, weekly Caesarean section review panel will be starting shortly and moving from NICE to FIGO method of monitoring foetal heart in labour and for this intensive training in master classes will be undertaken and changing the guidelines used.

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National pregnancy in Diabetes audit (Registered under Diabetes in Pregnancy Audit 2020 - Maternal and Fetal Outcomes of pre-existing Diabetes under the audit no 1711)

The audit is a measurement system to support improvement in the quality of care for women with diabetes who are pregnant or planning pregnancy.

Patients with Type 1 are seen in the Hospital and those with Type 2 are seen by General Practitioners and tier 3 Diabetic team in the community.

• The speciality work closely with primary care teams toidentify and inform all women with diabetes on how to plan their pregnancy and about effective contraception, to achieve this;

• Posters are made and directed GPs and patients to Tummy’spre-conception tool.

• Improved collaboration across community pharmacy,primary, intermediate, sexual health teams and secondary care.

• GP training and education - in GP forums/ Diabetesnetwork/LMS

• CGM training for staff and patients (all Type 1 on it sinceJuly 2019)

• Empowering women with structured education• Multidisciplinary care in joint endocrine antenatal clinic

Perinatal Mortality Surveillance (Part of MBRRACE Programme)

Every year MBRRACE-UK (Mother and Babies reducing risk through audits and confidential enquiries) produces a “Perinatal Mortality Surveillance” report which provides rates for stillbirths and neonatal deaths, and also for these deaths combined; known as ‘extended perinatal deaths’. It is useful to both commissioners of health care and healthcare professionals to know if any of these rates fail to reach either local or national targets for reduction

A National Benchmarking published on 30/1/2021 showed that our Trust was below National expectation in Stabilised and risk adjusted perinatal mortality rate (per 1,000 births).98 In 2019, 5.00 in 2018 and National Aggregate 4.79 and Stabilised and risk-adjusted extended perinatal mortality rate, excluding congenital anomalies (per 1,000 births) 4.24 in 2019 and National Aggregate is 4.16.

The perinatal mortality rates in this benchmarking referenced in the 2018 and 2019 report refer to deaths occurring in 2016 and 2017, respectively. Babies born prematurely were the main cause of this result. Significant work has been undertaken to reduce the risk of necrotizing enterocolitis (NEC) which is a serious illness in which tissues in the intestine (gut) become inflamed and start to die. This can lead to a perforation (hole) developing, which allows the contents of the intestine to leak into the abdomen (tummy). This can cause a very dangerous infection. NEC is the most common surgical emergency in new-born babies and tends to affect more babies born prematurely than those born full-term. NEC seems to be coming more common, but it is likely that this is because more premature babies are surviving The neonatal speciality in the Trust took this topic as the central to unit Quality improvement (QI) programme in 2018/19. Further to changes introduced (better anti-reflux medication stewardship, better adherence to enteral feeding pathways, access to donor human milk the Trust his resulted in 90 % decline in NEC rates. Ideally, extreme preterm infants under 27 weeks should be born in a tertiary neonatal unit which has been shown to improve survival. In order to improve obstetric-neonatal communication and facilitate timely in-utero transfers, twice daily multidisciplinary meetings between the antenatal, labour ward and neonatal staff have been established. These actions will be reflected in future National Benchmarking results.

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Sentinel Stroke National Audit programme (SSNAP)

The Trust performance against the 10 Key performance indicators in the National Stroke audit report and actions were:

• Standards met on staffing workforce (The Trust is one of58% of Trusts that met this criteria)

• No clinical psychologist in the Trust to meet the criteria ofCriterion: Presence of at least one (WTE) qualified clinical psychologist per 30 stroke unit beds-Business case was not approved by the Trust. Only 7% of the Trusts Nationally met these criteria.

• Criteria met on Out of hours presence of stroke specialistnurse (The Trust is one of 71% of the Trusts that met this criteria)

• The criteria not met (3.0 WTE nurses per 10 type 1 and 3beds (average number of nurses on duty on type 1 and type 3 beds)–Matron to look at the numbers again and benchmark against other Trust –Only 30 % of Trusts Nationally met these criteria.

• Criteria met on 7-day working for at least two types ofqualified therapy. Includes occupational therapy, physiotherapy and speech and language therapy (The trust is one of 38% of the Trust that met the criteria)

• Criteria met on Stroke team receives a pre-alert forsuspected stroke patients (The trust is one of 38% of the Trust that met the criteria)

• Criteria met on Access to a specialist (stroke/neurologicalspecific) early supported discharge (ESD) team (The trust is one of the 68% of the trusts that met the criteria)

• Criteria met on Formal survey undertaken seekingpatient/carer views on stroke services (met if at least one a year) (the trust ne of 56% of the Trusts that met the criteria)

• Criterion not met on irst line of brain imaging for TIApatients is MRI. Radiology Department confirmed that resources are not available because of demand on MRI machine in the Trust. Only 33% of the Trusts Nationally met these criteria

• Criteria met (if Executive on the Board, Non-executive onthe Board, or Chairman of Clinical Governance takes responsibility for the follow-up of stroke audit results. 63% of the trusts met these criteria.

National Oesophago- Gastric Cancer

The National Oesophago-Gastric Cancer Audit was established to evaluate the quality of care received by patients with oesophago-gastric cancer in England and Wales.

A benchmarking published by HQIP (Health Quality Improvement Partnership) on 22/12/2020, showed that out Trust was above National expectation in; case ascertainment in 2019 published report (85-100% versus National Aggregate 82.5%) and age and sex adjusted proportion of patients diagnosed after an emergency admission.

The results of the benchmarking also showed that the Trust is in line with expectation in; crude proportion of patients with stage 0-3 cancer with curative treatment plan and in Risk-adjusted 90-day post-operative mortality rate.

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National Prostate Cancer Audit

The National Prostate Cancer Audit was established to assess the process of care and its outcomes in men diagnosed with prostate cancer in England and Wales.

The Trust Cancer team is working on improving data collection on an on-going basis Trust Cancer lead meets weekly with Cancer MDT coordinator to complete missing items. Continue recording PSA (measures the level of prostate-specific antigen (PSA) in patients’ blood to help to detect prostate cancer, and other parameters in clinic letters to improve data capture.

This is reflected in National benchmarking published by HQIP on 11/1/2021 showed that data of men with complete information to determine disease status in 2019 report (data period April 2017-Marsh2018) was 91.67 % and that is above the National aggregate of 91.49%.

National Joint Registry (NJR)

Hip, knee, ankle, elbow, and shoulder joint replacements are common and highly successful operations that bring many patients relief from pain and improved mobility. Thousands of these joint replacement operations take place in the UK every year and the NJR collects and monitors information on these joint replacement operations to improve clinical standards and benefit patients, clinicians, and the orthopaedic sector as a whole.

The last benchmarking published by HQIP on 12/3/2021 and the Trust update for NJR for 2019/20 data shows that actions were undertaken, to increase the proportion of patients consented to have personal details included by including the NJR Consent form in the NOF pathway pack and increase awareness of staff to complete the consent form.

There will be variations from year to year in terms of revision rates. Looking at the 5-year results is more accurate than on a yearly basis. The Trust is lying within the expected range for both hips and knees on both Watford General Hospital and Saint Albans sites in the most recent data.

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National Vascular Surgery

The data in the National Vascular Registry (NVR) covers the process and outcomes of care for; patients undergoing carotid endarterectomy, patients undergoing abdominal aortic aneurysm (AAA) repair, patients undergoing a revascularisation procedure (angioplasty/stent or bypass) or major amputation for lower limb peripheral arterial disease (PAD). A Benchmarking published by HQIP on 4/12/2020 based on 2019 report shows that the Trust is within National expectation in:

• Case Ascertainment of both AAA and CarotidEndarterectomy

• Risk-adjusted post-operative in-hospital mortality rate inAAA

• Crude median time from symptom to surgery [CarotidEndarterectomy] -Risk-adjusted 30-day mortality and stroke rate [Carotid Endarterectomy]

National Emergency Laparotomy audit

National emergency laparotomy audit aims to enable the improvement of the quality of care for patients undergoing emergency laparotomy, through the provision of high-quality comparative data from all providers of emergency laparotomy. A Benchmarking published by HQIP on 18/9/20 showed that the Trust was above expectation in.

• Case ascertainment• Crude proportion of high-risk cases (! 5% predicted

mortality) with consultant surgeon and anaesthetist present in theatre

• The Trust was within National expectation in• Crude proportion of high-risk cases (! 5% predicted

mortality) admitted to critical care post-operatively • Crude proportion of cases with access to theatres within

clinically appropriate time frames • Crude proportion of cases with pre-operative

documentation of risk of death • Risk adjusted 30-day mortality

The Trust was an outlier in the risk adjusted 30 –day mortality. The Trust was an outlier in the previous benchmarking and actions were undertaken resulting in this improvement included The Speciality audited all deaths in both high risk periods. We found problems with data entry and removed some patients from the database who had been added in error, and also corrected a large number of incorrectly entered risk adjustment parameters. While this resulted in us no longer being a statistical outlier, we were concerned by the number of small bowel obstruction deaths within this cohort and have separately initiated a local audit/QIP

for small bowel obstruction management, based on and NELA's recent recommendations.

To improve NELA data robustness the NELA lead has been prospectively checking NELA records before they are locked.

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Bowel cancer

The National Bowel Cancer Audit (NBOCA) aims to describe and

compare the quality of care and outcomes of patients

diagnosed with bowel cancer in England and Wales.

A benchmarking published by HQIP on 9/6/2020 showed that The Trust had:

"! Case Ascertainment - Good above 80% "! Risk adjusted post operative length of stay after major

resection > 5 days in 2019 was 38.3% which is better than 57.4% in 2018. The figure is lower than national aggregate of 62%.

"! Risk Adjusted 90 days post operative mortality rate and 2-year mortality rate and 30 days unplanned readmission rate - All within expected range

"! Risk adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection is also within expected range

Reports published in 2020 did not identify our Trust as an outlier.

Falls and Fragility Fractures Audit programme (FFFAP) National Hip Fracture Database

The Falls and Fragility Fracture Audit Programme (FFFAP) is designed to audit the care that patients with fragility fractures and inpatient falls receive in hospital and to facilitate quality improvement initiatives. A benchmarking published by HQIP on 12/5/2020 showed that the Trust in 2019 report was within National expectation in:

"! Case ascertainment "! Crude proportion of patients having surgery on the day or

the day after admission "! Crude perioperative medical assessment within 72 hours "! Crude percentage of patients documented as not

developing a pressure ulcer "! Hospital length of stay "! Risk- adjusted 30 days mortality rate

The audit lead in the Trust looks at in-depth 30-day Mortality of Hip fracture and presents it to the relevant specialities.

UK Parkinson’s Audit

This UK-wide audit takes a multi-professional approach, involving Elderly Care and Neurology consultants, who care for people with movement disorders. It also includes Parkinson’s nurses, occupational therapists, physiotherapists and speech and language therapists who also care for people with Parkinson’s. The audit engages services within these professions to measure the quality of their practice, within their model of care provision, and trigger service improvement plans. Actions undertaken

•! Raising awareness by educational sessions and emails to physiotherapy speech and language therapy on following the standard of referring adults with Parkinson's disease to physiotherapy, occupational therapy or speech and language therapy if they have problems with balance, motor function, activities of daily living, communication, swallowing of saliva.

•! Arrange to provide access to clozapine and patient monitoring for treating hallucinations and delusions

•! Educational sessions to raise awareness on the need for adults with Parkinson's disease who are in hospital or a care home to take

•! Levodopa within 30 minutes of their individually prescribed administration time.

!

68

!!

!


!

SHOT Serious Hazards of Blood Transfusion

Serious Hazards of Transfusion (SHOT) is the United Kingdom's haemovigilance scheme. It collects and analyses anonymized information on adverse events and blood transfusion reactions. When SHOT has identified risks related to transfusion, it produces recommendations within its annual reports to improve patient safety.

The Transfusion Team in the Trust has worked extremely hard despite the challenges of COVID-19 they reviewed how transfusion training is being delivered and competency assessments to maintain patient safety.

Training has moved to an online format and a bespoke transfusion package for all staff practicing transfusion was produced, whether it be taking Group and Save samples or Administering a transfusion.

New documentation to improve competency assessments was designed by Transfusion Champions, which will be completed every two years alongside the online learning.

The Transfusion Policy has been reviewed. It now embeds the changes and improvements to ensure that the trust can demonstrate gold stand practice, every time to every patient.

Patients and their safety are at the heart of our practice, for this reason all incidents & near misses that are reported are thoroughly investigated, so that we can share the learning to continually improve practice.

The Trust work within national polices and guidelines to ensure patient identification is established prior to the blood administration and the blood is processed & verified by our colleagues in the laboratory before it is released for use. There are many systems in place to ensure that the right blood goes to the right patient.

69

Local clinical audit title Learning and action outcome of audit

Documentation of outcomes from Cardiology MDT meetings and

NSTEMI: presentation to needle time.

The former audit identified the need to have an MDT coordinator which is currently in post and it also resulted in identifying a clear duties and rota for the Chair and the Registrar in charge of the MDT meeting to ensure that documentation and reasoning is complete and accurate.

Cardiology consultants to review the guideline designed for the trust with the aim for trust wide distribution and to disseminate audit findings to junior Doctors. The findings were presented at the Excellence and Innovation Day on 21/7/20.

Re-audit to take place following distribution of the new trust guideline to see if this improves clinical practice.

Baby friendly initiative audit

WHHT were assessed for stage 2 Baby friendly initiative accreditation by UNICEF UK. Staff were found to be extremely confident and competent in describing care in many feeding and relationship building scenarios. It was identified that there were some areas where further improvements could be made. Local audit was used to monitor the achievement of the recommended actions. Actions undertaken included staff education to ensure they understand how to support mothers to maximise breast milk & the impact on health of giving formula milk to breastfed baby and updating the infant feeding guideline. The Trust won the award and stage 3 assessment should take place within a year of the date of accreditation at stage 2 i.e. July 2021

COVID-19 Mortality audit

This audit was presented at the COVID-19 Divisional meeting on 15/10/2020.The following tests /management suggestions were included in the learning points of what can the Trust do differently in the 2nd wave. Of note the Response rate with completed questionnaires was 37/70 (53%).

Procalcitonin: To rule out bacterial co-infection and indication for antibiotic therapy and as ey prognostic factor and patients with high levels will require more aggressive treatment.

D-dimer: To aid decision to give prophylactic dose or treatmentdose LMWH. And as Key prognostic factor and patients with high levels will require more aggressive treatment.

CRP: As a Key indicator for disease progression and severity.

Fluid challenge: Maintain a restrictive fluid strategy to avoid poor outcomes.

Nutritional support: To aid therapy and reduce mortality rate.

Proning: Aim to prone all patients unless contraindicated.

Prompt ceiling of care: To aid end of life care and avoid inappropriate escalation of the use of ventilator.

Appendix 6: Local Clinical Audits Completed During 2020/21

This section shows the local clinical audits we completed in 2020/21 and the actions we have taken to improve thequality of patient care. 106 local audits were completed during 2020/21 with reports, action plans and examples oflearning. Below is a section of what we have learned from these audits and the actions taken:

70

Local clinical audit title Learning and action outcome of audit

Improving Confusion Screening in Fractured Neck of Femur Patients and

Appropriate initial investigations in the acutely confused patient

The first audit was performed to ensure that the Trust is compliant with NHFD guidelines in order to improve confusion screening, in Neck of femur patients. Results showed that the Trust is 100% compliant with

AMTS (abbreviated mental health scores) preoperatively and 88.7% compliant with 4AT (Rapid

Clinical test for Delirium) within one week of surgery. Perioperative risk factors were identified, and a new tool was developed to manage them. A poster for Ridge wards showing this tool was also developed

Repeating 4AT after two weeks, if patient still in hospital was also recommended.

The second audit looked at appropriate initial investigations on admission as advised by NICE guidelines (Delirium in adults (QS63)) and Local protocol. The results identified the need to disseminate the findings via weekly teaching and posters and emails to ensure clerking junior doctors are aware of these audit findings and the protocol that needs to be met when admitting a delirious patient to ensure best possible outcome

71

Appendix 7: Participant Recruitment to Research

Title

Principal

Investigator Site Status

Portfolio Status

Sponsor Participants

recruited

Urg

ent

Pub

lic H

ealt

h C

OV

ID-1

9 St

ud

ies

RD2020-13: ‘RECOVERY Trial’

Dr Rama Vancheeswaran

Open to recruitment –

08/04/2020

Eligible – CPMS 45388

University of Oxford

39

RD2020-17: ‘REMAP-CAP’

Dr Valerie Page Open to

recruitment – 12/05/2020


University Medical Centre

Utrecht 30

RD2020-18: ‘PRINCIPLE’

Dr Andrew Barlow


03/07/2020

Eligible - CPMS 45457


0

RD2013-108: ‘Clinical Characterisation

Protocol for Severe Emerging Infection’



16/03/2020



1863

RD2020-15: ‘GenOMICC’




NHS Lothian 29

RD2020-31: ‘Neonatal

Complications of Coronavirus Disease (COVID-19) Study’

Dr Sankara Narayanan

Open to Recruitment –

07/05/2020



0

RD2010-57: ‘UKOSS’ Justine Chung

(local collaborator)


25/03/2020



0

RD2020-28: ‘PAN-COVID’



10/06/2020


Imperial College London

19

RD2020-27: ‘ILIAD-7’ (Commercial)




RevImmune 3

RD2020-21: ‘RECOVERY-

Respiratory Support’



26/05/2020


University of Warwick

78

RD2020-50: ‘CLARITY’

Dr Rakesh Chaudhary


05/11/2020


Royal Devon and Exeter NHS

Foundation Trust 31

RD2020-52: ‘HICC’ Dr Rama

Vancheeswaran


30/10/2020


Royal Papworth Hospital NHS

Foundation Trust 82

RD2021-08: ‘CO@H’

Dr Matthew Knight(with Dr David Evans as

co-PI)


11/03/2021


University College London

0

RD2020-43: ‘CCP-Cancer’

Jackie Evans TBC Eligible –

CMPS 46602

Clatterbridge Cancer Centre

NHS Foundation Trust

0

CO

VID

Po

rtfo

lio s

tud

ies

RD2019-23: ‘INHALE WP3 – Observational

Sub-study’ Dr Valerie Page

Open to recruitment – 17/04/2020-10/07/2020



15

RD2020-33: ‘Psychological impact of the

Coronavirus (COVID-19) pandemic and

experience: An international survey’

Not applicable Open to


Eligible – CMPS 45621

Southern Health NHS Foundation

Trust 0

COVID-Nurse: Staff survey, Version 1

Not applicable Accepted – 04/08/2020


University of Exeter

0

72

Using medical detection dogs to

identify people with SARS-CoV-2



London School of Hygiene &

Tropical Medicine 0

RD2021-‘PIM-COVID’ Dr Valerie Page Open to



Liverpool University

Hospitals NHS Foundation Trust

1

WH

HT

Spo

nso

red

Stu

die

s

RD2020-14: ‘NOVEL CT’

Dr Emre Pakdemirli

Open – 06/05/2020

Non-portfolio

West Hertfordshire Hospitals NHS

Trust

15

RD2020-22: ‘PREDICT COVID UK’

Dr Andrew Barlow

Open – 15/05/2020

Non-portfolio


Trust

700

RD2020-35: ‘RT-PCR Positive novel

coronavirus (Covid -19) patients’

Imaging findings at a DGH setting’

Dr Emre Pakdemirli

Open – 13/07/2020

Non-portfolio


Trust

100

CO

VID

No

n- p

ort

folio

stu

die

s

RD2020-20: ‘C-19-ACS’

Dr Nearchos Hadjiloizou


14/05/2020

Potentially eligible – no

decision made (CPMS

45418)


18

RD2020-32: ‘COVIDA’



Non-portfolio

University of Roehampton

Individual site recruitment not

monitored IRAS 278834: ‘The

drivers for, and barriers to,

radiographers reporting chest X-ray images in acute NHS

Hospitals in England.’



Non-portfolio

Walsall Healthcare NHS

Trust


monitored

IRAS 284411: ‘NHS Work

Communication & Impact of COVID-19’



Non-portfolio

Royal Free London NHS

Foundation Trust


monitored

IRAS 282827: ‘The COVID-19 Resilience

Project’ Not applicable


18/05/2020

Non-portfolio

Greater Manchester

Mental Health NHS Foundation


monitored

RD2020-34: ‘PREPARE-IBD’

Dr Rakesh Chaudhary


03/07/2020

Non-portfolio

Hull University Teaching

Hospitals NHS Trust

30

RD2020-35: ‘PROTECT-ASUC’

Dr Rakesh Chaudhary


12/06/2020

Non-portfolio

Hull University Teaching

Hospitals NHS Trust

10

Title

Principal


Portfolio Status


recruited

73

RD2020-23: ‘CERAbTc-19’



15/05/2020

Non-portfolio

University of Southampton

138

RD2020-25: ‘CERrnaTc-19’

Dr Hala Kandil Open to


Non-portfolio


473

RD2020-24: ‘COVPRO’



19/05/2020

Non-portfolio


900

RD2020-68 ‘COVID-19: emotional well-

being and psychological adjustment’


Non-portfolio

University of Huelva


monitored

No

n-C

OV

ID-1

9 st

ud

ies

that

hav

e re

op

ened

RD2019-13: ‘OPTIMAS Trial’

Dr Mohit Bhandari

Open to recruitment - (reactivated 11/05/2020)



27

RD2016-06: ‘POSNOC’

Miss Lee Min Lai

Open to recruitment – (reactivated 06/05/2020)


University Hospitals of Derby and

Burton NHS Foundation Trust

11

RD2017-32: ‘PRIMETIME’

Dr Narottam Thanvi



Institute of Cancer Research: The Royal Cancer

Hospital

3

RD2018-31: ‘BLING III’

Dr Valerie Page


(reopened 26/06/2020)

Eligible –CPMS 37390

The George Institute for

Global Health 2

RD2018-12: ‘A2B’ Dr Valerie Page



The University of Edinburgh &

Lothian Health Board, ACCORD and The Queen’s Medical Research

Institute

17

RD2019-23: ‘INHALE WP3’

Dr Valerie Page

Open to Recruitment – (reactivated 23/07/2020)



9

RD2019-27: ‘VODECA’

Dr Jon Landy



University of Liverpool

1

RD2019-25: ‘NED APRIQOT’

Dr Bruce MacFarlane



Newcastle Upon Tyne Hospitals

NHS Foundation Trust

0

RD2015-91: ‘BSTOP’ Dr Victoria

Brown



Guy’s and St. Thomas’ NHS

Foundation Trust 0

Title

Principal


Portfolio Status


recruited

74

RD2019-19: ‘PLUM’ Dr Victoria

Brown



Guy’s and St. Thomas’ NHS

Foundation Trust 1

RD2018-16: ‘ORION-4’

Dr Michael Clements



University of Oxford and The

Medicines Company

0

RD2009-52:’ BADBIR’ Dr Victoria

Brown


16/10/2009 (did not close due

to COVID)


University of Manchester

4

RD2017-08: ‘DNA Lacunar 2’

Dr Mohit Bhandari



Cambridge University


and the University of Cambridge

5

RD2017-33: ‘ATTEST 2’

Dr Mohit Bhandari



NHS Greater Glasgow & Clyde

3

RD2018-15: ‘ARREST’ Dr Masood Khan



Guy's & St Thomas'

Foundation NHS Trust

0

RD2018-24: ‘ContactME-IBS’

Dr Jon Landy



County Durham & Darlington NHS Foundation Trust

7

RD2016-44: ‘Baby-OSCAR’

Dr Nazakat Merchant

Open to recruitment – (reactivated 27/10/2020

then in follow up from

31/12/2020)

Eligible - CMPS 18528


0

RD2012-39: ‘ADDRESS 2’

Dr Thomas Galliford




0

New

No

n C

OV

ID P

ort

folio

stu

die

s th

at h

ave

op

ened

RD2020-29: ‘CEED’ Dr Rajesh

Vasiraju (local collaborator)


16/07/2020


Aston University 0

RD2020-10: ‘MEDICI’ Dr Stephanie Sutherland


30/09/2020

Eligible –CPMS 43032

University of Dundee and

Tayside Health Board

43

RD2019-28: ‘EVOCAR-1’

Dr Mohit Bhandari

Open (PIC site) – 06/10/2020


Imperial College Healthcare NHS

Trust of The Bays

0

RD2020-41: ‘COLOCOHORT’

Dr Jon Landy Open to



South Tyneside and Sunderland NHS Foundation

Trust

58

RD2020-07: ‘SurfOn’ Dr Sankara Narayanan


20/11/2020


University of Leicester

2

Title

Principal


Portfolio Status


recruited

75

RD2020-47: ‘ SSNOBS’

n/a TBC Eligible –

CMPS 42543

University of Central

Lancashire 0

RD2020-57: ‘M4EU’ Tracey Carter Open to


Eligible –CMPS 47249

Katholieke Universiteit Leuven (KU Leuven) and University of Southampton

0

RD2020-55: ‘ANTHEM’

Miss Lee Min Lai Open to



University Of Bristol

0

RD2020-03: ‘Serum Neurofilament’





Trust

TBC

RD2020-58: ‘DA VINCI’



University of Cambridge

0

RD2020-62: ‘EMBED’ Jackie Evans Open to



Cambridge University


& University of Cambridge

0

RD2020-69: ‘EVAREST’

Dr Joban Sehmi Open to




0

RD2021-01: ‘DDN study’



05/02/2021


University of Kent

0

RD2021-03: ‘CCE study’

Dr Jonathan Landy


10/03/2021


York Foundation Trust R & D Unit

1

New

No

n- p

ort

folio

No

n-

CO

VID

stu

die

s th

at h

ave

op

ened

RD2020-45: ‘Travel Fever 1’

Dr Michelle Jacobs


14/10/2020 Not eligible

Birmingham Women and

Children’s NHS Foundation Trust

0

Title

Principal


Portfolio Status


recruited

76

A&E Accident and Emergency

AAU Acute Admissions Unit

AHLT Acute Health Liaison Team

ATP Adenosine Triphosphate (test which measures organic matter in the environment)

BAF Board Assurance Framework

Big 5The Big 5 initiative has resulted from the Staff Survey. These are the top 5 themes identified as requiring improvementand which the Trust is taking forward.

BAME Black and Minority Ethnic

CCATT Children’s Crisis Assessment and Treatment Team

CED Children’s Emergency Department

CDI Clostridium Difficile infection

C.DiffClostridium Difficile. A bacterium that can infect the bowel and cause diarrhoea. The infection most commonly affectspeople who have recently been treated with antibiotics. It is easily spread and can be acquired in the community and inhospital.

CCG

Clinical Commissioning Group (CCG) - Commission most of the hospital and community NHS services in the local area forwhich they are responsible, including emergency care, elective hospital care, maternity services, and community andmental health services. Commissioning involves deciding what services are needed for diverse local populations andensuring that they are provided.

CNST Clinical Negligence Scheme for Trusts – handles clinical negligence claims

CPECarbapenemase-Producing Enterobacteriaceae - Enterobacteriaceae are bacteria that usually live harmlessly in the gut.This is called 'colonisation' and does not usually cause any problems, however, if the bacteria get into a wound or thebloodstream, they can cause infection.

CQC Care Quality Commission - The independent regulator of all health and social care services in England.

CQUINCommissioning for Quality and Innovation - A payment framework which allows commissioners to agree payments tohospitals based on agreed improvement work.

CT Computed Tomography

DATIX Software for healthcare risk management and incident reporting

DNA Did Not Attend

DIPC Director of Infection, Prevention Control

DoLS Deprivation of Liberty Safeguards

DSP Data Security and Protection Toolkit

DVT Deep Vein Thrombosis

E Colib Escherichia coli bacteria

ED Emergency Department (also known as A&E)

EEAST East England Ambulance NHS Trust

EPR Electronic Patient Record

FFT Friends and Family Test

FIGO International Federation of Obstetricians and Gynaecologists

FTSUG Freedom to Speak Up Guardian

HAPU Hospital Acquired Pressure Ulcer

HAT Hospital-Acquired Thrombosis

HCAI Health Care Acquired Infection

HEADSSS Home, Education and Employment, Activities, Drugs, Sex, Suicide and Safety

HEPA High Efficiency Particulate Air

HOUDINI

Nurse led urinary catheter removal protocol:• Haematuria (only requires catheter if in clot retention)• Obstruction/Retention• Urology surgery• Damaged skin (open sacral or perineal wound in an incontinent patient)• Input/output, fluid monitoring• Nursing care end of life/comfort care• Immobility, due to physical constraint eg unstable fracture and unable to use bottles/bedpans

HSCIC Health and Social Care Information Centre

HSMRHospital standardised mortality ratio - An indicator of healthcare quality that measures whether the death rate in ahospital is higher or lower than you would expect.

HVCCG Herts Valley Clinical Commissioning Group (see CCG)

Appendix 8: Glossary

77

ICS Integrated Care System

IG Information Governance

IPC Infection Prevention Control

KPIKey Performance Indicator - Commonly used across health and care systems to examine and compare performance. Theseindicators focus on areas such a length of stay, mortality rates, readmission rates, costs per episode of patient care and thenumber of staff employed.

LD Learning Disability

LeDeR Learning Disability Mortality Review Programme - a national programme

LGBT Lesbian, Gay, Bisexual, Transgender – sexual orientation and gender identity

MCA Mental Capacity Act

MDT Multidisciplinary team

MRI Magnetic Resonance Imaging

MRSAMethicillin-Resistant Staphylococcus Aureus – A type of bacterial infection that is resistant to a number of widely usedantibiotics.

MSSAb Methicillin-Sensitive Staphylococcus aureus bacteria

NCEPOD National Confidential Enquiry into Patient Outcome and Death

NeverEvents

Serious, largely preventable, patient safety incidents that should not occur if the relevant preventative measures havebeen put in place.

NHSINHS Improvement - An organisation responsible for overseeing foundation Trusts and NHS Trusts, as well as independentproviders that provide NHS-funded care.

PALS Patient Advice and Liaison Service

PERC People Research Education Committee

PMRT Perinatal Mortality Review Tool

Red2GreenThe Red2Green approach is a visual management system to assist in the identification of wasted time in a patient’sjourney. It is used to reduce internal and external delays.

RTT Referral To Treatment - A measure of the length of time from referral through to elective treatment.

SACH St Albans City Hospital

SAFER

A patient flow bundle which blends five elements of best practice which should be implemented together. It worksparticularly well when used with the ‘Red2Green days’ approach. S – Senior review. All patients will have a senior review before midday by a clinician able to make management anddischarge decisions.A – All patients will have an expected discharge date and clinical criteria for discharge. This is set assuming ideal recoveryand assuming no unnecessary waiting.F – Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards thatroutinely receive patients from assessment units will ensure the first patient arrives on the ward by 10 am.E – Early discharge. 33% of patients will be discharged from base inpatient wards before midday.R – Review. A systematic multi-disciplinary team review of patients with extended lengths of stay (>7 days – ‘strandedpatients’) with a clear ‘home first’ mindset.

SafetyThermometer

The NHS Safety Thermometer provides a ‘temperature check’ on harm. The tool measures four high-volume patient safetyissues (pressure ulcers, falls, urinary tract infection - in patients with a catheter - and venous thromboembolism).

SAR Safeguarding Adults Review

SHMISummary Hospital-level Mortality Indicator. A hospital-level indicator which reports inpatient deaths and deaths within30-days of discharge at Trust level across the NHS.

SJR Structured Judgement Review – A standardised methodology for reviewing case records

SISerious Incident – An incident that occurred in NHS funded services and resulted in one or more of the following:unexpected or avoidable death; serious harm; allegations of abuse; a prevention of continuation of the provision ofhealthcare services; or a never event.

SMART Senior Medics Assessment Review and Treatment

SSNAP Sentinel Stroke National Audit Programme - The single source of stroke data in England, Wales and Northern Ireland.

STARRING/STARR

Senior Team Assessment and Rapid Response

STPSustainability and Transformation Partnership - A partnership of NHS organisations and local councils to improve healthand care in a geographical area.

UTI Urinary Tract Infection

UTC Urgent Treatment Centre

VTEVenous Thrombo Embolism - a blood clot which forms most often in the deep veins of the leg, groin or arm (known asdeep vein thrombosis, DVT) and travels in the circulation, lodging in the lungs (pulmonary embolism, PE)

WACS Women and Children’s Service

WHHT West Hertfordshire Hospital NHS Trust

WRES Workforce Race Equality Standard

WTE Whole time equivalent – a measure used for employment reporting (WTE = full time)

78

Section 4. Annex

The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to

prepare Quality Accounts for each financial year.

In preparing the Quality Account, Directors are required to take steps to satisfy themselves that:

• the content of the Quality Account meets the requirements set out in the NHS Annual Reporting Manual 2020/21

and supporting guidance

• the content of the Quality Account is not inconsistent with internal and external sources of information for the

period April 2020 to March 2021, including:

o Board minutes and papers

o Papers relating to quality reported to the Board

o Feedback from Commissioners

o The Trust’s complaints report produced under Regulation 18 of the Local Authority Social Services and NHS

Complaints Regulations 2009

o The latest national patient survey (2020)

o The latest national staff survey (2020)

o The Head of Internal Audit’s annual opinion of the Trust’s control environment

• the Quality Account presents a balanced picture of the Trust’s performance over the period covered

• the performance information reported in the Quality Account is reliable and accurate

• there are proper internal controls over the collection and reporting of the measures of performance included in the

Quality Account, and these controls are subject to review to confirm that they are working effectively in practice

• the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms

to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review

• the Quality Account has been prepared in accordance with NHS Improvement’s annual reporting manual and

supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data

quality for the preparation of the Quality Account.

The Directors confirm to the best of their knowledge and belief they have complied with the above requirements in

preparing the Quality Report.

By order of the Board

Phil Townsend

Chair

West Hertfordshire Hospitals NHS Trust

Christine Allen

Chief Executive

West Hertfordshire Hospitals NHS Trust

Annex 1: Statement of Directors’ Responsibilities in respect of the Quality Account

79

Annex 2: Statement from Healthwatch Hertfordshire

Healthwatch Hertfordshire’s response to West Hertfordshire Hospitals NHS Trust (WHHT)Quality Account 2020/21

Healthwatch Hertfordshire values the relationship with West Hertfordshire Hospitals NHS Trust and looks forward to

continuing to work closely with the Trust to help improve services for patients including supporting the quality priorities

outlined in this Quality Account.

Steve Palmer

Chair Healthwatch Hertfordshire

May 2021

80

Clinical Commissioning GroupHerts Valleys

Annex 3: Herts Valleys Clinical Commissioning Group’s response to the Quality Account of West Hertfordshire Hospitals NHS Trust (WHHT) for 2020/21

HVCCG would like to firstly thank WHHT for preparing this Quality Account, for developing future quality assurance

priorities and acknowledging the importance of quality at a time when the Trust continues to experience additional and

unprecedented pressures due to the COVID-19 pandemic, impacting on both workforce and patient service

deliverables. The CCG recognises the hard work undertaken by the Trust throughout this period not only to support the

response to the pandemic but also to undertake recovery actions simultaneously to managing further surges. The

dedication, commitment and resilience of staff during this very challenging year has been remarkable, so thank you.

The CCG would also like to acknowledge the exceptional level of support WHHT have provided to the residents of west

Hertfordshire in addition to their own workforce regarding to the COVID-19 vaccination and testing programme.

HVCCG is responsible for the commissioning of health services from WHHT across all of its sites in St Albans, Hemel

Hempstead and Watford. During the year HVCCG have been working closely with WHHT gaining assurance on the

quality of care provided to ensure it is safe, effective and delivers a positive patient experience. In line with the NHS

(Quality Accounts) Regulations 2011 and the Amended Regulations 2017, HVCCG has reviewed the information

contained within the WHHT Quality Account and checked this against data sources where this is available and confirm

this to be accurate and fairly interpreted to the best of our knowledge.

In response to the first wave of COVID-19 , all non-urgent elective care was paused at WHHT to enable the

redeployment of staff and resources to care for the sickest patients and ensuring the most urgent, time critical and

cancer related care was maintained. As a result of this, along with many other acute trust’s nationally, waiting times for

routine care increased and the number of patients waiting more than 52 weeks grew. The CCG is pleased to see that

WHHT has continued to undertake clinical harm reviews and have developed robust quality assurance processes to

keep patients as safe as possible at this time. It is a testament to the Trust that to date, no patients have come to any

moderate or severe harm as a result of long waiting times. Recovering performance in this area will be a significant

challenge for the Trust for many years ahead. Innovation, pace of work and staff resilience will all be key areas of focus

going forward and it was good to note examples of all of this within the Quality Account, especially relating to staff

health and wellbeing.

From a cancer perspective the CCG acknowledges that during 2020/21 WHHT did not meet all of the national cancer

standards with challenges experienced in a range of areas including 2 Week Wait Breast Symptomatic (86.8% against

the 93% target), and 62 Day GP Urgent (82.2% against the 85% target). We are aware that cancer improvement work

continues and WHHT are committed to recovering performance in line with waiting time standards. It is positive to see

examples of the action taken being highlighted in the Quality Account, such as a demand and capacity assessment

completed for the Breast One Stop Clinic, an under 40’s clinic, and an increase to the number of elective patients (both

cancer and urgent) being accommodated. All of which are highlighted in the Trust’s overarching Cancer Improvement

Plan, which has recently been relaunched across the Trust.

The CCG are also mindful that attendances at the WHHT urgent and emergency departments (ED) were lower in

2020/21 when compared with 2019/20 as a result of the pandemic. The CCG are aware that this drop in attendances

enabled the ED to manage the separate streams of patients more effectively during the first wave, unlike the second

81

wave which did not see the same level of reduced attendances, together with an increase in COVID-19 patient

numbers, therefore impacting on flow throughout the organisation and resulting in multiple streams of patients

requiring support. This understandably impacted on ED performance with 81% of patients being seen within 4 hours

during 2020/21 against the 95% target.

The Trust has made good progress with the recovery following COVID-19 but still has a long way to go to build on the

pre-Covid performance that was reported.

In relation to patient safety the CCG is pleased to note that the Quality Account details information about learning

from Never Events as well as Serious Incidents (SIs). The CCG will continue to work proactively, and in partnership with

WHHT, to oversee the management of the backlog of SI investigations that has built.

In relation to external assurance provided by the Care Quality Commission (CQC) the CCG acknowledges that

following the February 2020 CQC inspection to the urgent and emergency care departments, the medical care and

surgery departments significant improvements were seen resulting in an increase in three domains - safe, effective and

well led. The CCG note this included the lifting of restrictions at the Minor Injuries Unit (MIU) at St Albans City Hospital

which was previously rated as inadequate, although acknowledge MIU has not been open in 2020/21 due to the

pandemic response in line with the need to maintain a ‘green’ site.

From an Infection Prevention Control (IPC) perspective, which was also a critical area of focus given the pandemic

response, achievements included hand hygiene compliance throughout 2020/21. Also the CCG are pleased to see that

WHHT met its mandatory and statutory training for Infection Prevention and Control, reporting 90% compliance.

Looking forward HVCCG support the Trust’s quality priorities and indicators for 2021/22, including actions relating to

improving the experience of patients with Mental Health and Learning Disabilities as well as through actions focused on

the provision of safe care and improvements to individual patient outcomes within neonatal and maternity services

amongst other areas.

The CCG recognises the challenges experienced by the Trust in 2020/21 and look forward to a continued collaborative

working relationship with WHHT especially as we approach the final developments of the Integrated Care System and

Place Bases Partnership arrangements. Together we will build on existing successes and take forward further

improvements to deliver high quality services for this year, next year and thereafter.

David EvansChief Executive OfficerHerts Valleys Clinical Commissioning Group14 June 2021

82

Annex 4: Hertfordshire Health Scrutiny Committee

On behalf of the Chairman of Hertfordshire Health Scrutiny Committee, Dee Hart:

Quality Account 2021

2020/21 has required all of us to adapt our ways of working. On behalf of the Hertfordshire Health Scrutiny

Committee I would like to thank the West Hertfordshire Hospitals NHS Trust for the services it continued to deliver

during the pandemic and its response in recovery. We are aware of the challenges facing the NHS and will seek to

continue working constructively with the trust.

Members of the committee have been appreciative of the support the West Hertfordshire Hospitals NHS Trust has

provided during this challenging period. The contribution from the trust has enabled the committee to maintain its

overview of the health system in Hertfordshire. It ensured that all our scrutiny members heard about the impact on

services and how the West Herts Hospital Trust was seeking to address on-going needs and additional pressures. The

trust has contributed to committee meetings in July and August 2020; provided written briefings for members in

October, November and December 2020; and officers of the West Hertfordshire Hospitals NHS Trust also participated

in the long planned scrutiny to consider the development of the trust’s estate at a scrutiny review which sat in

February 2021.

Despite the demands of the pandemic there has also been regular communication between the Health Scrutiny

Committee, Scrutiny Officers and the West Hertfordshire Hospitals NHS Trust over the last 12 months. West

Hertfordshire Hospitals NHS Trust has supported the scrutiny process when approached and the Committee look

forward to working with the Trust in the future.

Yours sincerely,

Dee Hart

Chairman Hertfordshire Health Scrutiny Committee

June 2021

Quality Account2020/21

© West Hertfordshire Hospitals NHS Trust. Design by Medical Illustration. Ref: 74810. June 2021Information correct at time of printing

2020/21 - nhs

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