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Hertfordshire Community NHS Trust

Evidence appendix Unit 1a, Howard Court 14 Tewin Road Welwyn Garden City AL7 1BW Tel: 01707 388000 www.hct.nhs.uk

Date of inspection visit: 6 to 7 November 2018 Date of publication: 24 January 2019

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.

Facts and data about this trust

Hertfordshire Community NHS Trust provides NHS healthcare services to a population of 1.2

million people in Hertfordshire. The trust provides community-based services for adults and older

people, children and young people, and a range of ambulatory and specialist care services. They

serve the communities of Broxbourne, Dacorum, East Herts, Hertsmere, North Herts, St Albans,

Stevenage, Three Rivers, Watford and Welwyn/Hatfield. In addition, the trust provides the

healthcare service to the Mount Prison in Bovingdon.

There were around two million contacts with people during a year and the services deals with

people from before birth until death.

The trust employs approximately 2,800 staff, one of the largest employers in the local area. In

2017/18, the trust had an income of £142.4m. Income for the trust for 2018/19 is £136 million.

For the financial year ending 31 March 2018, the trust reported a year-end surplus position of

£2,093k, which was £346k ahead of plan and delivered 100% of its Cost Improvement

Programme. At year end, its capital expenditure was £127k below the Capital Departmental

Expenditure Limit.

The surplus position included £916k of planned sustainability and transformation funding (STF)

income and an STF incentive bonus was received by the trust of £1,299k for over performing the

agreed control total by £79k.

For the current year 2018-2019, the trust was forecasting a year end surplus position of £1,966k.

The demographics in Hertfordshire mirror that of England, but deprivation in Hertfordshire is lower

than average. Life expectancy for both men and women overall is higher than the England

average, but in the most deprived areas of Hertfordshire, life expectancy is 7.0 years lower for

men and 6.0 years lower for women.

Hertfordshire Community NHS Trust provides the following core services:

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• Community adults

• Community inpatients

• End of life care

• Community dental

• Children and young people’s services

The trust has a total of 11 registered locations, although care and treatment is delivered from 347

sites across Hertfordshire. This includes nine sites offering inpatient services.

During 2017/18, the trust cared for 264,700 patients in the community and over 1,900 on their

inpatient units across the county. They carried out around 886,300 home visits, supporting people

with their health conditions and helping them to remain as independent as possible in their

community. Over the same period, staff made over 1.8 million separate contacts with patients, 1.4

million with adults and 480,000 with children.

Community hospital sites at the trust

Information about the sites and teams, which offer community services at this trust, is shown

below:

Location / site name

Team/ward/satellite name

Address (if applicable)

St Albans Rapid assessment; Leg

ulcer services 56 Waverley Road, St Albans, AL3 5PN

Howard Court

Integrated community

team; Lymphoedema

services

Unit 1a Howard Court, 14 Tewin Road,

Welwyn Garden City, AL7 1BW

Danesbury House Adult neurological centre,

inpatient units 75 School Lane, Welwyn, AL6 9SB

Hemel Hempstead

General Hospital

St Peters ward; Simpsons

ward

Hillfield Road, Hemel Hempstead, HP2

4AD

Hertfordshire and

Essex Hospital Inpatient units

Haymeads Lane, Bishop’s Stortford, CM23

5JH

Langley House Inpatient units 698 St Albans Road, Garston, Watford,

Hertfordshire, W25 9NQ

Potters Bar

Community Hospital Inpatient units Barnet Road, Potters Bar, EN6 2RY

Queen Victoria

Memorial Hospital

Intermediate care inpatient

unit School Lane, Welwyn, AL6 9PW

(Source: Universal Routine Provider Information Request (RPIR) – P2 Sites tab)

Is this organisation well-led?

Leadership

The trust had managers at all levels with the right skills and abilities to run a service

providing high quality sustainable care. There was a mix of experience within the executive

directors with some new to their executive roles at the trust and others with considerable

experience.

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To write this well-led report, and rate the organisation, we interviewed the members of the board,

both the executive and non-executive directors, and a range of senior staff across the trust. This

included a wide group of clinical and non-clinical service and specialty directors. We met and

talked with a wide range of staff to ask their views on the leadership and governance of the trust.

We looked at a range of performance and quality reports, audits and action plans; board meeting

minutes and papers to the board, investigations, and feedback from patients, local people and

stakeholders.

The trust had a strong senior leadership team in place, supporting the executive team, with the

appropriate range of skills, knowledge and experience. The trust board were a cohesive group of

executive and non-executive directors who supported each other and worked well together to

constructively challenge and ensure quality and safety was given sufficient attention. The trust

board included eight executive board members and six non-executive board members.

The previous chief executive resigned in May 2018 and the director of nursing acted in the position

as interim chief executive until October 2018, at which point was appointed as chief executive. The

deputy director of quality and governance and deputy chief nurse was acting as interim director of

nursing. The interim director of nursing had a large and challenging portfolio, which included the

roles as director of infection prevention and control and company secretary, in addition to the role

as director of nursing, quality and governance. However, the substantive post which was being

advertised during our inspection did not include responsibility for infection, prevention and control.

A series of executive (medical director and interim human resources director) and senior finance

personnel changes had taken place over 12 months before our inspection, including the departure

of the director and deputy director of finance. Despite this the trust described the head of

management accounts and the head of financial services as having provided sound support and

coverage during the period prior to the appointment of the current interim director of finance, who

joined the trust in July 2018. The current interim director of finance was a qualified accountant with

several years of experience and had supported the trust during a demanding period, which had

included support on a significant amount of tendering work.

The trust had recently successfully recruited a substantive deputy director of finance, who joined

the trust in September 2018 who had experience of working within a large accountancy firm. This

meant the finance team had five qualified accountants in place.

The trust had a historical track record of delivery of its financial plan and control total. However,

the underlying financial position of the trust remained unclear. Discussions with members of the

board indicated that this area was covered as part of the board’s oversight on financial

performance but a view on the underlying financial position was not offered during our inspection.

Whilst the trust had delivered its planned efficiencies in recent years, an element of this was non-

recurrent in nature and further non-recurrent efficiencies were being reported in 2018/19. Reliance

on non-recurrent efficiencies can erode the underlying financial strength of an organisation and

therefore it was important that the board were aware of its underlying trading position and regularly

reviewed for assurance within this area.

The board had an appropriate level of operational and financial experience and expertise across

both non-executive directors (NEDs) and executives. Sufficient board time was spent reviewing

the NHS trust’s finances and there was also separate monthly business unit performance review

(BUPR) meetings where divisional performance was discussed. BUPR meetings were chaired by

the interim director of finance and attended by the director of operations and the general

managers.

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The trust leadership team had a comprehensive knowledge of its current priorities and challenges

and acted to address them. There was clear strategic leadership from the board, with important

initiatives to support the trust’s strategy and sustainability owned by board members.

Non-executive directors were highly experienced with strong operational input. Several non-

executive board members had been in office in excess of eight years, including the chair and the

deputy chair. NHS trust NEDs are expected not to serve more than eight years in post, although

they can remain in post for up to 10 years, depending on individual circumstances. When we

raised the need for clear succession planning for the NEDs, the trust told us that this was a key

priority for the interim director of human resources, although the risk of losing all experienced

NEDs at one time was not recognised on the trust’s high-level risk register.

The board were viewed as accessible, approachable, visible, and supportive with transparent

accountability at decision-making levels. Staff spoke highly of local leadership within the trust and

felt supported by them. Middle managers we spoke with during the inspection and at focus groups

were supportive of senior managers. Management staff told us they were supported by senior

leaders to develop and improve their services.

The trust board and senior leadership team displayed integrity on an ongoing basis. We attended

a public board meeting prior to our inspection where we observed a good level of scrutiny and

challenge, with a focus on quality of service delivery, safety and finance in appropriate proportions.

We also observed the meeting was chaired in a manner that enabled all non-executive members

to ask questions. Members of the board we spoke with told us they felt challenged by others, and

felt able to challenge others in a professional and supportive environment.

The trust offered an extensive range of external and in-house leadership development, through

leadership programmes, masterclasses, coaching, mentoring, e-learning, bespoke team building,

action learning sets and leadership forums. Specific programmes were offered through Health

Education England (HEE) for black and minority ethnic (BAME) staff and women to develop

leadership. Development opportunities were communicated widely and data on ‘access to

leadership’ programmes was monitored for equity. Data provided by the trust demonstrated during

2017, 950 staff completed a leadership activity including 200 members of staff who completed

formal programmes. This included the Mary Seacole programme, making a difference band 6/7

programme, senior managers development programme, sustain, and the new managers

programme.

The trust applied a broad definition to leadership, aiming to support the development of leaders at

all levels. The trust’s workforce and organisational development (OD) strategy detailed their

strategic objective to ‘become a high-performance organisation through excellent leadership and

talent management’. Progress was monitored through the workforce and OD steering group and

monthly board reports. In addition, the board members were the first to undertake the new 360

healthcare leadership model (HCLM) assessment and created a case study with the Leadership

Academy and Health Education England.

The trust saw itself in playing a key role in shaping and supporting a system approach to

leadership development through the accelerated director development scheme. Internal staff were

identified and nominated for the scheme’s assessment process. The chief executive acted as a

mentor for selected candidates and career development opportunities were specifically

highlighted, and where appropriate, ring fenced for candidates

Fit and Proper Persons

Trusts are required to meet the Fit and Proper Persons Requirement (FPPR) (Regulation five and

19 of the Health and Social Care Act (Regulated Activities) Regulations 2014). These regulations

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ensure that directors of NHS providers are of good character and have the right qualifications and

experience to carry out this important role.

We carried out checks to determine whether appropriate steps had been taken to complete

employment checks for executive and non-executive directors, in line with the FPPR requirement.

During our core service inspection, we raised concerns surrounding the trusts compliance to

Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 Fit

and Proper Persons: directors. We reviewed the personnel files of eight executive directors to

determine the necessary fit and proper person checks had been undertaken. Files did not contain

evidence of ongoing Disclosure and Barring Service checks (DBS) monitoring by the trust for all

directors. We were concerned about the ongoing and overall governance of the trust’s

performance against this regulation. It was also disclosed that all clinical staff do not have repeat

DBS checks following the initial check at recruitment and we were not assured that the trust had

taken sufficient measures to protect patients from harm. We raised this as a concern at the time of

our inspection.

During the well led inspection, we saw the policy had been reviewed and updated. All HCT staff

were required to complete a fit and proper persons regulation form as part of their application

process, and would be subject to a DBS check relevant to their role. After this, directors were

required to make an annual declaration of their on-going fitness for their role, and all other staff

were ‘required to make the trust aware as soon as practicable of any incident or circumstances

that may mean they are no longer to be regarded as a fit and proper person’. The interim HR

director told us that she would rely on informal links with a local multi-agency committee (attended

by police and social services) to inform the trust if a member had become known to these

agencies and would follow this up to ascertain the staff members’ fairness to practice at the trust.

The trust provided us with their updated report on compliance to the Secretary of State

recommendations ‘’Themes and Lessons Learnt from NHS into Matters Relating to Jimmy Saville

(September 2017). This recommends all NHS hospital trusts should undertake DBS checks on

their staff and volunteers every three years. The trust had chosen to continue with DBS on initial

recruitment only, stating that staff are obliged to inform their managers of any changes that may

affect their status, and this was in line with CQC guidance.

Board Members

Of the executive board members at the trust, 18.2% were British Minority Ethnic (BME) and 54.5%

were female.

Of the non-executive board members none were BME and 50% were female.

Staff group BME % Female %

Executive directors 18.2% 54.5%

Non-executive directors 0.0% 50.0%

All board members 11.8% 52.9%

(Source: Universal Routine Provider Information Request (RPIR) – P64 Board)

Vision and strategy

The trust had a clear vision for what it wanted to achieve and workable plans to turn it into

action. The vision was developed with involvement from staff, patients and key groups

representing the community.

The trust had a clear vision and set of values, with quality and safety as the top priorities. The

trust’s vision was to maintain and improve the health and wellbeing of the people of Hertfordshire

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and other areas served by the trust. The trust’s values were care, respect, quality, confidence, and

improve. The trust’s vision and values were embedded at board level and informed how the senior

leadership team operated. The board culture was open and honest and demonstrated respect for

patients and those who worked in the trust.

The trust’s organisational objectives were to support people to manage their own health and

wellbeing, to improve outcomes and enhance patient safety, to expand community services

through the delivery of excellence, to use resources efficiently to improve services, and to

empower their workforce to deliver their vision and objectives. In addition, the trust had a ‘wildly

important goal’ to transform and mobilise community service models, in partnership, by October

2019. Staff knew and understood the trust’s vision, values and strategy and how achievement of

these applied to the work of their team. The trust had signed up to support the national 6Cs

strategy, which included care, compassion, competence, communication, courage, and

commitment. The trust supported patients, wherever possible, to remain at home. As part of this,

patients were empowered to participate and take care of their own needs as much as they could.

The trust had communicated its vision and values with front line staff and all staff we spoke with

were aware of these.

Local providers and patients had been involved in developing the strategy. The trust’s overarching

strategy and supporting strategies were fully refreshed in 2015 following presentations by the

medical director of emerging thoughts on the clinical strategy to commissioners. The strategies

were developed in consultation with key staff groups and in consideration of the changing context

in which services were provided. Alignment with the Five Year Forward View (FYFV),

Hertfordshire and West Essex Sustainability Transformation Partnership (STP) and priorities of

commissioners was achieved through review of relevant stakeholder plans and commissioning

intentions and through informal discussion with key stakeholders. Strategy workshops were held

with the board and senior management team, and roadshows led by the chief executive and

executive directors, sought staff views as the strategy was developed. These discussions led to

the development of the trust’s strategy ‘train’ which provided a visual summary of the overarching

strategy.

In 2017 the clinical and quality strategies were combined into a single health and wellbeing

strategy. Delivery of the quality element was driven through the workplans for patient safety,

experience and clinical effectiveness. As part of this, increased emphasis was placed on what

matters most to the people who received services and one of the quality priorities was to

implement patient reported outcome measures across all services by March 2019.

The trust had aligned its strategy to the wider health and social care economy. The strategy

focused on:

Health and wellbeing: working with other organisations to develop local, community approaches to

maintaining health and wellbeing

Self-management: supporting people with health conditions and disabilities to manage their own

care as far as possible

Coordinated care: providing well co-ordinated, personalised, multi-agency care for people with

complex needs.

The trust board had developed positive relationships within the wider health and social care

system and was dedicated to building a system that would be sustainable in the future delivery of

health and social care and the footprint of the Sustainability and Transformation Partnership

(STP). The trust was an active partner in the Hertfordshire and West Essex Sustainability and

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Transformation Partnership, working closely with others to increase their contribution to the health

and wellbeing of the wider population.

The trust worked collaboratively with stakeholders, other local NHS trusts and the third sector to

deliver services to patients. For example, the trust was working with neighbouring acute trusts to

support future service delivery in line with strategic priorities, to reduce its cost base, and to

minimise any burden on the local acute trust.

The trust had worked with its commissioners during the planning round in 2018/19 to target

required efficiencies and to deliver service redesign. This had included work to develop and deliver

a broader core adult community service, to equalise the service offerings across different parts of

the catchment population and to optimise skill mix within both the adult and young people’s teams.

The trust also had to respond to a number of tenders during 2018/19 and recognised that this had

been a significant demand on its resources. This had come at a time when there had been a

number of departures and changes within the trust’s executive team. The trust believed that the

service changes and tendering agenda had, to an extent, added to existing difficulties with

recruitment and retention, and its response to these challenges had meant that the longer term

strategic work had been put on hold.

One of the two local clinical commissioning group (CCG) had taken adult services out to open

market procurement, which could lead to the potential loss of some services. The trust were aware

this could result in financial loss and impact on the trust’s capacity to deliver against strategic

objectives. During our inspection the trust did not demonstrate a clear strategy for if the tender

were to be unsuccessful. After our inspection the trust informed us they had a robust downside

scenario and supporting plan for sustainability should the tender for adult services not be

successful.

The trust had recently appointed a new chief pharmacist (CP) to lead on medicine optimisation

(MO) who told us the pharmacy workforce was under resourced. Whilst there was no standalone

medicines safety officer (MSO), the role had been combined with the chief pharmacist role. The

CP told us that one of the immediate challenges was to recruit appropriate staff to deliver medicine

optimisation service required at the trust.

The main medicine optimisation priorities for the trust were:

• To undertake formal assessments of medicines used in bedded units and improve patient

engagement in the management of their medicines.

• To have pharmacist prescribers in the community and pharmacy technicians to help

administer medicines to patients seen in their own home.

• To bring value and governance to the medicines strategy, formulary adherence and cost

efficiency to the pharmacy service.

• To deliver a medicines management training programme for all patient facing staff.

The trust board received an annual report on infection control which for 2017/18 showed zero

MRSA, 100% of patients were screened for MRSA on admission to the community hospital wards

two cases of Clostridium Difficile apportioned to the trust services against a trajectory of six,

mandatory training compliance exceeded the overall trust target of 90% and staff flu vaccination

uptake was 73.4%. An annual work plan was also presented to the trust board, with themes from

routine audits informing more detailed future audit activity.

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Culture

Managers across the trust promoted a positive culture that supported and valued staff,

created a sense of common purpose based on shared values. Staff felt supported,

respected, and valued and felt proud to work for the organisation.

Staff culture within the trust was positive. Staff we spoke with throughout our core service and

well-led inspection told us they felt positive and proud about working for the trust and their team.

Staff felt empowered to make decisions and to make changes within their service and across the

trust.

Staff reported feeling respected, valued, supported and appreciated. Staff were proud of the trust

as a place to work and spoke highly of the culture. All staff we met were welcoming, friendly, and

helpful. It was evident that staff cared about the services they provided and were proud to work at

the trust. Staff were committed to providing the best possible care for patients and felt there was a

positive working culture and all teams and wards reported good team working. This mutual respect

and support for each other was clear in all areas. Staff agreed there was a culture of openness

and honesty throughout the service. Multidisciplinary teams worked collaboratively and were

focused on improving patient care and service provision.

The trust’s strategy, vision and values underpinned a culture which was patient-centred and

throughout our core service inspection, we saw staff delivering care in this way. Staff described a

no blame culture and how they were actively encouraged to raise concerns and report incidents

without fear of retribution. They also told us they were encouraged to be open and honest in

relation to issues arising. Candour, openness, honesty, transparency and challenges to poor

practice were encouraged by senior leaders.

To react to the recent challenges evident during 2018/19, including the need to respond to service

tenders and the changes within key executive leadership positions, the trust has needed to employ

effective teamwork. The challenges were described as a drain on executive resources and the

trust relied on the non-executive directors (NEDs) to provide additional support, particularly in

relation to the tenders. The risk of this is that when non-executive and executive directors work

closely together in this way it can have an impact on the independence, oversight and scrutiny

aspects of the non-executive role.

The additional workload from the tendering of services and executive level changes meant that

some important financial workstreams had been put on hold, such as the development of service

line management and reporting. However, the interim director of finance said that the pricing and

costing work conducted because of the tendering work, led to a greater level of engagement

amongst the business units and clinical staff, who wanted to see this level of data for their

services. It was therefore recognised by the trust that the development of service line

management and reporting will support a greater understanding of the importance of finances

throughout the organisation.

The trust recognised that some service changes and closures have had an impact on the

workforce, particularly in relation to recruitment and retention. This represents a challenge, in part

also due to the close proximity of the trust to London where many of the workforce could find

alternative employment.

Following Sir Robert Francis’s Freedom to Speak Up (FTSU) review in 2015, NHS England and

NHS Improvement expected all NHS organisations in England to adopt the Freedom to Speak Up:

Raising Concerns policy for the NHS (April 2016), as a minimum standard. The trust had a

Freedom to Speak Up policy (reviewed January 2018) and had appointed a freedom to speak up

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guardian. The FTSU guardian worked with FTSU ambassadors, trust staff and the leadership

teams promoting an open and transparent organisation and to enable a safe means by which staff

could speak up. The freedom to speak up guardian was passionate about enabling staff to raise

concerns and providing a link by which they could be heard. All staff we spoke with throughout our

core service inspection knew who they could raise concerns with at the trust.

Whistle-blowing

From April 2017 to March 2018, the trust reported nine incidents of whistleblowing. The number of

incidents included concerns and issues escalated through the Freedom to Speak up Guardian

(FTSUG). The concerns raised comprised incidents regarding behaviours (including

bullying/harassment), and/or patient safety/quality.

The executive and non-executive FTSU leads reviewed themes and learning and had taken

several actions to further strengthen the arrangements for FTSUG, and to increase staff

awareness and support staff to speak up safely, including:

• Reviewing FTSU policy in January 2018

• The role of FTSU ambassador was developed and eight staff ambassadors identified to

support the work of the guardian

• A new guardian was appointed to work in partnership with the Non-Executive lead

• Promoting raising concerns and the work of the Guardian

Duty of Candour

From November 2014, NHS providers were required to comply with the Duty of Candour

Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The duty of candour is a regulatory duty that relates to openness and transparency and requires

providers of health and social care services to notify patients (or other relevant persons) of certain

notifiable safety incidents and reasonable support to the person.

The trust had embraced the duty of candour regulation and had effective processes in place. The

duty of candour policy was clear, appropriate and reflected the requirements of the regulation and

was supported by a procedural guide that had been developed in December 2017. Incidents

submitted as part of the provider information request provided evidence of duty of candour had

been appropriately applied.

Staff knew the triggers (moderate harm or above) and awareness of the regulation was well-

embedded in areas visited. All patients who had suffered harm (moderate or severe harm)

received an apology within 10 days of the incident being reported. For minimal harm, duty of

candour according to the regulation does not apply, but there was an expectation at a local level of

being open and honest and still give an apology. Duty of candour was followed in all cases of a

serious incidents even when no harm had occurred.

Staff Diversity

The trust provided the following breakdowns of nursing and midwifery staff and qualified allied

health professionals by ethnic group.

Ethnic group Qualified nursing staff (%) Allied Health

Professional (%)

White – British 25.1% 16.9%

White – Irish 1.0% 0.3%

Any other white background 1.3% 1.1%

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Mixed White and Black Caribbean 0.2% 0.0%

Mixed White and Black African 0.0% 0.1%

Mixed White and Asian 0.2% 0.1%

Any other mixed background 0.3% 0.2%

Asian or Asian British – Indian 0.7% 1.0%

Asian or Asian British – Pakistani 0.2% 0.2%

Asian or Asian British – Bangladeshi N/A 0.1%

Any other Asian background 1.0% 0.1%

Black or Black British – Caribbean 0.4% 0.1%

Black or Black British – African 2.0% 0.2%

Any other Black background 0.2% 0.1%

Chinese 0.1% 0.2%

Any other ethnic group 0.4% 0.1%

Not stated 1.4% 0.8%

(Source: Universal Routine Provider Information Request (RPIR) – P6 Staff Diversity)

Workforce race equality standard

The scores presented below are the un-weighted question level score for question Q17b and un-

weighted scores for Key Findings 25, 26, and 21, split between White and Black and Minority

Ethnic (BME) staff, as required for the Workforce Race Equality Standard.

Note that for question 17b, the percentage featured is that of “Yes” responses to the question. Key

Finding and question numbers have changed since 2014.

In order to preserve the anonymity of individual staff, a score is replaced with a dash if the staff

group in question contributed fewer than 11 responses to that score.

Of the four questions above, the following questions showed a statistically significant difference in

score between White and BME staff:

• KF21: Percentage of staff believing that the organisation provides equal opportunities for

career progression or promotion

• Q17b: In the last 12 months have you personally experienced discrimination at work from

manager/ team leader or other colleagues?

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(Source: NHS Staff Survey 2017)

The trust had a NED lead for equality and diversity (E&D), and although it did not have a

standalone E&D strategy, this was overarching in all other trust policies. They shared an E&D

manager with the local acute trust who was very active both within the trust and in the community,

and had some success engaging with seldom-heard groups, especially the traveller community.

The E&D manager reported to the board quarterly and had run board development sessions which

they said were well received.

NHS Staff Survey 2017 – results better than average of community health trusts

The trust had 12 key findings that exceeded the average for similar trusts in the 2017 NHS Staff

Survey:

Key Finding Trust Score National Average

KF1. Staff recommendation of the trust as a place to work or receive treatment

3.83 3.76

KF7. Staff ability to contribute towards improvements at work

72% 71%

KF12. Quality of appraisals 3.34 3.13

KF13. Quality of non-mandatory training, learning or development

4.12 4.08

KF21. Percentage of staff believing the organisation provides equal opportunities for career progression / promotion

90% 88%

KF31. Staff confidence and security in reporting unsafe clinical practice

3.83 3.80

KF5. Recognition and value of staff by managers and the organisation

3.55 3.53

KF6. Percentage of staff reporting good communication between senior management and staff

40% 36%

KF10. Support from immediate managers 3.89 3.86

KF32. Effective use of patient / service user feedback 3.78 3.69

KF23. Percentage of staff experiencing physical violence from staff in the last 12 months

0% 1%

KF26. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

16% 19%

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NHS Staff Survey 2017 – results worse than average of community health trusts

The trust has five key findings worse than the average for similar trusts in the 2017 NHS Staff

Survey:

Key Finding Trust Score National Average

KF11. Percentage of staff appraised in the last 12 months 85% 91%

KF29. Percentage of staff reporting errors, near misses or

incidents witnessed in the last month 90% 93%

KF16. Percentage of staff working extra hours 75% 71%

KF2. Staff satisfaction with the quality of work and care

they are able to deliver 3.73 3.80

KF24. Percentage of staff reporting most recent

experience of violence 65% 76%

(Source: NHS Staff Survey 2017)

Several members of the board also described an open and honest culture, which they believed

was reflected within the improvement seen within the staff survey results.

The trust used pulse surveys in addition to national surveys to enable a greater drill down on

issues of concern to the staff. It was the trust’s aim to continue to improve the results from these

surveys with recommended place to receive treatment and as a place to work.

Friends and Family test

The Friends and Family Test was launched in April 2013. It asks people who use services whether

they would recommend the services they have used, giving the opportunity to feedback on their

experiences of care and treatment.

From July 2017 to June 2016, the trust scored above the England average for recommending the

trust as a place to receive care, with the exception of March 2018 where this was slightly below

the England average.

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(Source: Friends and Family Test)

Sickness absence rates

From February 2017 to June 2017, the trust’s sickness absence levels were similar to the England

average and from July 2017 to January 2018, these levels were below the England average.

(Source: NHS Digital)

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Guardian of Safe Working Hours

The trust did not have a guardian of safe working hours. The role is a mandated requirement and

was introduced to protect patients and doctors by making sure doctors were not working unsafe

hours. There was lack of oversight of issues relating to junior doctors’ adherence to safe working

hours, as there was no clearly identified person in the guardian of safe working hours role or

reporting to the board.

The trust advised us after our inspection that the junior doctors working at the trusts were on

rotation from the local acute trust and had access to a guardian of safe working hours there. The

new medical director was planning to have discussions with the local trust medical director and the

British Medical Association relating to the guardian to safe working hours role.

Governance

Whilst the trust generally used a systematic approach to continually improve the quality of

its services and safeguarding high standards of care there were some areas that were not

fully effective. These included the arrangements for monitoring the progress of actions

from internal audits and the escalation process for the business units which required a

more detailed scrutiny of their performance.

The trust had structures, systems and processes in place to support the delivery of its strategy.

There were five sub committees, which reported into the board. These included the remuneration

committee, healthcare governance committee, partnership and engagement committee, strategy

and resources committee, and the audit committee. An internal audit was usually commissioned

every three years to review the effectiveness of the committees.

The programme of internal audit work for the year was informed by the trust’s strategic objectives

and the risks identified to the achievement of these. The programme appeared to be

comprehensive and to target a broad range of areas spanning across the corporate objectives. A

review of a sample of internal audit reports provided indicated few ‘high’ level risks were identified

from the reviews undertaken. However, a review of the internal audit progress report (August

2018) identified that there were two actions from the internal audit recommendations made in

2017/18 that had not been implemented by their due date, and one of which was classified as

‘medium’ risk. A further five recommendations had revised implementation dates agreed, following

discussions between internal audit and trust management.

Therefore, we could not be assured that the trust had robust internal arrangements for monitoring

the progress of actions from internal audits to capture and escalate those that are at risk of

missing their implementation dates. This meant the trust was missing the opportunity to take

action to support the delivery of internal audit actions within the agreed timescales, particularly for

and high or medium risks identified.

The governance structure at the trust enabled an embedded risk management approach across all

corporate and operational services, with discussions being reflected at key governance

committees.

Financial and operational performance was reviewed monthly at the business unit performance

review (BUPR) meetings, which were attended by NEDs in rotation. The trust executives that chair

these meetings described a deep dive process, which was conducted with business units where

they may have concerns. The business units remained under an enhanced level of scrutiny until it

was felt that the concerns had been addressed and improvements made. However, other

members of the trust board suggested that the escalation process was not formalised or fully

understood. In addition to this there was no follow up review process in place to confirm and

15

provide assurance that the improvements made from the deep dive and enhanced scrutiny work,

had been embedded. Therefore, we were not assured that the current performance framework

was robust and ensured any improvements were embedded and scrutinised once the business

unit returned to standard monitoring.

The trust had a good structure and governance accountability for medicines management. The

chief pharmacist was managed by the medical director, and attended the trust healthcare

governance committee which fed into the trust board. Therefore, there was no gap in reporting

lines between governance committees, enabling the chief pharmacist to provide medicines expert

opinion at a higher governance level, which would bring value and governance to medicines

optimisation strategy and improve treatment outcomes to patients at the trust.

All aspects of medicines optimisation issues would be discussed at medicines management forum

(MMF) which was chaired by the medical director. Clinical aspects of medicines governance would

then go to the clinical effectiveness group, and incidents/safety aspects would be taken to the

patient safety and experience group. On-call pharmacy services were not always available to ward

staff out of hours. The trust had a verbal service level agreement (SLA) with other trusts to provide

on-call services, although this was not always met, and the chief pharmacist accepted that clearer

accountability and performance monitoring of the (SLA) was required.

The chief pharmacist had approached the trust board to discuss the gaps in medicines

optimisation and their plans to make improvements. The chief pharmacist was seeking funding

from the board to improve pharmacy staffing to enable them to increase their patient facing role

which was needed to improve value, quality and patient centred care to the population, in line with

Carter 2 recommendations. There was also a plan to monitor outsourced pharmacy provision and

to review and implement a formal medicines optimisation policy, as the trust did not have one in

place.

Papers for board meetings and other committees were of a reasonable standard and contained

appropriate information. There was a strong focus on quality with every board meeting starting

with a patient/staff story and quality items first on the agenda. The board welcomed patients and

those close to them at board meetings where they were invited to tell their story of the care they or

their loved one had received at the trust. Board members told us they found this invaluable as it

set the tone for each meeting by focusing on putting patients, their carers and families at the

centre of service delivery. The trust responded to patient stories and used them to share learning

and to improve service delivery.

Prior to our inspection we attended a board meeting. We could see the influence the non-

executive directors (NEDs) had on the overall leadership of the trust. We saw an appropriate level

of challenge from NEDs at board meetings.

Non-executive and executive directors were clear about their areas of responsibility.

Appropriate governance arrangements were in place in relation to safeguarding. The trust had a

clear safeguarding governance structure in place which included a safeguarding executive lead,

named nurses for adults (SGA), children (SGT) and looked after children and care leavers

(LAC/CL) and a named doctor. Safeguarding training/supervision was monitored monthly at the

business unit performance reviews and presented to the board through the Integrated Board

Report. The trust were assured that safeguarding/LAC/CL responsibilities were maintained by

ensuring the following scrutiny was in place:

• Clinical Commissioning Group Section 11 annual audit

• Trust annual audit plan

16

• Hertfordshire Safeguarding Children Board (HSCB) / Hertfordshire Safeguarding Adult

Board (HSAB) annual audit programme

• Monthly safeguarding and LAC dashboards shared with CCG

Audits of staff safeguarding knowledge and awareness of process provided positive assurance. All

risks, action plans, audits, formal case reviews, and activity such as compliance to key

performance indicators (KPIs) were progressed and monitored by the respective safeguarding

forums, HSCB/HSAB Executive and Scrutiny board, or LAC Leadership forum. There were robust

pathways through the trust’s committee governance structure that reported to the executive team,

including reporting pathways from the Safeguarding forum to the Patient Safety Experience Group.

Any identified risks were escalated to the Executive board for discussion and action planning.

LAC activity was shared at the Safeguarding Children (SGC) forum and the CCG LAC Leadership

forum. A quarterly joint Safeguarding and LAC/CL meeting enhanced communication and

imbedded integration across these services.

To provide assurance to the trust and the CCG that staff were keeping vulnerable children and

adults safe, compliance was closely monitored in relation to:

• Adherence to policies and guidance

• Training uptake

• Staff Supervision

• Audit

Staff at all levels of the organisation understood their roles and responsibilities and what to

escalate to a more senior person.

Board Assurance Framework

The board received regular updates in relation to the board assurance framework (BAF)

throughout the year. The board assurance framework identified the risks to delivering key

organisational objectives and the controls in place to mitigate those risks.

The trust provided their board assurance framework, which details five strategic objectives within

each and accompanying risks. A summary of these is below.

• Support the people served to manage their own health and wellbeing

• Improve clinical outcomes and enhance patient safety

• Support the substantial expansion of community services through the delivery of excellent

core services for adults and children

• Use resources efficiently to enhance our ability to improve services

• Develop the organisational capacity to deliver vision and objectives

(Source: Trust Board Assurance Framework – March 2018)

The trust’s BAF and risk registers included financial risks to the organisation. From a review of the

BAF submissions it was not possible to see how assurance was directly linked to each of the

strategic risks, to demonstrate that the current status on assurance had been sufficiently

understood in each case. The BAF extracts provided set out a section titled ‘recent assurances’ for

each strategic risk, which could be marked as either positive, negative, mixed or neutral, in each

case, and there were several areas of potential assurance listed. However, no overall conclusion

was made as to the level of assurance provided, and whether this was adequate, or if not, what

17

was the required course of action to address any gaps in assurance. This meant we could not be

assured that the trust was fully aware of the level of risk to its strategic objectives were contained

within the BAF and had a robust system in place to address these.

Management of risk, issues and performance

The trust had effective systems for identifying risks, planning to eliminate or reduce them,

and coping with both the expected and unexpected.

Finances Overview

Historical data Projections

Financial metrics Previous

Financial Year (2016/17)

Last Financial Year (2017/18)

This Financial Year (2018/19)

Next Financial Year (2019/20)

Income £148.3m £142.5m £136.0m £132.5m

Surplus (deficit) £2.5m £2.1m £2.0m £1.6

Full Costs £145.9m £140.4m £134.0m £130.9m

Budget (or budget

deficit) £1.5m £1.7m £2.0m £1.6m

(Source: Universal Routine Provider Information Request (RPIR) – P59 Finances)

The trust had a strong track record in financial performance and had previously delivered a surplus

in each of its years of operation. The trust had met all financial duties for the previous seven years.

For the financial year ending 31 March 2018, the trust reported a year-end surplus position of

£2,093k, which was £346k ahead of plan and delivered 100% of its cost improvement programme.

At year end, its capital expenditure was £127k below the capital departmental expenditure Limit.

The surplus position included £916k of planned sustainability and transformation fund (STF)

income and an STF incentive bonus was received by the trust of £1,299k for over performing the

agreed control total by £79k. For the current year 2018-2019, the trust was forecasting a year end

surplus position of £1,966k.

Month-end and year-end processes were clear and did not historically result in large and

unwarranted adjustments (internally and through audit). The finance team undertook a

reconciliation between its internal management accounts and the ledgers on an ongoing basis.

Trust corporate risk register

The trust provided a document detailing their two highest profile corporate risks as at May 2018.

Both had a current risk score of 15. Risk targets were not provided.

ID Service Description

Risk score (previous)

Risk level

(current)

Target date for

resolution

526

Human Resources

Insufficient availability of workforce with the right skills to fill trust vacancies and meet future requirements. Leading to difficulties in delivering current services and in adapting services to meet the STP and 5-year forward view. Resulting

15 15 April 2018

18

in potential service delivery/ safe staffing breaches and inability to meet future service demand.

589 Corporate

Herts Valley CCG’s decision to take adult services out to open market procurement is leading to the potential loss of the following services, resulting in financial, reputational loss, and knock-on impact on the organisations capacity to deliver against strategic objectives: Integrated community nursing and therapy services; Community intermediate care beds; Specialist palliative care; Bladder and bowel; Adult speech and language; Lymphoedema; Leg ulcer and tissue viability services; Community Neurological rehabilitation services; Podiatry (excluding diabetes); Nutrition and dietetics.

15 15 Sept. 2018

In addition, the trust provided their eight highest profile operation risks as at May 2018. Each of

these have a current risk score of 15 or higher. Risk targets were not provided.

ID Service Description

Risk score (previous)

Risk level

(current)

Target date for

resolution

567 Skin health

service

The lack of a robust clinical/medical governance structure and the lack of a clinical lead on the dermatology specialist register is leading to the clinical lead, two dermatology doctors, a surgeon and the five GPs with a Special Interest (GPwSIs) are not being adequately supervised clinically, resulting in a lack of assurance that performance targets are met and patients are being provided safe, effective care and jeopardises the continued viability of the service.

16 16 April 2018

577 Nascot lawn

The HV CCG has rescinded the notice given on Nascot Lawn (due to take effect from May 2018) following the outcome of the judicial review to enable consultation with HCC. The risk around ensuring safe, effective service delivery continues to be monitored.

16

16

May 2018

458 Watford

integrated Ongoing shortage of staff as difficulty in recruiting leading to

15 15 May 2018

19

community team

unfilled vacancies, recruitment of bank and agency staff, increase in resignations, long term sickness, resulting in risk to continuity of care, patient’s safety and patient experience.

570 Specialist

palliative care service

Reduction in specialist palliative care clinicians within HCT and local hospices may lead to reduced capacity resulting in number of patients with complex needs not being seen within service specification and potential for increased number of complaints from patients, families and other health care professionals.

15 15 July 2018

590

Integrated community

teams – East and North

Herts

The removal of funds from the contract with ENHCCG across East and North community localities, based on equalisation may lead to a reduction in staffing at all levels resulting in a reduction in activity, not meeting KPIs or Quality metrics, poor patient experience and reputational damage.

15 15 April 2018

602

Hertsmere community adult health

services

On-going nursing vacancies are leading to gaps in experienced staff; potential overspending on bank and agency staff to maintain service continuity; potential gaps in service provision to the Herts Valleys Intake Referral Hub and the ability to deliver CAHS and complex case management contractual obligations, resulting in concerns over patient safety and experience, staff morale and sickness, inability to deliver required contractual response times, and HCT reputational loss.

15 15 Sept. 2018

605 Community Hospitals -

Herts Valleys

A high number of patients whose onward destination from a community hospital bed is delayed (DTOC), is leading to high numbers of patients waiting for admission to a community hospital bed within the Herts Valley locality resulting in patients waiting in a community bed for longer than they should.

15 15 July 2018

608 Community nursing and integrated

Mobilisation and delivery of new Community and Adult Health Services (CAHS) across Herts Valley Integrated Community

15 15 July 2018

20

teams – Herts Valleys

Therapy and Nursing Services to a new service specification, outcomes and contract is leading to an inability to demonstrate delivery of all elements and components of the new CAHS contract. This is resulting in an impact on: current contractual arrangements (impact on performance and activity against original agreed specification); staffing levels and workforce; KPIs/ Outcomes; referral Hub/ CST programme; risk to HCT reputation.

(Source: Universal Routine Provider Information Request – P113 High level risk register)

The trust board had sight of the most significant risks and mitigating actions were clear. All senior

executive directors were aware of the risks within the organisation and in the wider local health

system. The top risks that the team identified were recruitment and retention (staffing and

workforce), and decommissioning of services.

Robust arrangements were in place for identifying, recording and managing risks, issues and

mitigating actions. Staff had access to a risk register and could effectively escalate concerns as

needed. Staff concerns matched those on the risk register.

The chief pharmacist managed the pharmacy risk register, including corporate medicines risks.

The highest risk held in both pharmacy and corporate risk register was lack of pharmacy

resources, which had led to the chief pharmacist seeking approval of more funding for pharmacy

staffing.

Escalation processes were clear and performance was scrutinised at committee and board level.

The trust wide quality report and data pack was sufficient to enable the board to understand the

trust’s performance and challenge areas where improvement was required.

The trust had assurance systems and escalated performance issues appropriately through clear

structures and process. Staff reported incidents appropriately and managers investigated all

incident reports. However, one senior member of staff told us she was concerned that near miss

incidents were not always reported. The incident investigation informed the risk assessments and

the risk register dependent of the risk rating.

There was a clear process for incident reporting. If the level of harm was moderate or above, it

was considered to be a serious incident or never event. All serious incidents had a lead

investigator appointed who would contact the patient/family at the beginning of the investigation.

We reviewed eight serious incident investigations and found all had been completed in a timely

manner and carried out according to the trust policy and procedures. Records and actions plans

were clear and appropriate identified onward learning from each incident.

The pharmacy team conducted quarterly controlled drug (CD) and medicines storage audits, and

quarterly antibiotic and high-risk medicines audits. The results were presented at the medicines

management forum for dissemination. The chief pharmacist accepted that the current audit

programme was reactive, however, there were plans to conduct more proactive audits and

analyse the results and subsequent action plans to improve patient safety and outcomes.

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Senior management committees and the board reviewed performance reports. Leaders regularly

reviewed and improved the processes to manage current and future performance.

Leaders were satisfied that clinical and internal audits were sufficient to provide assurance. Teams

acted on results where needed. There was a yearly audit plan and oversight of every internal audit

was through the audit committee.

Business continuity plans were in place for all services and locations for emergencies and other

unexpected or expected events. The trust was in the process of updating these to make them

simpler and more user friendly. The trust plans, tests, and verifies plans on a regular basis,

providing regular training on the processes and subsequent plans for business continuity.

A hub process had been introduced for organising visits and monitoring referrals. All referrals

come into the local hubs; all localities had a hub, which meant that there was a single point of

access. Referrals were then triaged by a qualified registered nurse or qualified therapist. The visits

were then scheduled in accordance to priority to improve efficiency.

Learning from Deaths

Although a process for reviewing deaths was in place, it was not well established and

shared learning from deaths was not effective.

The trust’s learning from deaths process was not fully established and embedded. The trust had a

mortality review policy in place which was approved in September 2017, and had been promoted

to all staff through ‘Noticeboard’, the trust’s staff newsletter.

A mortality review group (MRG) was also in place and the panel met on a quarterly basis. The

group provided an annual report to the trust board, in addition to quarterly mortality reports

provided and reviewed by the healthcare governance committee and board. The mortality group

was chaired by the associate medical director, who was relatively new to chairing the mortality

group, and a variety of staff attended. There was no representation from a non-executive director.

The notes of the mortality group had limited detail, lacked uniformity and did not always detail any

lessons learnt.

All in-patient deaths were screened using a mortality review trigger tool (MRTT) and reviewed

using the structured judgement review (SJR) method within a month, by a nominated reviewer.

Two SJR templates were used by the trust. One for community inpatient unit deaths and one to

review community deaths. The trust reviewed all deaths in scope using the Royal College of

Physicians (RCP) structured judgement review methodology. The methodology was developed for

acute trusts and had been adapted by Hertfordshire Community Trust to meet the needs of a

community trust. Findings from SJRs helped to identify problems in care that contributed to the

death. In these circumstances, an investigation would be considered under the trust’s ‘Serious

Incident Policy’.

Case reviews considered whether there were problems in the care provided which contributed to

the death. All cases reviewed by the trust to date had not identified that problems in care

contributed to the death, therefore the trust felt investigations were not required. Should such a

death occur and serious incident investigation be required, the serious incident report template

would be used to present investigation findings.

Clinical staff undertaking mortality reviews should have received training on undertaking SJRs.

The previous medical director delivered SJR training in January 2018 after he had received tier

one SJR training. The associate medical director attended tier one SJR training in October 2018.

The head of patient safety attended training delivered by the medical director in January 2018 and

22

had since run a workshop to train additional community clinicians in undertaking SJRs. During our

inspection, we found roles of the reviewers varied and included locality managers, lead nurses and

allied health professionals. The new chair stated that they would like to involve more medical staff

in the reviews. All the reviewers had completed SJR training either from a tier one trainer or

delivered by the head of patient safety. However, the standard of reviews was different throughout

the ten that were looked at. Not all SJR’s were fully completed and had details missing, for

example, two looked at did not contain a cause of death.

Learning from deaths was discussed at quarterly mortality meetings to validate data and identify

further action required to make any improvements. The meetings also looked at whether the death

was avoidable or unavoidable and this was scored between one to six. If it was totally unavoidable

they scored it a six or if it was definitely avoidable it scored a one. We reviewed ten SJR’s. Nine

were scored at a six and one was scored at a five. One we reviewed, scored at a six, showed

potential errors in care which could have led to the patient’s death. There was no evidence of a

discussion about this within the mortality meeting minutes and the summary of the discussion said

that the patients care had been good but the documentation had been poor. This was different to

the outcome by the reviewer of the death. There were 47 deaths in the last year. No deaths went

to an investigation. The policy said that if poor care was found, they would repeat the review or do

an investigation. We were not assured that the trust had an effective process for learning from

deaths.

Following the discussion of the death at the mortality meeting, a mortality review finding form was

completed. This was attached to the incident report that was associated with the patient death.

This record did not show the learning from the death or demonstrate that there is any learning.

There were 47 deaths in the last year and they found that two had evidence of avoidability, score

of five. The associate medical director picked up that these were both due to sepsis. This was

raised as a learning for the year with the medical director. They had since allocated a sepsis lead

for the trust.

Families were not contacted to give them an opportunity to raise any concerns about their

relatives’ care. They were not involved in learning from deaths. The policy stated that they were

going to consider involving families. The lead for mortality said that it is something they were

considering at present.

The trust produced a ‘Sharing Lessons in Practice’ newsletter that included action points for the

staff to focus on. Learning from deaths was reported quarterly to the board through the mortality

reports and was included in the trust quality account.

When interviewed, the new medical director said he had confidence in the process the trust had in

place for learning from deaths. However, the lead for mortality was fully aware that the process

needed to improve and be more robust and had arranged a workshop for the week after our

inspection. The agenda was set and included review of the policy, training, improve the quality of

the reviews and them more focussed. They also stated that they had invited a non-executive

director to attend the meeting. The lead had recently attended SJR training and felt that they

would to be able to improve the quality assurance of the process. They were very focussed on

improving the review process and to ensure that the trust was learning from all deaths reviewed.

After our inspection the trust confirmed that the workshop had taken place and in addition to

reviewing current procedures and seeking approaches from other trusts, regular quality assurance

checks from the chair of the panel within a quality improvement framework were planned.

23

Information management

The trust collected, analysed, managed and used information well to support all its

activities, using secure electronic systems with secure safeguards.

The trust used a wide number of information systems across the organisation which captured and

recorded relevant clinical and demographic data about patients along their pathway. Together with

clinical systems, there were also non-clinical systems in place that captured such areas as

incident reporting; this directly contributed to improving the quality of care for patients.

The trust governance framework, including committee and performance reports, meant that the

board could receive timely data as required. Board papers held the necessary information to allow

the board to review risk, performance and quality and make decisions.

Leaders used meeting agendas to address quality and sustainability sufficiently at all levels across

the trust. Staff told us they had access to all necessary information and were encouraged to

challenge its reliability. Team managers had access to a range of information to support them with

their management role. This included information on the performance of the service, staffing and

patient care.

Information technology (IT) systems and telephones were working well and they helped to improve

the quality of care. Staff had access to the IT equipment and systems they needed to do their

work. The trust had recently invested in new systems and upgrades to their IT infrastructure,

including:

• Rolling out of a clinical records system in all services and inpatient wards, allowing staff to

work in a virtually paperless system

• New business intelligence systems to allow teams to analyse performance information in

much greater detail

• Increased range of non-clinical support systems, including an online learning and

development system allowing staff to check their own training records and book onto

courses

Investments into the IT infrastructure with new data centres had increased the trust’s IT resilience

and reliability. The trust were continuing to roll out improved digital and technological platforms to

help teams to communicate more effectively, for example rolling out Skype for Business video

conferencing and introduction of smart phones for front line staff. The new phones will include

apps and functions such as email, staff news app, and the ability for staff to book additional shifts

through the NHS Professional bank site.

The trust submitted notifications to external bodies such as the Care Quality Commission as

required.

Information governance systems were in place including confidentiality of patient records.

Discussions with board members provided a consensus that financial information was viewed as

being fit for purpose and that there were no concerns over data accuracy. The interim director of

finance stated that he has not been requested to change the format or content of his financial

reports since being in post. The recent use of tableau (an analytics platform) and the introduction

of dashboards was viewed as having improved access to data.

Engagement

The trust engaged very well with patients, staff, the public and local organisations to plan

and manage services, and collaborated with partner organisations effectively.

24

The trust had a structured and systematic approach to engaging with patients, those close to them

and their representatives. Patients could meet with members of the trust’s leadership team to give

feedback. To ensure that the voice of patients was heard, all board meetings included a patient

story.

The trust had carried out a series of events which demonstrated public engagement and

community involvement, including:

• Launching Health for Teens website and ChatHealth text messaging service through three

events across the county with secondary schools.

• Interviewed parents, children and young people to develop Patient Centred Outcome

Measure (PCOM) tool

• Focus groups with parents to understand perceptions of health visitors and school nurses,

how they would find out about services and access health information about their child.

• Focus groups with parents to gain views on current occupational therapy service prior to

service redesign

• Public engagement meetings on closure of community beds and commissioning of the new

FIRST service

• Bi-monthly engagement events to provide information and gain public feedback about the

new Health and Wellbeing Centre

• Public events to provide information and obtain feedback on redevelopment plans

• Public events for patients with Healthwatch Hertfordshire around redesign of integrated

care teams in Hertfordshire Valleys area; collated patient stories to gain feedback from

service users and highlight potential impact of redesign

The trust’s ‘High Value Healthcare’ outlined their key priorities in improving patient safety,

improving clinical outcomes and providing excellent patient experience. The patient safety and

experience group (PSEG) reported to and was accountable to the healthcare governance

committee, a formal trust board committee.

The PSEG delivery plan set priority areas and actions required; it was aligned to the trust’s health

and wellbeing strategy, which incorporated the quality strategy, and focused on key areas,

including:

• Promoting/embedding a positive/proactive patient safety culture for implementing safe

patient care

• Developing systems that ensure patient care is safe and compliant, specifically infection

prevention and control, safeguarding adults and children, and medical devices

• Demonstrating gathering, analysing, reporting and sharing patient feedback/experience

through surveys, FFT, compliments, complaints, PALS enquiries

• Demonstrating openness and shared learning from incidents, serious incidents, complaints

• Ensuring safe staffing and effective escalation processes

Communication systems such as the intranet and newsletters were in place to ensure staff,

patients and carers had access to up to date information about the work of the trust and the

services they used. Staff told us the executive and senior management team were visible and

approachable.

25

In the most recent NHS staff survey 2017, 58.4% (1586 employees) responded to the survey,

which was an improvement on the previous year’s response (54%). Despite an extensive period of

organisational change and service de-commissioning, the overall level of staff engagement was a

score of 3.83, which was higher than national average for community trusts. Staff recommendation

of the trust as a place to work or receive treatment was above average, as was staff ability to

contribute towards improvements at work, with staff motivation at the average. In terms of

leadership, staff felt supported, recognised and valued by their managers (above national

average). Staff reported good communication between senior management and staff. The trust

score for quality of appraisals was the top score for all community trusts. Staff survey results for

the effective use of patient/service user feedback was also higher than average.

The trust recognised a weakness was the impact of organisational change and decommissioning

of services on staff morale longer term. Staff satisfaction with the quality of work and care

delivered was lower than 2016. Recent quarterly pulse survey free text comments indicated that

staff were concerned about the uncertainty and the work pressure they were under. Staff we

spoke with told us they felt involved in the tender process and were kept up to date with

information relating to this.

Since the appointment of the new chief pharmacist, there was better engagement with the wider

local health economy, through the chief pharmacist networks and area prescribing committees.

However, the collaborative relationship with trusts providing outsourced clinical services needs to

be strengthened, to ensure a quality review of the service level agreement and monitor

performance framework for the pharmacy services provided.

The trust was actively engaged in collaborative work with external partners, such as involvement

with sustainability and transformation plans (STPs).

Learning, continuous improvement and innovation

There was trust wide commitment to innovation with patient experience and safety at the

heart of improvements.

The trust commissioned an external organisation to review the integrated teams’ delivery of

services. This was undertaken to identify opportunities to improve effectiveness and efficiency in

service delivery through utilising real-time data from practitioners and how they believe things

could be improved. This work led to inclusion of a number of the recommendations incorporated

into the newly designed Community Adult Health Service which went live in November 2017. It

was also used to inform procurement to provide support to teams to drive improved effectiveness

and to develop the culture of local leadership and decision making.

The trust participated in the Lord Carter review of productivity and efficiency in community and

mental health services, and shared transformation work undertaken to date to improve customer

service. This was multi-faceted and included: restructuring administrative functions to a semi-

centralised model based on three contact centres for the county, expanding the use of

technology/mobile working, increasing clinical patient facing time for clinicians and introduction of

e-rostering, reducing bank and agency spend. This was noted in the Carter report May 2018.

The trust was part of the South London Health Innovation Network and information gained from

this network had informed practice to strengthen and support implementation of the duty of

candour regulations.

The trust actively sought to participate in improvement and innovation projects. The trust’s Change

Management Toolkit was developed in 2015/16 to support the delivery of the trust strategy. The

toolkit was available online and used by the transformation team and others involved in delivering

26

change. The strategy and approach to change was communicated to staff through a series of

roadshows.

Opportunities to shared learning, for example, ‘Glimpses of Brilliance’, were available through

social media, the annual 'Leading Lights' award ceremony, quarterly Leaders forum, locality

events, ‘Making a Difference’ workshops facilitated by PMO and NHS Elect masterclasses.

Lessons learned reviews were completed post-change and learning shared.

During 2017, 20 staff from across the STP attended NHSI Quality Service Improvement and

Redesign (QSIR) training and had become accredited practitioners. The trust had individuals

qualified to teach QSIR and a further 50 staff were being trained. A revised approach to

continuous quality improvement, using QSIR was due to be piloted in preparation for a trust-wide

roll-out.

A key component of the trust strategy involved equipping patients with the knowledge, skills, and

information they need to manage their own health and wellbeing. In December 2017, the trust

rolled out a patient-held “My Health Plan” that supported patients to identify their personal goals.

Improvements were planned to reflect best practice learning from stakeholders. To enable staff to

have the right conversations and promote self-care, a three-tier training plan had been

implemented to equip staff with the right skills to support patients to take ownership of their own

health plan. Plans were also in place to make self-management resources available to patients on-

line. Working with NHS Digital, the trust recently undertook a pilot of a MediPi telehealth solution.

The trust was now considering how to use telehealth to support patients with LTCs to self-

manage. The trust's Public Health Nursing (PHN) service will be implementing a range of outcome

measures which will be used to measure the service's contribution to delivering healthy lifestyles.

These include: (1) Hertfordshire County Council's 6 Bees; (2) the outcomes and indicators relevant

to the children and young people in the PHOF; (3) NHS outcomes framework; (4) Ages and

STages 3 (ASQ3) and the Ages, Social, and Emotional Questionnaire (ASQ SE).

The trust had a focus on digital solutions and ways of working to make more efficient use of

resources and to improve working practice. They had introduced the country’s first electronic

consent form.

The trust had completed a three-year transformation project in speech and language therapy to

make best use of a scarce resource and improve care to patients while making the service

sustainable.

The trust was actively participating in clinical research studies, including Healthy Start, Happy

Start – preventing enduring behavioural problems in young children through early psychological

intervention, KASPAR – investigating the effectiveness of a humanoid robot to support social skills

development in children with an autism spectrum disorder.

There were organisational systems to support improvement and innovation work. The trust’s

healthcare assistant insulin initiative had been adopted by the NHSI national nursing team for roll

out across all providers of community services.

A Dragon’s Den panel was started, which included a NED, and was developed into the Innovation

panel, whereby any member of staff could approach with ideas or innovation they had. The panel

was empowered to provide resources and support as well as expertise to make change happen.

Bladder scanning in ICTs/CAHS and a volunteer scheme to deliver crucial prescription medicines

to patients at home who were at end of life were implemented as a result.

27

Complaints process overview

The trust was asked to comment on their targets for responding to complaints and current

performance against these targets for the last 12 months.

Question In days Current performance

What is your internal target for responding to complaints? 3 days 100%

What is your target for completing a complaint 25 days 92%

If you have a slightly longer target for complex complaints

please indicate what that is here N/A N/A

Number of complaints resolved without formal process in

the last 12 months? (July 2017 – March 2018) - 154

(Source: Universal Routine Provider Information Request (RPIR) – P51 Complaints Overview)

Number of complaints made to the trust

From April 2017 and March 2018, the trust received 152 complaints. The core service that

received the most complaints was community health services for adults with 82 (54%).

A breakdown of complaints by core service is below.

Core Service Number of

complaints

Percentage of

total

CHS - Adults Community 82 53.9%

CHS - Children, Young People and Families 47 30.9%

CHS - Community Inpatients 22 14.5%

CHS – End of life care 1 0.7%

Total 152

A breakdown of the main themes of complaints is below.

Complaint theme Number of

complaints

Percentage of

total

All aspects of clinical treatment 56 36.8%

Appointments, delay/cancellation (out-patient) 31 20.4%

Communication/information to patients (written and oral) 20 13.2%

Attitude of staff 15 9.9%

Admissions, discharge and transfer arrangements 12 7.9%

Others 11 7.2%

Aids and appliances, equipment, premises (including access) 4 2.6%

Appointments, delay/cancellation (in-patient) 1 0.7%

Patients’ property and expenses 1 0.7%

Failure to follow agreed procedure 1 0.7%

Total 152

(Source: Universal Routine Provider Information Request (RPIR) – P52 Complaint)

Although the trust had a process to capture informal complaints, they were unsure whether all

informal complaints were captured through this process.

Formal complaints would be investigated by the service the complaint related to and an

investigator would be allocated for each formal complaint. However, although informal training was

offered, there was no formal training in place for investigators on how to investigate complaints.

28

The trust had processes in place to ensure the quality of complaint investigations were of a good

standard.

The trust shared learning from complaints through the weekly newsletter, sharing learning in

practice newsletter, team meetings, training events, and development days.

Compliments

From April 2017 to March 2018, the trust received over 12,000 compliments.

No themes have been identified from compliments received, however, the trust’s patient

experience team reported on number of compliments received by service. The top three

compliments by service is reported on in their staff noticeboard to encourage services to record

compliments received, and to evidence continued good work.

A breakdown of compliments received by core service is below:

Community Inpatients:

Location Number of compliments

Danesbury House 142

Hemel Hempstead General Hospital 132

Langley House 97

Potters Bar Community Hospital 87

Queen Victoria Memorial Hospital 61

Holywell 55

Hertfordshire and Essex Hospital 6

Total 580

Community Adults:

There were 4,818 compliments relating to 47 service types in community services for adults.

End of life care:

Service Number of compliments

Specialist palliative care service 26

ICT North & Stort Valley 1

Homefirst North Herts 1

Total 28

The above information does not represent the full 12,000plus compliments. The trust did not

provide any information relating to compliments about community services for children and young

people.

(Source: Universal Routine Provider Information Request (RPIR) – P53 Compliments)

Accreditations

NHS Trusts can participate in a number of accreditation schemes whereby the services they

provide are reviewed and a decision is made whether or not to award the service with an

accreditation. A service will be accredited if they are able to demonstrate that they meet a certain

standard of best practice in the given area. An accreditation usually carries an end date (or review

date) whereby the service will need to be re-assessed in order to continue to be accredited.

The table below shows which of the trust’s services have been awarded an accreditation.

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Accreditation scheme Team/Service accredited

Disability Confident Scheme Trust wide, achieved in 2017

Hertfordshire County Council Purple

Star Promise Scheme

Queensway Clinic, podiatry service, June 2016.

Special Care Dental Service – all services

Health Education England Quality

Framework for Practice Providers Trust wide, confirmed in March 2018

Desmond Diabetes Training

Accreditation Centre Diabetes service

DAFNE (Dose adjustment for normal

eating) Diabetes service

UNICEF Baby friendly initiative stage 3

accreditation Trust wide – July 2017

Accreditation for Psychological

Therapies Services (APPTS) -

(Source: Universal Routine Provider Information Request (RPIR) – P66 Accreditations)

30

Community health services

Community health services for adults

Facts and data about this service

Hertfordshire Community NHS Trust (HCT) has organised community services for adults into one

management team (adult’s services business unit) led by the associate director of operations.

This management structure is split into four portfolios each managed by a deputy general

manager.

The Hertfordshire Valleys Community Adult Health Service (CAHS) portfolio consists of the

integrated community teams across Hertfordshire Valley clinical commissioning group (CCG)

geographical area and is split into four localities with each managed by an HCT locality manager.

The managers for this service portfolio had recently, (November 2017), completed a re-

commissioning exercise by the CCG. This consisted of a reduction in funding, the development of

a new delivery model and service specification. In addition, the name of the teams changed

during this time to CAHS. This portfolio also includes the HCT discharge home to assess team.

The East and North integrated community team’s portfolio consists of the community teams

across East and North CCG geographical area and is split into six localities with each managed

by a HCT locality manager. This service is currently undergoing a re-commissioning exercise by

the CCG. This consists of a reduction in funding, the development of a new delivery model and

service specification.

The specialist community services portfolio includes multiple large and small services for

example; podiatry, bladder and bowel and heart failure services. These have multiple different

commissioners (NHSE, Herts Valleys and East and North CCG, acute trusts). Some span the

whole of Hertfordshire and some part of the county only.

(Source: CHS Routine Provider Information Request (RPIR) – Context CHS)

Community health services for adults at this trust has two registered locations. Howard Court is

the registered location for 232 services and St Albans is the registered location for two services:

rapid assessments and leg ulcer services.

(Source: Universal Routine Provider Information Request (RPIR) – P2 Sites tab)

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Is the service safe?

Mandatory training

The service provided mandatory training in key skills to all staff and made sure almost all

completed it and remained up to date.

Staff received mandatory training in safety systems, processes, and practices. Mandatory training

consisted of a range of topics, which included health and safety, information governance, conflict

resolution, equality and diversity and infection prevention and control. Staff received their

mandatory training either online or face-to-face.

The following information was routinely requested within the universal provider information request

spreadsheets, and was completed within a standard template.

The service did not separate their mandatory training data by staff group. Therefore, the data

below includes nursing and midwifery staff, medical and dental staff, allied healthcare

professionals, and healthcare assistants/infrastructure support staff in community inpatient

services.

The trust set a target of 90% for completion of all mandatory training courses except for health and

safety and information governance, which both had a target of 95%.

The breakdown of compliance for mandatory courses for staff in community adult services from

April 2017 to March 2018 is shown below.

Trustwide

Training module name

Number

of staff

trained

Number of

eligible staff

Completio

n (%)

Target

(%)

Target

met

Infection Prevention (Level 1) 278 280 99.3% 90% Yes

Equality and Diversity 1,081 1,115 97.0% 90% Yes

Manual Handling - Object 320 330 97.0% 90% Yes

Information Governance 1,086 1,124 96.6% 95% Yes

Conflict Resolution 849 919 92.4% 90% Yes

NHS |CSTF| Fire Safety 1,030 1,124 91.6% 90% Yes

NHS |CSTF| Resuscitation - Level

2 777 902 86.1% 90%

No

Infection Prevention (Level 2) 566 666 85.0% 90% No

Manual Handling - People 625 769 81.3% 90% No

Health and safety 888 1,119 79.4% 95% No

(Source: Universal Routine Provider Information Request (RPIR) – P40 Training)

For trust wide in community services for adults the 90-95% target was met for six of the ten

mandatory training modules for which staff were eligible. The health and safety module had the

lowest completion rate with 79.4%, compared to the trust target of 95%.

The trust supplied updated mandatory training data as of August 2018. The breakdown by training

module for staff across community adults as of that date is shown in the table below. Please note

that the health and safety training module was not included in the updated data. In addition, some

other training modules had been amalgamated or renamed.

32

Training module name

Number

of staff

trained

Number of

eligible staff

Completion

(%)

Target

(%)

Target

met

Fire 1,010 1,098 92.0% 90% Yes

Conflict Resolution 923 1,033 89.4% 90% No

Equality and Diversity 1,040 1,165 89.3% 90% No

Infection Control Mandatory 926 1,043 88.8% 90% No

Information Governance 1,032 1,165 88.6% 95% No

Resuscitation 865 1,034 83.7% 90% No

Moving and Handling 693 852 81.3% 90% No

Fire Evacuation 51 69 73.9% 90% No

In community adults, as of August 2018 the trust’s training targets were met for one of the eight

mandatory training modules for which staff were eligible.

(Source: DR110, Mandatory training compliance August 2018) Howard Court

Training module name

Number of staff trained

Number of eligible

staff Completio

n (%) Target

(%) Target

met

Infection Prevention (Level 1) 278 280 99.3% 90% Yes

Manual Handling - Object 319 329 97.0% 90% Yes

Equality and Diversity 1,061 1,095 96.9% 90% Yes

Information Governance 1,066 1,104 96.6% 95% Yes

Conflict Resolution 830 900 92.2% 90% Yes

NHS |CSTF| Fire Safety 1,011 1,104 91.6% 90% Yes

NHS |CSTF| Resuscitation - Level 2 759 883 86.0% 90% No

Infection Prevention (Level 2) 551 647 85.2% 90% No

Manual Handling - People 608 750 81.1% 90% No

Health and safety 870 1,099 79.2% 95% No

(Source: Universal Routine Provider Information Request (RPIR) – P40 Training)

For Howard Court in community services for adults, from April 2017 to March 2018 the 90-95%

target was met for six of the ten mandatory training modules for which staff were eligible. The

health and safety module had the lowest completion rate with 79.2%, compared to the trust target

of 95%.

St Albans

Training module name

Number

of staff

trained

Number

of

eligible

staff

Completion

(%)

Target

(%)

Target

met

Conflict Resolution 19 19 100.0% 90% Yes

Equality and Diversity 20 20 100.0% 90% Yes

Information Governance 20 20 100.0% 95% Yes

Manual Handling - Object 1 1 100.0% 90% Yes

NHS |CSTF| Fire Safety 19 20 95.0% 90% Yes

NHS |CSTF| Resuscitation - Level 2 18 19 94.7% 90% Yes

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Health and safety 18 20 90.0% 95% No

Manual Handling - People 17 19 89.5% 90% No

Infection Prevention (Level 2) 15 19 78.9% 90% No

(Source: Universal Routine Provider Information Request (RPIR) – P40 Training)

At St Albans community services for adults, from April 2017 to March 2018 the 90-95% target was

met for six of the nine mandatory training modules for which staff were eligible. Infection

prevention had the lowest completion rate with 78.9%, compared to the trust target of 90%.

Data provided demonstrated that the service achieved compliance with the trust target percentage

for six out of the 10 mandatory training modules. For the remaining four modules, compliance with

mandatory training was between 79% and 86%.

(Source: DR110, Mandatory training compliance August 2018)

During the last inspection in February 2015 staff told us they had to travel considerable distances

for training and had problems getting protected time to attend training. During this inspection, staff

told us that accessibility of training had improved and training records seen, showed improved

compliance.

Staff received reminder emails, with their managers copied in, from the learning and development

department when they were due any mandatory training updates. Managers discussed any

training issues during staff appraisals and one to one meetings. Staff stated it was their own

responsibility to book onto training courses. Minutes of meetings that we saw, showed that

mandatory training was discussed at both team meetings and managers’ meetings.

Safeguarding

Staff understood how to protect patients from abuse and worked well with other agencies

to do so. Staff had training on how to recognise and report abuse and they knew how to

apply it. Staff had the appropriate level of safeguarding training for the services they

delivered.

There was a safeguarding adults’ policy in place, which was in date, outlined what safeguarding

was, its importance, and provided definitions to the different types of abuse. The policy also

covered staff responsibilities about raising and reporting safeguarding concerns. It was accessible

to all staff via their intranet and staff knew where they could find this.

We saw information on staff boards offering advice and guidance on recognising and responding

to abuse. Staff were aware of the trust safeguarding lead and this information was displayed on

notice boards within departments. Teams had safeguarding champions who supported staff with

training and referrals.

Grade 3 and above pressure ulcers were not routinely referred to the local safeguarding team. A

tissue viability nurse told us they referred any grade 3 ulcers to the local safeguarding team if

there were additional safeguarding circumstances. This was in line with the trust policy.

Safeguarding Training completion

The service did not separate their mandatory training data by staff group. Therefore, the data

below includes nursing and midwifery staff, medical and dental staff, allied healthcare

professionals and healthcare assistants/infrastructure support staff in community inpatient

services.

34

Up to date mandatory training data seen following our inspection showed that, trust wide, the 90%

target was met for all safeguarding training modules.

Prevent training is a government directive to support vulnerable individuals. Prevent is the duty in

the Counter -Terrorism and Security Act 2015 on specified authorities, in the exercise of their

functions, to have due regard to the need to prevent people from being drawn into terrorism. It is

mandatory for all trust staff to complete prevent training. The trust set a target of 90% compliance;

Howard Court were 92.3% complaint and St Albans were 75% complaint.

From April 2017 to March 2018 the breakdown of compliance for safeguarding training for all staff

in community services for adults is shown below.

Trust wide

Training module name

Number

of staff

trained

Number

of eligible

staff

Completio

n (%)

Target

(%)

Target

met

Safeguarding Adults (Level 1) 195 195 100% 90% Yes

Safeguarding Adults (Level 2) 906 929 97.5% 90% Yes

Safeguarding Children (Level 1) 191 196 97.4% 90% Yes

Safeguarding Children (Level 2) 905 929 97.4% 90% Yes

NHS |CSTF| Preventing

Radicalisation - Levels 3, 4 & 5

(Prevent Awareness) 781 824 94.8% 90% Yes

NHS |CSTF| Preventing

Radicalisation - Levels 1 & 2 (Basic

Prevent Awareness) 196 213 92.0% 90%

Yes

Safeguarding Children (Level 3) 5 6 83.3% 90% No

In community services for adults the 90% target was met for six of the seven safeguarding training

modules for which staff were eligible. Level 3 safeguarding children module did not meet the target

with 83.3%.

The trust supplied updated safeguarding training data as of August 2018. The breakdown by

training module for staff across community adults as of that date is shown in the table below.

Please note that the different levels of safeguarding adults and preventing radicalisation training

had been replaced by a single module for each of these two training subjects by August 2018.

Name of course

Number of

staff

trained

Number of

eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Safeguarding Children (Level 3) 32 32 100% 90% Yes

Safeguarding Adults 1,121 1,169 95.9% 90% Yes

Safeguarding Children (Level 2) 970 1,019 95.2% 90% Yes

Safeguarding Children (Level 1) 140 152 92.1% 90% Yes

Preventing radicalisation 1,025 1,123 91.3% 90% Yes

SAFA Champions 15 31 48.4% 95% No

In community adult services, as of August 2018 the trust’s training targets were met for five of the

six safeguarding training modules for which staff were eligible. SAFA champions did not meet the

target with 48.4% completion rate, compared to 95% trust target.

35

(Source: DR110, Mandatory training compliance August 2018)

Howard Court

Training module name

Number

of staff

trained

Number

of eligible

staff

Completio

n (%)

Target

(%)

Target

met

Safeguarding Adults (Level 1) 194 194 100% 90% Yes

Safeguarding Adults (Level 2) 887 910 97.5% 90% Yes

Safeguarding Children (Level 1) 190 195 97.4% 90% Yes

Safeguarding Children (Level 2) 886 910 97.4% 90% Yes

NHS |CSTF| Preventing

Radicalisation - Levels 3, 4 & 5

(Prevent Awareness) 766 808 94.8% 90%

Yes

NHS |CSTF| Preventing

Radicalisation - Levels 1 & 2 (Basic

Prevent Awareness) 193 209 92.3% 90%

Yes

Safeguarding Children (Level 3) 5 6 83.3% 90% No

At Howard Court in community services for adults, the 90% target was met for five of the seven

safeguarding training modules for which staff were eligible. Safeguarding adults (level 3) did not

meet the target with 83.3% completion rate.

St Albans

Training module name

Number of staff trained

Number of eligible

staff Completio

n (%) Target

(%) Target

met

Safeguarding Adults (Level 1) 1 1 100% 90% Yes

Safeguarding Adults (Level 2) 19 19 100% 90% Yes

Safeguarding Children (Level 1) 1 1 100% 90% Yes

Safeguarding Children (Level 2) 19 19 100% 90% Yes

NHS |CSTF| Preventing Radicalisation - Levels 3, 4 & 5 (Prevent Awareness) 15 16 93.8% 90%

Yes

NHS |CSTF| Preventing Radicalisation - Levels 1 & 2 (Basic Prevent Awareness) 3 4 75.0% 90%

No

At St Albans in community services for adults the 90% target was met for five of the six

safeguarding training modules for which staff were eligible Preventing radicalisation – levels 1 and

2 (Basic prevent awareness) training module did not meet the target with 75% completion rate.

(Source: Universal Routine Provider Information Request (RPIR) – P38 Training)

Safeguarding referrals A safeguarding referral is a request from a member of the public or a professional to the local

authority or the police to intervene to support or protect a child or vulnerable adult from abuse.

Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and

institutional.

36

Each authority had their own guidelines as to how to investigate and progress a safeguarding

referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will

work to ensure the safety of the person and an assessment of the concerns will also be conducted

to determine whether an external referral to children’s services, adult services or the police should

take place.

Referrals were provided on a trust wide level so we were unable to break this down to core

service.

From 1 April 2017 to 31 March 2018 there were 382 safeguarding referrals for adults made by

HCT staff. During the same period the trust made 390 safeguarding referrals for children.

(Source: Universal Routine Provider Information Request (RPIR) – P11 Safeguarding)

Safeguarding referral forms were accessible online via the patient’s record on the trust’s electronic

record keeping system. Staff knew how to complete a referral and an incident report in line with

policy. The system was a database used by all clinicians across the trust detailing all patients’

episodes of contact with the health service.

Staff discussed safeguarding issues, lessons learnt and action points during handover meetings.

Staff told us the actions they would take if they suspected a safeguarding incident; this was in line

with policy. Staff gave examples of what they would consider to be a safeguarding incident, such

as patterned bruising. Staff felt that they worked well as a team to safeguard patients. For

example, a patient with a grade 3 pressure ulcer thought to have been the result of neglect in care,

was the subject of a multi-agency meeting to discuss their management plan and actions required

to safeguard them.

Cleanliness, infection control and hygiene

The service controlled infection risk well most of the time. Staff generally kept themselves,

equipment and the premises clean. They mostly used control measures to prevent the

spread of infection.

Most staff adhered to infection prevention and control measures. Arms were bare below the

elbows and nursing staff wore wearing personal protective equipment (PPE) when carrying out

clinical tasks. This was also shown in the locality audit results for February to June 2018 where

100% of staff were bare below the elbow. We observed staff on home visits, in the rapid

assessment unit and in the leg ulcer clinic using gloves and aprons. They washed their hands or

used hand gel between patients and created a clean area for dressings. However, we saw one

physiotherapist wearing a stoned ring whilst performing a clinical task.

Hand sanitiser dispensers and hand washing facilities were available in all clinical areas. We

observed most staff completing hand hygiene before, between and after patient contact. This was

in line with National Institute for Health and Care Excellence (NICE) guidance for infection

prevention and control, Quality Standard 61 (April 2014). The guidance states that healthcare

workers should decontaminate their hands immediately before and after every episode of direct

contact care.

During an observation of the leg ulcer clinic and a home visit we saw staff delivered clinical care

using aseptic (sterile) techniques.

We saw elbow operated, or sensor operated ‘no touch’ clinical hand wash sinks in clinical

environments. These met health building note standards. Health building notes give best practice

guidance on the design and planning of new healthcare buildings and on the adaptation or

extension of existing facilities. Most clinic rooms had hand wash sinks, paper towels, liquid soap,

37

and pedal bins available, with posters displaying effective handwashing techniques. We found that

at St Alban’s City Hospital, during the speech and language therapy clinic, the speech and

language therapist was in a room without a sink or hand gel dispenser. We also found that in the

gymnasium within the physiotherapy department at Queen Elizabeth II Hospital (QEII) the sink

was broken, this meant that staff were unable to wash their hands before and after patient contact.

However, there were hand gel dispensers on the wall, which facilitated decontamination of hands.

Most of the areas we visited appeared visibly clean. In the physiotherapy clinics at both Lister

Hospital and QEII Hospital, we observed staff cleaning the examination couch and equipment in-

between patient use. Staff used specialist cleaning wipes to reduce the risk of cross

contamination.

There was limited use of ‘I am clean’ stickers in clinic areas to indicate that equipment had been

cleaned after patient use. Staff said that they did not routinely use these stickers. We could not,

therefore, be assured that all equipment had been cleaned after each patient use. However,

following inspection, the trust informed us that their cleaning and disinfection policy only required

high risk items, such as commodes, to be cleaned after each patient use.

We saw that cleaning schedules were not always completed when they were in place. For

example, at Potters Bar Community Hospital, we saw that in two out of the three rooms, checklists

were completed on eight occasions during 2018. A third room had the checklist completed on

three occasions during 2018. Data sent by the service showed poor completion rates across

several locations of service delivery. The manager of Cheshunt Community Hospital had provided

an action plan for improving this within their service.

There were clear processes for the management and disposal of clinical waste. In clinics, clinical

and non-clinical waste were segregated into foot operated colour-coded bins. We saw that sharps

bins in clinics were mostly secured to the wall. They were signed, dated, and not overfilled.

However, we saw a partially filled sharps bin in the clinical room at Potters Bar Community

Hospital, which was not secured to the wall and was balancing on a chair.

The trust had a target of 90% for mandatory training. Infection prevention and control mandatory

training compliance was 99.3% trust wide for level 1 and for level 2 it was 85.0%.

Data seen showed that hand hygiene dip test results were mostly 100% across the localities

between February to June 2018. Two localities had compliance of 97% and 94% due to missed

hand hygiene following contact with the patient surroundings.

In the musculoskeletal (MSK) clinic and leg ulcer clinic, there were disposable curtains around

each cubicle area. These curtains were in date and were replaced regularly as required.

Environment and equipment

The service generally had suitable premises but did not always have equipment that was

regularly maintained. When we found out of date equipment during our inspection, we

raised this with managers, who took action to address this. Following our inspection, we

saw that there were large amounts of equipment on the service equipment maintenance

logs that were out of date for annual testing. We were not assured that the service had

effective processes for ensuring that all equipment was maintained in line with policy.

We visited several buildings and saw that most were purpose-built. However, not all buildings

were fit for purpose. Some services were delivered in older buildings, which were not always

suitable for their intended use. For example, at St Albans City Hospital, the clinic room being used

was carpeted and had no sink. This meant that the staff using it were unable to comply with the

38

trust’s infection control policy. After our inspection we were told that these services had moved to

a new unit on 1 October 2018 and all the environmental issues were resolved fully.

We found that the environment in the Nevells Health Centre was in a poor state of repair and

needed updating. For example, the doors to the clinic rooms in the physiotherapy department

were not soundproofed. This meant that conversations could be heard easily through the door.

Clinic storage rooms were clean, tidy, and well organised. We observed equipment was stored

appropriately in clinics; however, access to some storage rooms was not always restricted to staff

only. Clinic storage rooms in Potters Bar Community Hospital and QEII physiotherapy gymnasium

had been left unlocked. There was a risk that unauthorised people could therefore have had

access to medical consumables and presented a tamper risk for essential equipment.

Medical devices were managed by the trust’s medical devices team. A list of all medical devices

was maintained. We found that not all equipment and consumables were in date. For example, at

the hand therapy clinic at Lister Hospital, there were items found that expired in 2011, 2014, 2016

and 2017 and the splint pan expired in June 2018. The splint pan is used to allow custom shaping

hand splints for patients. In QEII Hospital, the ultrasound unit and the shockwave unit were due for

testing in January 2018. This was raised with senior staff at the time of the inspection. Staff stated

that these items would be removed from use immediately and they would arrange for equipment to

be tested where required. The service confirmed that all items were removed immediately and

staff have been reminded to routinely check use by dates prior to use.

The service gave us a copy of their medical devices maintenance logs. This showed that 1,378

items of equipment out of 5,638 were overdue for a service. We saw that 13 of these were high-

risk items, such as syringe drivers (battery-powered pumps that deliver medication at a constant

rate through a very fine needle under the skin). All items on the log were rated on a risk level from

low to high. Managers told us that the risk rating formed a basis for prioritisation of their annual

schedule. The overdue equipment maintenance was not included on the service risk register. The

service stated that some items of equipment were now serviced in-house, in order to improve the

quality and responsiveness of the service. However, due to the large numbers of equipment that

were not compliant with annual testing requirements, we were not assured that all equipment was

well maintained.

The treatment room and clinical area at Potters Bar Community Hospital were visibly clean and

tidy. However, cleaning schedules checks were rarely recorded daily. We also found some out of

date items such as cannulas, paediatric emergency oxygen masks and blood taking equipment.

Staff received training to use specialist equipment. For example, community nurses used syringe

drivers to deliver doses of drugs to patients in their own homes.

During the last inspection, in February 2015, we were informed that equipment was not always

readily available at weekends including commodes, mattresses and walking frames. During this

inspection, staff said this had improved and equipment was readily available. Stock was

replenished from a central warehouse and was maintained weekly by technical instructors. Staff

stated that they did not have any issues obtaining the equipment.

Staff ordered mobility equipment and pressure-relieving equipment through an online portal for

community equipment service. Staff stated that they had good access to equipment and it was

usually available quickly. If any equipment was needed urgently it was always delivered within 24

hours.

We saw bariatric equipment in clinics and staff stated that they could order for patient’s homes if

needed.

39

There were emergency call bells in most consulting rooms and clinic areas. However, the rapid

assessment unit at St Albans City Hospital had no emergency call bells, therefore, patients were

given a hand bell to use. The manager of the service told us that they were due to move premises

on 1 October 2018 to a unit where emergency call bells were installed.

There was not a robust process in place for daily checking of the items on the resuscitation trolley

at Potters Bar Community Hospital. The checklist was basic and did not include a full list of the

items on the trolley, checks of the sealed tamper proof tag number, or clear responsibilities for

checking the trolley daily. The checklist was completed 14 days in August 2018 and nine days out

of 18 in September 2018. We saw that the emergency medicines kept on the trolley were stored in

a box with a sealed tag which was tamper evident. However, these medicines were kept on top of

the trolley, not locked away and the sealed numbered tag was not checked daily. We were

therefore not assured that these medicines had not been tampered with. We raised this

immediately with senior staff who locked the medicines away in the resuscitation trolley and

informed us that they would do a full check of the trolley and all its contents immediately.

The resuscitation trolley at St Alban’s City Hospital was stored in a room behind a door which was

difficult to access. The checklist for this was completed daily during September, August and July

2018 and all items on the trolley were in date. However, it contained the cardiopulmonary

resuscitation policy which was out of date. The service confirmed that following the move to the

new unit, the resuscitation trolley was stored in a centralised location.

Minutes seen showed that medical device alerts had been discussed and actions were taken

where needed.

Assessing and responding to patient risk

Whilst systems and procedures were mostly in place to assess, monitor and manage risks

to patients, not all patients had up to date risk assessments recorded.

Patients in all services were assessed with a range of holistic assessment tools which were in line

with national practice. Staff completed risk assessments as part of the electronic patient record.

This included malnutrition universal screening tool (MUST), Waterlow (to assess the risk of skin

damage) and falls. We reviewed 19 patient records and found that care plans were completed.

However only 15 had up to date risk assessments. We found two Waterlow risk assessments that

had not been updated since March 2018 and one since April 2018. This was in line with the

service’s own dip test audit results from February to July 2018. Discussions in some locality team

meetings also highlighted that Waterlow and MUST risk assessments were not always completed.

Action plans were not seen within the locality meetings for increasing compliance or re-audit. The

policy stated that Waterlow risk assessments must be reassessed no less frequently than a

monthly basis. Staff told us that if a patient was high risk, the risk assessments would be updated

weekly. Following our inspection, the service provided an action plan. This included reviewing care

plan completion and increasing the dip testing of the notes to provide assurance that all records

were completed. The service leads also stated that the locality managers would review the data

quality reports which identified patients who were outstanding risk assessments and ensure gaps

in the recording were resolved.

The service had been using Waterlow risk assessments to evaluate a patient’s risk to developing a

pressure ulcer. The service was piloting the ‘Purpose T’ risk assessment which was an evidence

based holistic tool and included a more detailed skin evaluation. As this was still in the pilot phase

its efficiency had not been fully tested.

40

At St Albans City Hospital in the rapid assessment unit, no documentation templates including

Waterlow, MUST, or pain had been completed. All patients had pre-populated care plans in place

and staff only completed risk assessments if a problem had been identified. We spoke with staff

who stated a policy for the implementation of these assessments was under development. The

manager stated that an action plan was being implemented to improve compliance. This included

regular auditing and data quality reports. This was planned to commence following the move of the

unit on 1 October 2018. After our inspection, the service advised us they had introduced new

processes including the use of a designated assessment bay, training of the team manager to

access reports on the electronic record keeping system in order to monitor the team’s

effectiveness and commenced dip testing of the records. The locality manager also met with the

local team to reinforce expectations around the use of risk assessments.

Staff were aware of how to manage deteriorating patients. Nursing staff offered patients advice on

the phone or arranged for an urgent visit. If staff remained concerned about a patient’s condition,

they contacted the patient’s GP or emergency services. There were no specific tools to monitor

deteriorating patients, such as community early warning scores. We saw that if a patient’s vital

signs of, for example, pulse, blood pressure and respirations were outside of the normal range,

once inputted onto the electronic system, it changed from black to red. There was no agreed

action plan for the nurse to follow when discovering an out of range result. We did see in the rapid

assessment unit that national early warning scores (NEWS) were being used. We observed staff

monitoring a patient through using the NEWS chart for deterioration of their condition.

Most patient referrals were processed through a central hub. A triage system was in place to direct

referrals to the most appropriate service. This was led by administrators who recorded referrals on

the trust’s record keeping system, noted their urgency and then passed them on to the appropriate

clinician. Staff used their clinical judgement to triage referrals and identified patients based on a

fixed criterion and then prioritised their urgency. This meant that patients were directed to the right

service first time. Patients who were deemed to require prioritising were seen by the nursing or

therapy teams on the same day, to prevent hospital admission. Routine patients were seen within

72 hours or one week depending on their clinical need. We observed a staff member appropriately

triaging referral emails and calls that were made to one of the referral hubs.

Some services had separate systems for referrals. For example, the musculoskeletal (MSK)

physiotherapy service categorised patients into acute, sub-acute and chronic. Any referrals then

identified as urgent and complex were allocated to senior staff for assessment within two weeks.

In the patient records we saw that where patients had been identified as being at high risk of skin

pressure damage or falls, care plans were put in place. These listed actions to mitigate and

minimise these risks. Actions included ordering pressure relieving equipment and regularly

reviewing dressings. The service’s record keeping system prompted staff to act on risk

assessments. For example, if a patient scored two or more for falls risk assessment, the system

would prompt the staff member to make an online referral to the therapy team.

All new pressure ulcers that were categorised at grade two, three and four were reported as an

incident. The report was sent to the tissue viability team lead to review and decide if further

investigation was needed. Community teams had a weekly handover where all members of the

multidisciplinary team discussed all new pressure ulcers reported in the previous week. The

community teams had tissue viability link nurses who also worked closely with the tissue viability

team. They were readily available for advice and support to community nursing staff. One tissue

viability link nurse stated that they tried to see all new pressure ulcers within their team.

41

There were systems in place to protect lone workers, including a trust wide lone worker policy.

Staff were issued with mobile phones which had the ability to track their locations by GPS. All

managers had their team’s whereabouts and staff were required to update the system as they

progressed throughout the day. There was a panic button for help through the record keeping

system if staff felt in danger whilst with a patient. If there was any increased risk perceived, staff

would visit in pairs, for example when staff were working after dark or in isolated locations.

Staffing

The service did not always have enough staff with the right qualifications, skills, training

and experience to keep people safe from avoidable harm and abuse and to provide the

right care and treatment. There were high vacancy levels for nursing staff and a

dependence on bank and agency staff to cover shifts. However, managers were aware of

the issues and had put strategies in place to try and address this situation.

During the last inspection, there were shortages of nursing staff and therapists. Staff were worried

about understaffing and the impact that this had on the service. In the follow up inspection in April

2016, it was found that staffing levels had improved and that the service had introduced new

measures to attract and retain staff and the vacancies had decreased from 13% to 9%. This risk

had remained open on the risk register since the previous inspection. Data provided showed there

was an overall vacancy rate of 12% which was above the target of 10%. The vacancy rate was

19% for registered nurses. The service stated that they had ongoing recruitment campaigns, for

example, advertising, open days, an introduction of flexible working and specialist interest roles.

Recruitment was identified by managers as being an issue due to the trust’s location, as it was

close to London where salaries there, included London weighting allowance. There was high

turnover and high vacancies, particularly in Lower Lea Valley and Stevenage integrated

community teams, and Watford CAHS. This had an impact on patient care at times, which led to

appointments being deferred. There was an escalation policy that had a clear process when

deferral was required. Only low risk patients were deferred. However, from July to September

2018, 456 clinical visits were deferred which resulted in nine incidents. Seven of these incidents

were relating to insulin administration and two were due to poor communication between the

teams. Managers stated that these were all identified within 24 hours of the missed visits and did

not cause severe harm to the patients. It was not clear what level of harm the patients sustained.

Most nursing staff and managers we spoke with identified staffing levels as a concern. Managers

held a daily pressure point call where they reviewed staffing levels across all services and moved

staff to cover staffing shortages.

We were informed that the community nursing teams were considering introducing auto

scheduling of their caseloads. This system allocated patients to each nurse according to their

priority. This was assessed by allocating patients based on minutes of care needed and

determined by the care plans on the patient’s record. The new system allocated a maximum

number of minutes per staff and allowed for lunch breaks and administration time. Staff stated that

when this was trialled, they were much happier with the allocation of their caseload and felt that it

was fair.

The managers used a spreadsheet to create an operational pressures escalation levels (OPEL)

status for staffing. The OPEL framework was an NHS England tool which produced a RAG rating

level of escalation. RAG rating uses a red, amber green traffic light system to indicate high to low

risk. There were four levels of escalation, categorised as green, amber, red and black, where

black indicated the most severe level of alert. The report split the trust into two areas,

Hertfordshire Valley Community (HVC) and East and North Hertfordshire Community (ENHC). The

42

HVC status report showed that 14 out of 21 days were red (OPEL three) and one day was black

(OPEL four). This meant that their staffing levels were at 60-80% of optimum for at least half of the

month. This meant that visits that had been deemed low priority, were cancelled. The data ENHC

showed that 14 out of 27 days were green (OPEL one) and 13 days were amber (OPEL two). This

demonstrated that their staffing levels were consistently above 80% with the majority over 90% for

the month of September 2018.

There were a few teams such as Danesbury community neurology team and the tissue viability

team that were fully staffed, however managers stated that they still felt short staffed due to an

increase in demand.

The service had adopted several initiatives to maintain safe staffing levels. Band three healthcare

assistants (HCAs) had undergone extra training to enhance their skills. Competencies had been

introduced to enable them to undertake some nursing tasks, for example, administering insulin to

clinically stable diabetic patients, within their homes. HCAs completed a comprehensive teaching

and assessment programme prior to administering insulin alone. This involved mentoring, an

insulin workbook and competency sign off. Staff we spoke with stated that this had reduced the

pressure on the district nursing team at key times such as 8am to 10am and 4pm to 6pm. This

meant that they could concentrate on seeing urgent patients during these times.

Nursing managers told us that there was high use of bank and agency staff to cover unfilled shifts.

We were told that there was an induction process in place for new agency staff. We saw

completed forms whilst on inspection. Managers reported that most agency staff used were

regular returners who knew the services well. When a visit was completed by an agency nurse, a

permanent member of the team would do the following visit. Therapy services managers told us

that they did not generally use bank and agency staff.

Managers stated that they had issues with staff retention, especially in MSK physiotherapy where

staff often left to work elsewhere. The diabetes team however had retained all staff for more than a

year and were at full establishment. We were told that the staff were happy.

Planned v Actual Establishment

Year 1 section:

Details of staffing levels within community services for adults by staff group as at March 2017 are

below.

Community adults total:

Staff group Planned

staff WTE

Actual Staff

WTE Staffing rate (%)

NHS infrastructure support 188.0 182.3 97.0%

Other Qualified Scientific, Therapeutic & Technical staff (Other qualified ST&T)

16.9 19.1 Over-established by

13.4%

Public Health & Community Health Services

2.6 0.6 21.8%

Qualified Allied Health Professionals (Qualified AHPs)

363.3 320.0 88.1%

Qualified ambulance service staff 5.0 6.4 Over-established by

28.3%

43

Qualified nursing & health visiting staff (Qualified nurses)

478.6 389.0 81.3%

Support to doctors and nursing staff 133.8 127.1 95.0%

Support to ST&T staff 81.6 79.7 97.7%

Total 1,269.6 1,124.2 88.5%

Year 2 section:

Details of staffing levels within community services for adults by staff group as at March 2018 are

below.

Community adults

Staff group

Planned

staff

WTE

Actual Staff

WTE Staffing rate (%)

NHS infrastructure support 169.5 152.3 89.9%

Other Qualified Scientific, Therapeutic &

Technical staff (Other qualified ST&T) 17.0 18.0

Over-established by

5.8%

Public Health & Community Health

Services 1.8 0.4 22.7%

Qualified Allied Health Professionals

(Qualified AHPs) 321.9 285.7 88.8%

Qualified ambulance service staff 6.0 9.0

Over-established by

49.5%

Qualified nursing & health visiting staff

(Qualified nurses) 439.1 330.7 75.3%

Support to doctors and nursing staff 129.4 138.9

Over-established by

7.3%

Support to ST&T staff 86.5 80.5 93.1%

Total 1,171.1 1,015.5 86.7%

(Source: Universal Routine Provider Information Request (RPIR) – P16 Total Staffing)

Vacancies

The trust target was 10% for vacancy rates. From March 2017 to April 2018, the trust reported an

overall vacancy rate of 12% in community services for adults. This did not meet their target.

Across the trust overall, vacancy rates for nursing staff were 19% and for allied health

professionals were 10%.

A breakdown of vacancy rates by staff group in community services for adults at trust level is

below:

Community adults total

Staff group Vacancy rate

Public Health and Community Health Services 72.4%

44

Qualified Nursing and Health Visiting Staff 19.2%

Qualified Allied Health Professionals 9.7%

NHS Infrastructure Support Staff 8.8%

Support to doctors and nursing staff 5.2%

Support to Scientific, Therapeutic and Technical Staff 4.7%

Other Qualified Scientific, Therapeutic, Technician Staff -1.4%

Qualified ambulance service staff -98.0%

Total 11.8%

(Source: Universal Routine Provider Information Request (RPIR) – P17 Vacancy)

Turnover

The trust target was 12% for turnover rates. From April 2017 to March 2018 the trust reported an

overall turnover rate of 15.8% in community services for adults. This did not meet their target.

Across the trust overall turnover rates for nursing staff were 19.8% and for allied health

professionals were 10.9%.

A breakdown of turnover rates by staff group in community services for adults at trust level is

below:

Community adults total

Staff group Turnover rate

Qualified Ambulance Service Staff 56.6%

Qualified Nursing and Health Visiting Staff 19.8%

NHS Infrastructure Support Staff 16.2%

Support to Doctors and Nursing Staff 15.7%

Support to Scientific, Therapeutic and Technical Staff 12.6%

Other Qualified Scientific, Therapeutic, Technician Staff 12.3%

Qualified Allied Health Professionals 10.9%

Public Health and Community Health Services 0.0%

Total 15.8%

(Source: Universal Routine Provider Information Request (RPIR) – P18 Turnover)

Sickness

The trust’s target was 3.6% for sickness rates. From April 2017 to March 2018, the trust reported

an overall sickness rate of 4% in community services for adults. This did not meet their target.

Across the trust overall sickness rates for nursing staff were 5% and for allied health

professionals were 2.2%.

A breakdown of sickness rates by staff group in community services for adults at trust level is

below:

45

Community adults total

Staff group Sickness rate

Support to Doctors and Nursing Staff 5.4%

Qualified Nursing and Health Visiting Staff 5.0%

Qualified Ambulance Service Staff 4.9%

Support to Scientific, Therapeutic and Technical Staff 4.6%

NHS Infrastructure Support Staff 3.2%

Qualified Allied Health Professionals 2.2%

Other Qualified Scientific, Therapeutic, Technician Staff 1.0%

Public Health and Community Health Services 0.0%

Total 4.0%

(Source: Universal Routine Provider Information Request (RPIR) – P19 Sickness)

Nursing – Bank and agency qualified nurses

From April 2017 to March 2018 the trust reported bank and agency usage for qualified nurses in

community services for adults as below:

Type of shift Total number of shifts

Shifts available 9,630

Filled by bank 2,537

Filled by agency 5,383

Shifts not filled 1,710

Nursing - Bank and agency nursing assistants

From April 2017 to March 2018 the trust reported bank and agency usage for nursing assistants in community services for adults as below:

Type of shift Total number of shifts

Shifts available 6,410

Filled by bank 704

Filled by agency 5,080

Shifts not filled 626

(Source: Universal Routine Provider Information Request (RPIR) – P20 Nursing Bank Agency)

Medical locums

From April 2017 to March 2018 the trust reported agency usage for consultants and registrars in community services for adults as below:

46

Staff group Shifts available Not filled

Consultant 1 1

Registrar 6 6

Total 7 7

The trust stated that they did not have a medical bank due to low usage; however, one was being

set up via National Health Service Professional (NHSP) in 2018.

(Source: Universal Routine Provider Information Request (RPIR) – P21 Medical Locum Agency)

Suspensions and supervisions

During the reporting period from April 2017 to March 2018, community services for adults reported

that there had been a suspension of a member of staff within one of the inpatient units.

(Source: Universal Routine Provider Information Request (RPIR) – P23 Suspensions or

Supervised)

Quality of records

Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-

date and available to all staff providing care.

We saw that all services used electronic patient records. These were accessible through password

protected systems to authorised staff. Staff could view and share patient information to deliver

safe care and treatment in a timely and accessible way. Staff allocated tasks to their colleagues

through the system; for example, a physiotherapist tasking the occupational therapist to see a

patient, so that they received a system alert. Staff had laptop devices to access and updated

records whilst in patients’ homes. We were informed that connectivity was limited at times,

especially in remote locations. There was an alternative system that staff used, where templates

were downloaded in advance and then were completed with the patient present. These

automatically updated on the electronic record keeping system when connectivity was restored.

Paper light folders were kept in the patients’ homes which contained basic information. The folder

contained contact information for both in working hours and out of hours, if the patient felt they

required swift attention. We also saw information, in the folder, about how to make a complaint.

There were comprehensive assessment processes in place in the records that we reviewed. Staff

used a range of pre-determined assessment tools to ensure that there was both a consistent

approach and that a holistic assessment of patient’s needs was completed. Following assessment,

care plans were agreed with patients. We saw that patients with the mental capacity to do so,

were asked for their consent to the agreed care plans. We saw that all notes entries were

contemporaneous and up to date. They were dated, timed and electronically initialled by staff

completing the entry, which is in line with national guidance.

The nurse who specialised in treating leg ulcers, stated that their productivity had improved since

gaining access to the electronic system which contained the laboratory results. This was a system

used by GPs to obtain sample results such as wound swab results. This meant that the specialist

leg ulcer nurses were able to access their own results and act on them immediately, as the

majority were nurse prescribers. This meant patients had quicker access to antibiotics if needed.

Staff informed us that the quality of care records were audited. All services had submitted data for

May 2018. There was variable compliance with the audit standards. The data showed that some

areas had a compliance of 61% whereas others were higher, at 89%. The combined compliance

47

was 80.41%. We asked the service what actions they had taken to improve the record keeping

standards. The minutes of the clinical effectiveness group in August showed that the clinical

record keeping audit report was discussed. Each team received an individual audit report to share

with their teams. There was no evidence of these results being discussed in locality team meeting

minutes or any action plans made to improve practice.

The service had a business continuity plan for if access to the electronic record system had been

lost. This detailed using an alternative site for access if possible. One manager stated that each

Monday the total visit list for the week was loaded onto a secure USB stick which was locked away

securely. This was ‘wiped’ and replaced each Monday morning. This process was not seen within

the business continuity plan.

Medicines

Although medicines were prescribed, given, recorded and generally stored in accordance

with best practice, there was lack of knowledge surrounding some significant policies and

key audits were not undertaken.

Medicines were not generally stored or transported by staff in the community health services, with

the exception of adrenaline. Most handling of medication happened in patient’s own homes or care

homes. If a patient ran out of medication staff would request it from their GP, or request that

community pharmacy set up a delivery system. Additionally, all staff carried adrenalin ampules or

automatic injection devices containing adrenaline for allergic emergencies. Staff did not transport

oxygen or other medical gases in their vehicles.

The service had advanced nurse practitioners (ANP) and some specialist nurses who were non-

medical prescribers. Non-medical prescribers are health professionals who have undergone

additional training and are qualified to prescribe some medication. This meant that patients did not

have to wait to see their GP to have changes to existing prescriptions or new medication

prescribed. ANPs prescribe medication if it had already been prescribed by the GP and a repeat

prescription was required. If a new medication was prescribed, the ANP informed the patient’s GP

through the electronic patient record system or email before prescribing.

Most medications used by the community health services were prescribed by GPs. Prescription

pads were all reconciled according to which staff member they were allocated to. They were

signed out to staff and it was their responsibility to keep the pad secure.

Patient group directions (PGDs) provide a legal framework that allows some registered health

professionals to supply and administer specified medicines to a pre-defined group of patients,

without them having to see a doctor. We saw PGDs in place for specified medicines for specialist

physiotherapists. This ensured the service complied with the National Institute for Health and Care

Excellence (NICE) guidance when prescribing medication for individual patients. We saw

completed PGDs in the MSK department at QEII Hospital, but staff at the pulmonary rehabilitation

service were unable to produce a signed PGD for frequently used medicines such as salbutamol

(an inhaler used to treat shortness of breath in, for example, acute asthma attacks). We were not

assured that the unit had signed PGDs in line with guidance.

In the MSK physiotherapy service, there was a policy for completion of injection therapy for pain

relieving and anti-inflammatory medicines, which were part of a PGD. The PGD consisted of

written instructions which enabled suitably qualified therapists to administer certain medicines to

patients in planned circumstances. The PGDs had appropriate detail and description and were

signed off by an authorising doctor. The PGDs were due for renewal in November 2018.

48

Care plans and journal entries in patients’ records detailed their allergy status and information

about insulin management, such as time and site of administration of dose. Staff did not

administer time specific medicines unless there was a two-hour window which allowed for any

delays. For example, they administered low molecular weight heparin and used syringe drivers as

there was a two-hour window. All details of these were included in patient’s care plans. Care

agencies usually dealt with time specific medicines.

Healthcare assistants (HCAs) and band four staff, had been trained to administer insulin to stable

diabetics. These patients were selected against a strict criterion and were monitored monthly by

the community nurses and diabetic nurses. They reviewed the management plan and ensured that

the patients were still suitable to be seen by HCAs. The June 2018 audit showed that 100% of

patients were seen weekly by a registered nurse in addition to the unregistered staff. All the staff

had attended diabetes training at the local university. They were assigned a registered nurse as a

mentor who signed them off when competent. We saw two sets of completed competencies. The

policy for this was due for renewal in April 2018 and was being reviewed at the time of our

inspection. Since this initiative, there had been no insulin related incidents reported and managers

were considering extending the patient criteria for band 4 staff as they had completed further

training. The efficiency of this project was monitored by regular dip tests of the patient electronic

notes and discussions at monthly meetings. The project had been presented by the project lead

and HCAs at the Leeds ‘Leading Change and Adding Value’ conference and the service had been

informed that there were plans to publish it.

All medication that we checked was in date within a locked cupboard or fridge. However, fridge

temperatures were not always completed daily. In addition, the minimum and maximum

temperature was not monitored in line with the policy. At Stevenage integrated community team,

they were found to be monitored daily, but at Potters Bar Community Hospital they were

completed 16 times in July, 14 times in August and eight times out of 18 in September. This was

raised immediately with staff on site who told us that Hertfordshire Community Trust nurses were

not always on site. Additionally, there was lack of guidance with regards to who was responsible

for these checks when they were not on site. They stated that they would pass this onto the

manager and ensure a plan was put into place.

QEII physiotherapy department stored medication within their clinical room. The temperature of

this room was monitored on a weekly basis. The policy did not state a frequency of requirement for

checking the room temperature. However, the approved checklist within the policy stated that the

monitoring should be completed daily. It was checked five times in July, four times in August and

six times in September. The temperature was consistently recorded at above 25 degrees which

was above the recommended temperature for storing medicines. Staff had discussed the elevated

temperatures with the pharmacy department who said that no escalation was required. Following

the inspection, we were sent a memorandum which had been sent to the staff on the 9 August

2018 regarding the storage of medication in elevated temperatures. There were clear guidelines

on actions to be taken. We were not assured that staff were aware of how to store medicines

safely in line with their manufacturer guidelines and trust policy.

In locality team meetings, drug alerts were discussed and any actions required as a result.

The service did not complete any medication chart audits within the community setting, this was

due to lack of capacity within the team. The chief pharmacist stated that they monitored any errors

through the incident reporting system. This was recognised as a gap in their service and had been

added to the trust risk register.

49

Safety performance

Safety Thermometer

The Safety Thermometer was used to record the prevalence of patient harms and to provide

immediate information and analysis for frontline teams to monitor their performance in delivering

harm free care. Measurement at the frontline is intended to focus attention on patient harms and

their elimination.

Data collection takes place one day each month – a suggested date for data collection was given

but the wards were able to change this. Data was submitted within 10 days of suggested data

collection date.

Community Settings

Data from the Patient Safety Thermometer showed that the trust reported 178 new pressure

ulcers, 89 falls with harm and 81 new urinary tract infections in patients with a catheter from July

2017 to July 2018 within community services for adults. However, it should be noted that pressure

ulcers may have been acquired prior to the patient being referred for care to HCT.

0

5

10

15

20

25

30

Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18 Mar18 Apr18 May18 Jun18 Jul18

Pressure Ulcers - New

0

2

4

6

8

10

12

14

Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18 Mar18 Apr18 May18 Jun18 Jul18

Falls with Harm

50

(Source: NHS Safety Thermometer)

There was an increase in the number of cases of harm free care from July 2017 to July 2018 in

new pressure ulcers and the prevalence of urinary tract infections in patients with catheters.

However, there was a slight decrease in the number of cases of harm free care for patient falls.

Senior managers told us that safety thermometer data was collected and submitted by community

nursing teams monthly. However, we were informed that in Quarter 1, the results did not correlate

with the number of patient contacts on the day of the survey. Senior managers found that staff

were not always aware of the criteria. Managers were discussing this within their teams to improve

compliance. A podcast had also been recorded, outlining the purpose of the safety thermometer

and how to report effectively. Results and lessons learned were shared at monthly senior nurse

meetings. We saw that action plans were created by the locality leads and reviewed monthly at the

meetings. There was also evidence of safety thermometer results being discussed at speciality

meetings, for example, such as the pressure ulcer forum.

Incident reporting, learning and improvement

The service managed patient safety incidents in line with best practice. Staff recognised

incidents and reported them appropriately. Managers investigated incidents and

sometimes shared lessons learned with the whole team and the wider service, although

this was variable. When things went wrong, staff apologised, but not all staff were aware of

their duties with regards to their duty to give patients honest information and suitable

support.

Staff understood their responsibilities in raising safety concerns and reporting them as incidents.

All staff had access to the electronic reporting system. Staff described what they would report as

an incident and the process for doing this. Staff told us that they received an email

acknowledgement when they submitted an incident and managers discussed the incident with

them before completing an investigation. Service and locality leads were responsible for

completing incident investigations. The community trust had monthly meetings to discuss

complaints, litigation, incidents, concerns from the PALS team, and safeguarding - CLIPSS. These

detailed any incidents that had occurred. It contained top three lessons learnt and team actions

and this was sent to senior managers for review. There was a varying level of detail within these

reports, across the different teams, within the service.

The service had a variety of methods to share lessons learned from a review of incidents, such as

team training, team meetings, emails, and handovers. Learning from incidents was discussed at

0

2

4

6

8

10

12

14

16

Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18 Mar18 Apr18 May18 Jun18 Jul18

Catheter & New UTI

51

weekly or monthly team meetings. There was variable quality of meeting minutes across the

service and the majority lacked detail regarding specific incidents and lessons learned. Some

services had made changes for example, an occupational therapist told us that they had an

increase in incidents surrounding poor referrals that had lacked clarity of diagnosis. They had met

with the clinical lead and developed a training programme for the junior doctors to provide them

with guidelines for hand therapy. They said that this had led to an improvement in the clarity of the

referrals.

Staff described the principle and application of duty of candour, Regulation 20 of the Health and

Social Care Act 2008, which relates to openness and transparency. It requires providers of health

and social care services to notify patients (or other relevant person) of ‘certain notifiable safety

incidents’ and provide reasonable support to that person. There were duty of candour posters

seen in waiting rooms and on staff notice boards. Some staff we spoke with had a good

understanding of the principles of being open and honest when something went wrong, however

not all were aware of the duty of candour.

There was a serious incident panel that reviewed all serious incidents and whether action plans

had been completed.

Never events

Never events are serious patient safety incidents that should not happen if healthcare providers

follow national guidance on how to prevent them. Each never event type has the potential to cause

serious patient harm or death but neither need have happened for an incident to be a never event.

From August 2017 to July 2018, the trust reported no never events in community services for

adults.

(Source: Strategic Executive Information System (STEIS))

Serious Incidents

Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).

These include ‘never events’ (serious patient safety incidents that are wholly preventable).

In accordance with the Serious Incident Framework 2015, the trust reported 12 serious incidents

(SIs) in community services for adults, which met the reporting criteria, set by NHS England from

August 2017 to July 2018.

Of these, the most common types of incident reported were:

• Pressure ulcer meeting SI criteria with three (25% of total incidents).

• Abuse/alleged abuse of adult patient by staff meeting SI criteria with three (25% of total

incidents).

• Sub-optimal care of the deteriorating patient meeting SI criteria with three (25% of total

incidents).

• Slips/trips/falls incident meeting SI criteria with one (8.3% of total incidents).

• Treatment delay meeting SI criteria with one (8.3% of total incidents).

• Confidential information leak/information governance breach meeting SI criteria with one

(8.3% of total incidents).

52

(Source: Strategic Executive Information System (STEIS))

Serious Incidents (SIRI) – Trust data

From April 2017 to March 2018, trust staff within community services for adults reported seven

serious incidents. There were three pressure ulcers reported as ‘other’ and four of the seven

incidents involved pressure ulcers.

Of these, none involved the unexpected death of a patient.

The most common types of serious incidents were abuse/alleged abuse of adult patient by staff,

(three incidents;) treatment delay, (one incident) and one incident of sub-optimal care of the

deteriorating patient.

The number of the most severe incidents recorded by the trust incident reporting system is

comparable with that reported to Strategic Executive Information System (STEIS).

(Source: Universal Routine Provider Information Request (RPIR) – P29 Serious Incidents)

Prevention of Future Death Reports (Remove before publication)

The trust had no deaths requiring Coroner's Inquest in the last 12 months for community services

for adults.

(Source: Universal Routine Provider Information Request (RPIR) – P86 Prevention of future death

reports)

53

Is the service effective?

Evidence-based care and treatment

The service generally provided care and treatment based on national guidance and

evidence of its effectiveness, although some polices were beyond their date for review.

Managers checked to make sure staff followed guidance.

We found that staff in the community health services used a variety of techniques and resources

to ensure that care and treatment was delivered in line with legislation, standards and evidence-

based guidance to achieve effective outcomes. Staff followed best practise guidelines from

professional registration bodies such as the Nursing and Midwifery Council (NMC) and the Health

and Care Professions Council (HCPC). Staff were able to access guidelines and standards on the

trust intranet which was available in all office bases.

We saw that there were local policies produced based on national best practise guidelines such as

the local pressure ulcer policy and the urinary catheterisation management policy. These policies

should be reviewed every three years in line with trust guidelines. However, we noted that not all

the policies staff showed us were in date, for example the urinary catheterisation management

policy we saw was last reviewed in May 2014 and the resuscitation policy we saw was last

reviewed in November 2011. However, following inspection, the trust stated that the resuscitation

policy was last reviewed and issued in May 2016. Staff in the service were unable to show us this

up to date policy at the time of inspection.

We saw that most staff used nationally recognised assessment tools to holistically assess patients

physical, mental health and social needs. Most services used core assessment and care planning

tools, which listed which assessments should be used. However, in the community treatment unit

(previously known as the rapid assessment unit) we noted that no assessment templates were

completed within the patient’s electronic records. The templates were part of the electronic record

system but were not routinely completed by staff. These templates included tools for recording of

past medical history, pain, medication, allergies and risk assessments, for example, Waterlow

scoring and the malnutrition universal screening tool (MUST). However, they were blank in all

records we reviewed. When we asked about this, staff told us that there was no requirement to

complete these but that there was a policy under development for implementation of this process.

In other services, for example, nursing and therapy, nationally recognised tools, were used

including the Waterlow scoring tool for pressure area risks, the elderly mobility scale, and the

Montreal cognitive assessment (a screening tool for mild cognitive impairment.) We saw that

where risks were identified following assessment, action plans were in place in the form of care

plan documents. Care plans, for example for catheter care, were based on NICE guidelines and

the Royal Marsden clinical nursing recommendations (a nationally recognised manual of evidence

based clinical nursing procedures).

Staff in the community neurology team told us that they used a range of national guidance to

influence their practise and deliver evidence-based care. These included the Royal College of

Physicians stroke guidelines, the NICE guidelines for stroke rehabilitation, the National Stroke

Strategy standards, and vocational rehabilitation standards within the National Service Framework

for long term conditions. Therapy leads in the community neurology service told us how they had

developed a new group exercise programme for patients in the early stages of Parkinson’s

disease based on current evidence and emerging research. The community neurology team told

us that they held journal clubs as part of their monthly in-service training programme; at these

54

sessions they reviewed and discussed journal articles to ensure they were following best and

current practise.

The tissue viability team told us that standardised wound assessments and tissue viability

pathways of care were being developed based on NICE guidelines, and the National and

European Pressure Ulcer Advisory panels guidelines. Best practise statements for all staff to

follow had been developed following attendance at a tissue viability forum. The service lead

explained that there was a tool for pressure ulcer categorisation on all staff laptops which had

been developed by the NHS England Midlands and East clinical network.

Staff in the integrated care team explained how they had used the NICE guidelines for falls to

develop a standardised approach to assessments and a more multidisciplinary approach to falls

management.

In a physiotherapy clinic at Lister Hospital staff who worked with patients following amputation

surgery told us how they followed NICE guidelines for provision of compression stump socks

within 10 days of amputation surgery.

Service leads in several services explained that they received a monthly email with a summary of

new NICE guidance published, which they reviewed to identify any relevant guidance which

needed actions to implement in service delivery.

The diabetes team used a nationally recognised structured education programme to support

patients with type 2 diabetes. The DESMOND (diabetes education and self-management for

ongoing and newly diagnosed) programme was developed by NHS staff following research and

pilot studies.

Pain relief

Pain was assessed as part of the core assessment templates used on the trust’s electronic record

keeping system by most services. In one of the integrated care teams, for example, we saw that

pain assessment was part of the core assessment templates, the wound care template and end of

life care template. This pain assessment included a review of the cause of pain, medications for

pain, and visual analogue pain scoring scales. There was an Abbey pain scale score option to

assist in assessing pain for patients with learning disabilities or living with dementia. However, in

the community treatment unit, we saw that the pain assessment templates were not routinely used

by staff.

During our observations of care in the physiotherapy service, we saw that staff were sensitive to

patients in pain, and checked throughout their intervention how their pain was affected.

In the podiatry clinic we observed that the staff member asked the patient about their pain levels

throughout their assessment of a foot wound.

Staff used a variety of methods to address pain including repositioning patients, provision of

pressure relieving equipment, exercises and advice, and adjustment of pain relieving medication

through liaison with GPs or nurse prescribers.

Patient outcomes

The service monitored the effectiveness of care and treatment and used the findings to

improve them. They compared local results with those of other services to learn from them.

Audits – changes to working practices

55

The trust participated in 23 clinical audits in relation to this core service as part of their Clinical

Audit Programme.

Audit name Area covered Key Successes Key actions

National Parkinson's

Audit NCAPOP

Quality Account

Audit 2017/18

Neurological

Service

100% cases submitted -

minimum of 10

responses for

Speech and

Language Therapy,

Occupational

Therapy and

Physiotherapy.

Full report still to be

issued, so cannot

yet demonstrate

where practice has

been changed.

Report yet to be

presented.

National Sentinel

Stroke National

Audit Programme

(SSNAP) NCAPOP

Quality Account

Audit 2017/18

Community

Hospitals and

all Integrated

Community

Teams

Ongoing data collection

from 1 November

2013 - data

submitted for 737 in

2017/18.

As part of the

Sentinel Stroke

National Audit

Programme

(SSNAP) our Acute

Therapy Services

(Occupational

Therapy and

Physiotherapy) at

the Lister Hospital

and the Adult

Speech and

Language Therapy

teams at Lister and

Watford General

have significantly

improved their

performance moving

from a C rating to ‘A’

rating over the last

16 months.

Achieving the rating

of ‘A’ puts the

Service in the top

No key actions.

56

23% out of 215

stroke services

across the country.

SSNAP audit results

[Q3 2017] (released

to the public in

March) show that

Danesbury have

maintained their `A`

rating and Holywell

have achieved their

first `A` rating.

National COPD

Rehabilitation Audit

NCAPOP Quality

Account Audit

2017/18

Pulmonary

Rehabilitation

Service

Data submitted for 118

eligible patients’.

Organisational

questionnaire

completed.

Full report is to be

presented to Clinical

Effectiveness Group

in August 2018, so

cannot yet

demonstrate where

practice has

changed.

Report yet to be

presented.

Sight Impaired Audit

(CVI) - WHDESP

(46)

Diabetic

Retinopathy

Services

Submitted annually to West Herts Diabetic Eye

Screening Programme (DESP) board meeting

with NHS England.

National Diabetes Adult

(NDA) Audit

NCAPOP Quality

Account Audit

2017/18 (3)

Adult Diabetes

Community

Service

Data was submitted for

3648 patients.

• Fewer people with

Type 1 than with

Type 2 and other

diabetes receive

their annual checks.

• The last four years

have seen

improvements in the

combined 3

treatment target

achievement in both

Type 1 and Type 2

and other diabetes.

• Timely offers of

structured education

have improved over

the last three years

• Our Diabetes Service

will continue to offer

monthly Saturday

DESMOND

Education Clinics to

increase participation

in structured

diabetes education

(especially for

patients under 40).

• Diabetes Service to

work with GP's and

Practise Nurses to

increase their

awareness of the

need for retinal

screening and to

provide clarity

around referral

57

• Timely offers of

structured education

have improved over

the last three years

• The apparently low

rates of attendance

may be due to

incomplete recording

of attendance data in

GP electronic

records.

Good compliance

was seen in

monitoring key

aspects of Diabetes

care, in accordance

with NICE Quality

Standard QS6 -

Diabetes in Adults.

responsibilities and

routes for patients.

• Seek new

approaches to

improving

management for

those overall doing

worst. Design and

test new approaches

to providing regular

review and

optimising treatment

for people with

diabetes aged

younger than 65.

• Type 2 diabetes

care providers

should work with

people who have a

Severe Mental

Illness (SMI) to

increase care

process completion.

National Audit of

Intermediate Care -

NAIC NCAPOP

Quality Account

Audit 2017/18 (4)

Bed Based IC,

home based

IC and re-

enablement

services

Intermediate Care

Teams/Community

inpatient units: 65

questionnaires

submitted

Community ICT

Teams: 52

questionnaires

submitted

• Dependency levels

recorded were 31%

for homebased, 35%

for bed-based and

36% for re-ablement

services.

• The dependency

levels of people on

admission, and the

improvements made

during their stay,

were similar to the

2015 results for

home and re-

ablement services.

• Over 96% of

It is suggested that the

audit content is

reviewed in the light

of the NICE

Guidelines issued in

2017: NICE

guideline, NG74

Intermediate care

including re-

ablement.

• Share results at the

Operational Senior

Management Team

(OSMT)/Operational

Services at HCT to

identify whether

there is any learning

to be shared

(feedback at CEG

meeting in October

2018 once this work

stream has been

undertaken).

• Work with

Operational Teams

58

service users replied

‘yes – definitely’ to

the

question ‘I was

aware of what we

were trying to

achieve’.

• Over 91% of

people felt they had

been treated with

dignity and respect.

Evidenced that we

are treating people

with respect and

kindness.

to improve the

Average Length of

Stay in hospital.

Work has been done

with the CCGs, in

particular Herts

Valley to address

this and improve

practices.

• Work with the

Acute Trusts and the

local CCGs to

improve the winter

pressure planning

and ensure

admission criteria

are being followed.

National NDFA

Diabetes Foot Care

Audit part of NDA

2016/17

NICE GUIDANCE

NCAPOP Quality

Account Audit for

2017/18 (10)

Podiatry • Podiatry SystmOne

templates now

incorporate a wound

care classification as

recommended by

NICE in NG19.

• Patients who ‘self-

present’ have the

highest healing rates

but they also have

less severe ulcers.

• To increase

participation rates in

this audit by July

2018.

• Reviewed the

referral pathway.

• By July 2018, work

with commissioners

to improve access to

Multi-Disciplinary

Footcare Team.

• Amended

SystmOne podiatry

template and

incorporated a

wound care

classification as

recommended by

NICE Guideline

NG19.

• Podiatry Service

referral form

reviewed and

updated.

• All Podiatrists

completed at least 2

NDFA forms as part

of their objectives to

increase audit

numbers.

• Review current

59

pathway for foot care

and work with our

commissioners and

other providers to

develop a Multi-

Disciplinary foot care

clinic to ensure

compliance with

NICE guidance for

preventing and

managing foot

problems in adults

with diabetes by

allowing 24 hours

access to the

specialist multi-

disciplinary team.

June 2018 update:

Recruitment to extra

posts has been

carried out and staff

are now in place and

finalising the clinics.

The funding is

available until March

2019.

National NDFA

Diabetes Foot Care

Audit part of

National Diabetes

Audit (NDA)

2017/18.

NICE GUIDANCE

NCAPOP Quality

Account Audit for

2017/18 (10)

Podiatry • People are alive and

ulcer-free at 24

weeks in only two

thirds of cases of a

diabetic foot ulcer.

• At the 12 week

outcome, 60% of the

population with less

severe ulcers were

alive and now ulcer-

free.

• At the 24 weeks

outcome, 74% of the

population with less

severe ulcers were

alive and now ulcer-

free.

• Across all ulcers at

the 24 weeks

outcome, only 3% of

the population had a

new ulceration after

• All people with diabetic

foot ulcers should be

referred promptly for

early specialist

assessment,

according to the

NICE guidance

NG19.

• Providers should

endeavour to record

all new instances of

diabetic foot ulcers,

and to complete

outcome data for all

patients registered in

the audit.

• Reviewed the

Podiatry Service

referral form and

current pathway for

foot care and have

worked with

60

being ulcer-free.

Increased reporting

of diabetic ulcers,

more follow-up and

treatment, therefore

better diabetic care.

commissioners and

other providers to

develop a multi-

disciplinary foot care

clinic to ensure

compliance with

NICE Guidance for

preventing and

managing foot

problems in adults

with diabetes by

allowing 24 hour

access to the

specialist multi-

disciplinary team.

Referrals to the

Podiatry Service for

Non-Acute Nail

Surgery (19)

Podiatry • 302/380 patients had

the A3 (Non-acute

Nail Surgery)

invitation letter sent

to them.

• 131 people ( 44%)

have chosen to not

respond to the invite

and have therefore

been discharged

• 161 people (55%)

have responded to

the invite and have

been seen at an

assessment

appointment

• Of the 161 people

who came for an

assessment

appointment for Nail

surgery, 65% went

on to have nail

surgery.

• Clear benefit in the

outcomes of the

patients, there is

clarity in the

invitation letter that

is sent initially to

patients laying out

clearly what service

can be offered so

that there can be no

• It was decided to

continue with the

system of placing the

patients triaged to

the A3 group (Non-

acute Nail Surgery)

on the separate

waiting list.

• Send out the

specific A3 invitation

letter to the patients,

relevant to their

group.

61

misunderstanding as

to what their

treatment plan will

offer.

For the Podiatry

service the benefits

have been that

resources are used

effectively, seeing

fewer assessments

booked and those

patients are able to

follow the correct

clinical pathway to

achieve the best

outcome.

Audit of the Community

Clinic Caseload

(26)

Adult Diabetes

Community

Service

• A total of 232 patients

were identified from

the search. When

the patient records

were reviewed, it

was found that 32 of

these patients

already had CCC

appointments

allocated, so these

were excluded,

leaving a total of 200

patients eligible for

the audit.

• 80% of patients

were seen within the

last 6 months.

Implemented a

cashing up process

for all clinicians (i.e.

ensuring all patients

have an onward

action at the end of

clinics)

• Audit repeated in 6

months to ensure

above process

embedded

• All actions have

been implemented

as a result of the

audit, including

implementing a

cashing up process

for all clinicians.

Reviewed the

process for patients

phoning up to cancel

appointments, and

trained staff on the

cashing up process

and issued

flowcharts.

Infection Control (IPC)

(40)

Environment/Safety

Audit - includes

Sharps Safety (I)

Hand Hygiene (ii)

MRSA Screening

(iii) Urinary Catheter

Bed Bases

monthly

audits:

Integrated

Community

Teams

quarterly

audits: Health

All audits reported at the Infection Prevention and

Control Forum.

62

Care (1) Insertion

and (2) Continuing

Care (iv) Peripheral

Vascular Catheter

(v) Enteral Feeding

(vi) Commode (vii)

a) Hand Hygiene

Urinary catheter

care insertion and

continuing care.

Vascular devices b)

Hand Hygiene

Environment/safety

audit (and specific

dental service

audits).

Visitors, MIU

(HEH) RAU

(SACH)

Dental

service.

Diabetes Audit on 9

Care Processes

(66)

Adult Diabetes

Community

Service

100% of results (56/56)

have:

•

Discussed/reviewed

the results of the 9

Care Processes with

the patient

• Evidenced the

results of the 9 Care

Processes in the

patient discharge

letter

100% was achieved

in 4/9 Core

Processes:

• Smoking Status

• Albumin: creatinine

ratio

• Serum creatinine

measurement

• Foot examination

Over 90% was

achieved in 4/9 Core

Process:

• BMI

• Cholesterol

measurement

• Blood Pressure

• HbA1c

Measurement

• Continued to embed

the 9 care processes

within the service

and ensure ongoing

monitoring of this.

• Reported on the

audit findings to East

and North Herts

Clinical

Commissioning

Group (CCG).

• Shared

results/findings with

the Community

Diabetes Specialist

Service.

• Diabetes Service

are working with GPs

and practice nurses

to increase their

awareness of the

need for annual

retinal screening and

to provide clarity

around referral

responsibilities and

routes for patients.

• Increase structured

diabetes education

programme

(DESMOND) offered

to patients in West

63

Hertfordshire, and

although diabetes

patient education is

not commissioned in

East and North

Hertfordshire, HCT’s

Diabetes Specialist

Nurses are providing

education to practice

nurses, community

nurses and GPs.

• The new Integrated

Diabetes Service has

now aligned services

in the acute (WHHT),

community (HCT)

and mental health

(HPFT) Trusts to

provide a seamless

pathway for patients.

Consultants,

diabetes specialist

nurses, dietitians,

podiatrists,

Improving Access to

Psychological

Therapies (IAPT)

and Rapid

Assessment,

Interface and

Discharge (RAID)

services now provide

a holistic service that

will meet the needs

of the population in

Herts Valley.

• Participate in the

next round of the

National Diabetes

Audit (2018/19).

Diabetes Service

DESMOND Audit

(74)

Adult Diabetes

Community

Service

• 74% of patients are

extremely likely to

recommend this

Service to friends

and family if they

needed similar

treatment.

• 94% of patients felt

• Regular CCG

meetings undertaken

with the local CCGs

to improve the

achievement of NICE

recommended

treatment targets.

• Improve

64

they were treated

with dignity and

respect.

• 88% of patients felt

the information was

given to them in a

way they could

understand.

• 81% of patients

were clear about

what would happen

next.

Overall, patients

were well-informed

about their

treatment.

collaboration

between West

Hertfordshire

Hospitals Trust

(WHHT) and HCT

Diabetes Service to

develop an

integrated model for

the delivery of care

across acute and

community sectors

(Action complete).

• Practice education

training for nurses

increased to benefit

patient care and

further improve

patient clinical

outcomes. Started in

one locality – now

rolled out to three

localities and

planning to expand

this further.

• Diabetes Specialist

Nursing (DSN) Team

have now trained

Health Care

Assistants (HCAs)

for administering

insulin. Patient

feedback as part of

the HCA project:

Single collated list -

WHDESP (92)

Diabetic

Retinopathy

Services

Submitted annually to West Herts DESP

programme board meeting with NHS England.

Slit Lamp

Biomicroscopy -

WHDESP (93)

Diabetic

Retinopathy

Services

Submitted annually to West Herts DESP

programme board meeting with NHS England.

Plus Size Patients

Management Audit

(46)

East & North &

Herts Valleys

(Adult bed

bases, ICTs

and clinic-

based

services - Leg

Ulcer,

• 90% (18/20) of staff

were aware of the

Management of

Plus-Size Patients

policy

• 70% (14/20) were

aware of the risk

assessment tools for

• Re-launch of the Plus-

Size Patients policy

following review with

a requirement for

managers to ensure

that staff are aware

of the content of the

policy, specifically

65

Podiatry,

Diabetes,

Bladder &

Bowel

Plus-Size patients.

• 95% of staff were

aware of how to

report an incident

related to the moving

and handling of a

patient.

• 90% (18/20) staff

would know how to

report moving and

handling equipment

if it is not fit for

purpose.

• In response to the

question, ‘Are you

aware of how to

access moving and

handling and other

specific equipment

for plus-size

patients?’, 18

responded positively

(90%).

Over 90% of staff

were aware of how

to manage and

handle plus-size

patients effectively,

in accordance with

HCT's Management

of Plus-Size Patients

policy (2015).

relating to the risk

assessments, patient

pathway and

processes to be

taken when

accepting plus-size

patients on referral.

• There was an

apparent lack of

awareness of which

Trust Director is the

nominated

responsible person

for Risk and Health

and Safety. This was

addressed through

the re-launch of the

policy and training.

• All staff who

provide care for plus-

size patients should

be aware of how to

order appropriate

equipment; this is

addressed through

raising awareness of

the policy and

through manual

handling training

sessions.

(Source: Universal Routine Provider Information Request (RPIR) – P37 Audits)

During the inspection we found that there was a clear approach to monitoring, auditing and

benchmarking the quality of services or the outcomes for patients receiving care and treatment in

community health services. We saw that services participated in a range of local and national

audits and that there were action plans in place to address any issues of reduced compliance with

standards. Service leads told us that audit findings were regularly discussed at team meetings,

such as results of the safety thermometer, catheter care, hand hygiene and record keeping audits.

For example, locality managers in the integrated care team told us that record keeping audits were

completed annually and that themes identified were recorded on a tracker which was added to

team meeting agendas for discussion. There were quality leads for each team who collated and

analysed audit data and informed locality leads of any areas of concern. There was a process for

the locality leads to share this information with the team leaders, who would cascade any

information for sharing to the rest of the team. We saw that the locality leads created performance

matrices and action plans from this data, which was reviewed at monthly managers meetings. For

example, we saw that record keeping audit results showed a theme of the use of abbreviations

66

and a failure to consistently document a patient’s allergy status, and that there was an action plan

to address this. The plan included raising the issues at staff team meetings, targeted staff training

and a review of compliance.

Outcome measures were routinely used in most multidisciplinary teams; staff told us they used a

range of outcome measures as appropriate to each patient group. These included balance and

mobility measures, quality of life measures and cognitive assessment tools. Staff we spoke with

told us that the before and after data for these outcome measures was reviewed for individual

patients. However, staff reported that there was not a process in place to routinely collect, analyse

and report on specific outcome measures, as a whole service. The lead for allied health

professionals told us that the patient specific functional scale (PSFS) was used across all

therapies. This was a self-reported, patient-specific outcome measure, designed to assess

functional change. Although there was reporting of completion rates of this measure, the lead told

us that the process for reporting on the impact demonstrated by any change observed, was still

under development. All therapy teams used goal setting as a method of identifying patient’s

outcomes.

The tissue viability lead told us that they audited wound care by reviewing pain scores and

infection rates documented in patient records. This data was analysed and shared at team

meetings where actions were discussed, such as the provision of additional training. The team

were in the process of rolling out a new pressure risk assessment tool called PURPOSE–T

(pressure ulcer risk primary or secondary evaluation tool). This was a holistic assessment tool

which was evidence based and had been piloted with positive staff feedback. Staff were being

trained in its use and a template for completion on the electronic records system was being

developed. The tissue viability team were completing an audit on whether delivery of care was in

line with care plans such as use of recommended wound dressings and antibiotics. The results of

this had led to the development of treatment decision tool posters designed to guide staff in best

practice.

In the leg ulcer clinic, healing rates were used as an outcome measure, through an assessment

tool on the electronic record keeping system. The service reported that rates of leg ulcers healing

within 12 weeks was at 68%. There was an informal process of raising awareness and teaching in

place to improve this, but no documented action plan.

There were a range of key performance indicators used across community health services which

were reported to commissioners of services. These included, for example, screening for anxiety

and depression, patient uptake of self-management programmes, and prevention of admission

data. Senior staff were involved in collating and reporting this data and told us that it was shared

with staff at team meetings. There were some Commissioning for Quality and Innovation (CQUIN)

goals in place. CQUINs are national goals which make a proportion of healthcare providers'

income conditional on demonstrating improvements in quality and innovation in specified areas of

patient care. Services used data from the CQUINs to monitor and evidence that patient’s needs

were being met.

The community neurology service was seeking funding for a research trial of the Parkinson’s

exercise programme which they had developed. The programme called STABLE- staying active

with big limb exercises, had been developed by therapists working within the service. Staff

explained that they wanted to complete a randomised controlled trial of the STABLE programme

as a quality improvement initiative to demonstrate its effectiveness.

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Competent staff

The service made sure staff were competent for their roles. Managers appraised staffs’

work performance and held supervision meetings with them to provide support and

monitor the effectiveness of the service.

Clinical Supervision

The service provided the following information about their clinical supervision process:

Supervision was delivered in line with the clinical supervision framework policy; supervision

happened in groups, action learning sets; individual supervision and informal support to enable

staff to reflect on their practice. There was no formal prescription of either frequency or percentage

compliance.

Supervision was managed and monitored by services with variation in the robustness of

processes and recording. Data from 2017 identified gaps where supervision did not happen or was

incorrectly recorded.

Further work was being undertaken in the trust to enable improved access to supervision,

including development of formal groups within services by locality quality leads and more robust

monitoring systems.

(Source: CHS Routine Provider Information Request (RPIR) – CHS4 Clinical Supervision)

Staff we spoke with all told us that they had regular supervision. Staff described a variety of

supervision methods, including one to one meetings, peer support, and group supervision. There

was also opportunity for clinical supervision in the form of observation of staff practise or joint

working on visits. Team leads monitored supervision processes and ensured that all staff had

access to supervision. Physiotherapy staff described a peer supervision where groups of staff met

to discuss complex patients and share knowledge in order to deliver effective treatment. In the

integrated care team there was a reflective supervision group which staff attended weekly to

discuss any cases that they may have found emotionally stressful. There were action learning sets

in place for senior therapists to share knowledge through sharing of experiences and peer support

groups for technical instructors in the service.

There were clinical quality leads in post in the integrated care teams who supported nursing staff

and health care assistants. They told us that their role was to provide clinical leadership and

effectiveness such as competency based provision of care, for example for catheter care and

wound care.

There were clinical nurse specialists in post for example tissue viability, leg ulcer and diabetes

services who were available to support, advise and train staff in other teams. For example, the

diabetes nurse specialists met regularly with district nurses and delivered education sessions to

the team. Forums for practice nurses for staff who worked at GP practices were held every six to

eight weeks, in order to provide updates on best practice. We were told that there was a pressure

ulcer link nurse who worked in the integrated care team who provided updates to staff at weekly

handover meetings and sent email updates on any new guidance for practise. In addition, there

were champions roles within teams for specialist areas such as safeguarding and dementia.

These staff were given extra training to enable them to develop specialist knowledge and be a

resource for the whole team.

There were competency assessment frameworks in place for staff for specific tasks within their job

role. These were assessed by senior staff and signed off once completed. In some services, such

as physiotherapy, there was an annual review of competencies for staff. For example, competence

68

in delivering emergency respiratory physiotherapy as part of the on call respiratory physiotherapy

rota, was assessed by the senior member of staff by observing individuals practise for half a day.

There were competencies in place in nursing teams for interventions such as delivery of insulin

therapy. All registered nurses completed mandatory update training for insulin therapy annually.

There was a programme in place for training health care assistants to deliver insulin therapy. This

involved completion of a workbook, specific training sessions and observations of care to

demonstrate competency in the role. There were criteria for to enable health care assistants to

administer insulin to suitable patients, which included a standard operating procedure to follow.

This meant that assistant staff were given opportunity for personal development and could acquire

the rights skills and knowledge for safe and effective patient care.

Appraisal rates

From April 2017 and March 2018, 93.2% of all staff within adult community services had received

an appraisal compared to the trust target of 90%.

(Source: Universal Routine Provider Information Request (RPIR) – P39 Appraisals)

Data showed that compliance rates for staff receiving annual appraisals were above the trust

target. Appraisals had been completed annually with all staff we spoke with, and some staff

described a six-monthly review of objectives set during the appraisal process. Staff told us that

appraisals were used to identify goals for learning and further development.

Staff told us that there were different types of additional training opportunities for ongoing learning

and development. This included in house training, attendance at external courses, opportunities

for master’s degree qualifications and development of extended scope skills such as nurse

prescribing. Examples of in house training available were top to toe clinical skills training for

nurses and therapists, updates on inhaler techniques and auscultation skills and therapy journal

clubs. In the community neurology service, during our inspection, there was a guest speaker from

an orthotics company who was attending to deliver a training session to staff. Staff in the

physiotherapy service told us that they attended in-service training sessions every six weeks. In

the community adult’s health service staff told us that in-service training sessions were held after

team meetings every few weeks.

External training opportunities included community nursing qualifications, associate practitioner

qualifications for health care assistants, specialist palliative care courses, a Pilates course and

injection therapy training for physiotherapists. Several staff reported that they had had funding

provided for such training as it was identified in their appraisal as a training need. One technical

instructor we spoke with told us they had completed a level three national vocational qualification

whilst in post, which had been funded by the service. A health care assistant told us that they were

currently completing a foundation degree in health and social care through a local university,

which had been funded through the service. An occupational therapist told us that they were

completing an advanced clinical practise course through a local university which was being funded

through the service. One therapist was attending a multiple sclerosis annual conference but told

us the service had been unable to fund this. A further two therapists also reported that they had

not been able to access funding for external courses for the past two years. Service leads we

spoke with acknowledged that funding for external courses could be challenging. They explained

that they planned to bring in external speakers to run local workshops which could be attended by

more staff at a reduced cost to the trust.

The tissue viability lead told us that a joint role had been developed to work across the tissue

viability and community nursing teams. This role meant that specialist knowledge could be

developed by the staff member and shared widely in the community nursing team. The role acted

69

as a specialist resource within the nursing team to educate staff and increase their knowledge.

The staff member in the role told us that it had provided a good learning opportunity for them to

develop additional skills and experience.

There were rotational physiotherapy posts within the trust which meant that staff were able to work

across a range of different clinical areas to develop a breadth of knowledge and skills.

A new staff member in post in the physiotherapy service described their induction process and told

us it involved specific training and opportunities to shadow experienced staff, in order that they

could develop knowledge, skills and competence.

Staff told us that there were support systems in place for staff undergoing the revalidation process.

There was opportunity for support by community matrons and line managers as well as a peer

group support for nurses. For allied health professionals (AHPs) the leads kept a log of all staff

who had been called to provide reregistration evidence to the health and care professions council.

They asked these staff to share their learning from the process and to be available for peer

support for other staff.

There were allied health professional forums held quarterly which were open to all AHPs.

Managers told us that the agendas for these forums were developed collectively with staff.

Multidisciplinary working and coordinated care pathways

Staff in different clinical roles worked together as a team to benefit patients. Doctors,

nurses and other healthcare professionals supported each other to provide good care.

Staff worked with referrers and other care providers, such as the local hospital and GP

surgeries to ensure patients were seen by the most appropriate service. There were

effective communication systems and clear referral processes in place.

During the inspection, we saw positive examples of multidisciplinary working throughout the

services. We saw that multidisciplinary teams worked together in shared open offices which staff

told us facilitated better communication and good team working. Integrated care teams referred

patients to other specialist teams when necessary, such as lymphoedema, diabetes, speech and

language therapy, dietetics and podiatry services. Staff explained how they requested other

members of the multidisciplinary team to assess patients by sending messages, or ‘tasks,’ through

the electronic records keeping system. Staff told us how they worked jointly with staff in the

respiratory and diabetes services to manage more complex patients on the caseload. The

specialist services offered training and support for staff in the integrated care team.

Staff reported that they had good working relationships with other teams and that there was easy

access to referral on to services or requests for advice.

The electronic records system was used by the majority of services and some GPs, which meant

that staff could see which other teams were involved in patient’s care and could see the other

team’s care record entries. This facilitated joined up and holistic care delivery.

Within teams such as the integrated care team, we were told that there were daily and weekly

handovers for sharing information about the caseload. In addition, there was a monthly meeting

with each of the GP practices in the team’s geographical patch. This comprised a group of staff,

including a nurse, therapist, pharmacist, and representatives from social care and mental health

services, met with the GP to jointly review any patients with complex needs. Staff told us that each

practice had a named therapist and community matron who would represent the integrated care

team at these meetings.

70

There was a referrals hub and a triage system where clinicians considered referrals to ensure they

were appropriate and to prioritise their urgency. Referrals could be made to the hub by nurses,

GPs and other health professionals. For some services, patients were able to self-refer, if they

were previously known to the service.

For specialist services such as the community neurology team, there was a need to have a

confirmed diagnosis of a neurological disease in order to access the service. In the integrated care

teams, referrals were received by email through a referrals hub and forwarded to nursing and

therapy staff who were on a rota to triage all new referrals to the service. There was a document to

support the triage process which identified suitable conditions that could be seen and any

exclusion criteria. Staff told us that they used their experience to allocate patients into different

categories, depending on the urgency of their condition. These categories were urgent (meaning

they should be seen on the same day), one week and four weeks. Managers told us that staff kept

protected time slots in their diaries on the electronic system to ensure that patients identified as

urgent, could be offered a same day appointment. This level of urgency aimed to avoid

unnecessary hospital admission through the delivery of rapid response care in the community.

Referrals to services were handled effectively with clear criteria and a multi-agency approach to

ensure people got the right care swiftly. For example, in the physiotherapy service, referrals were

received by email and triaged by senior clinical staff in order to review the appropriateness of the

referral and prioritise its urgency. There were criteria for three different categories of urgency:

• Priority one patients were those who were post-surgery or whose symptoms were so

severe they were off work or unable to sleep; these patients could be seen within two

weeks of referral.

• Priority two patients were those who were sub-acute and were still able to function despite

their symptoms; these patients were seen within six weeks of referral.

• Priority three patients were those with more chronic symptoms which were longer term and

stable problems; these patients were offered an appointment within 14 weeks of referral.

In the speech and language therapy, the service lead told us that referrals were triaged by a senior

therapist in each locality to identify the urgency of each referral.

In the community neurology team at Danesbury, staff told us that there was a holistic approach to

care and that they had introduced a joint assessment process for all new patients. Occupational

therapists and physiotherapists in the team worked together to complete the core assessment and

set joint patient goals. For patients with Parkinson’s disease and multiple sclerosis, the service

offered monthly ‘one stop shop’ appointments, where patients could be seen by the therapists and

specialist nurses at the same appointment.

In the musculoskeletal (MSK) triage service, patients with orthopaedic problems were referred by

GPs or consultants for triage and reviewed by extended scope practitioner (ESP) physiotherapists.

ESPs could determine treatment options including referral to orthopaedic consultants for possible

surgery. The MSK triage staff were able to request images such as x-rays and could offer injection

therapy for pain and inflammation and advice on exercises for strengthening. This meant that

some patients’ needs could be met through this service and avoid unnecessary referral to an

orthopaedic consultant.

Some teams, for example, integrated care included nursing and therapy staff. The community

neurology team also had psychology support and specialist nursing roles to support patients with

multiple sclerosis and Parkinson’s disease. The community neurology service employed a clinical

navigator for patients with rare or rapidly progressing neurological diseases. This enabled patients

71

referred to the service to be assessed at home quickly and referred on to different team members

and other support services as required. The clinical navigator linked in with local hospices, support

groups and charities, and social care services through monthly case conferences, where patients’

needs were reviewed and discussed to ensure they were being met.

We saw that there were multidisciplinary clinics for diabetes and podiatry, where patients would

see different types of staff at the same appointment. This reduced the need for unnecessary

appointments and enabled staff to work together to provide holistic patient care. Staff told us that a

diabetes consultant and diabetes specialist nurse visited each GP practice within the team’s

geographical patch to provide specialist education and review the clinical governance of

community diabetes care. There was a community pharmacist who worked alongside the diabetes

specialist nurses to review patient’s medications and provide education to the team.

In the hand therapy clinic, we saw that occupational therapists, physiotherapists and doctors

worked together to provide pathways of care. The team were in daily contact to ensure a

coordinated approach to patient care.

Health promotion

The service had an embedded approach to promoting self-management with patients. Staff had

received training in delivering a self-management programme to patients. Teams were prompted

to encourage patients to attend self-management programmes and reported on the number of

patients who took up the opportunity to attend. The community neurology team described how

they were considering incorporating the programme as a part of one to one therapy, or as an

online activity in order to increase uptake.

The lymphoedema service promoted self-management of the condition through the use of

compression hosiery, which patients could apply independently, rather than attending a clinic to

have their limb bandaged by a nurse.

We saw that most locations we visited had notice boards displaying a comprehensive range of

information on health matters. For example, we saw information on diabetes education

programmes, support groups for respiratory conditions, long term health conditions information

leaflets, and posters from local charities advising patients how to stay safe and warm during

winter.

The service offered a diabetes education programme known as DESMOND which delivered self-

management education modules, toolkits and care pathways for people with, or at risk of

developing, type 2 diabetes.

We saw a range of ‘myth busting’ posters in the physiotherapy clinic waiting area which

encouraged patients to self-manage conditions such as back and neck pain and arthritis. The

service had developed links with local gymnasiums to support patients to attend and take

responsibility for improving their own health.

Staff in the pulmonary rehabilitation service told us that they participated in public awareness days

called ‘healthfests’ and provided a stall at these events for information and advice about lung

diseases.

Staff told us that their core assessment templates included assessments of smoking, alcohol

intake and diet. There was a smoking cessation programme available which all staff could access

to refer patients on to.

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Some teams had key performance measures in place to screen patients for anxiety and

depression and refer on to additional mental health support services if wellbeing concerns were

identified.

The patient specific functional scale was used with all patients in the service. The scale was used

to encourage patients to identify their own goals for achievement which empowered them to

manage their own health and wellbeing.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the

Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health

and those who lacked the capacity to make decisions about their care.

There was a consent policy in place which community services adhered to. The policy was in date

and provided information on gaining, and recording consent for provision of care and treatment.

We observed that consent was recorded in the patient records that we reviewed.

The templates where risk assessments were recorded, had a section to indicate that patients were

in agreement with their care plans. There was a tick box on the electronic records system which

enabled staff to indicate at each visit, that patients had consented to delivery of the care plan.

During our observations of care, we heard staff asking patients if they were happy for treatments

to be carried out. Staff told us that it was usual practise to ask patients for verbal consent to

treatment prior to every intervention. We asked staff how they would ensure consent from patients

who were not able to verbally or otherwise, indicate their agreement to treatment. The integrated

care team explained that there was a learning disabilities team who could be contacted for advice

and support with patients who may need support in making decisions about their care. Staff in the

tissue viability service described how they would consider best interests decision making for

patients who lacked capacity, and told us that they would involve relatives in order to do this. We

saw that there was a capacity assessment template within the electronic records keeping system

which could be used if a patient’s capacity to consent to treatment was unclear. Staff in the service

were able to access community psychiatric nurse support from a neighbouring trust when

undertaking complex mental capacity assessments.

Staff in the community neurology team told us that they used pictures and cards with patients who

had communication difficulties in order to facilitate conversations about consent.

In the physiotherapy service, there was a consent policy for more invasive procedures, such as

acupuncture and injection therapy. In addition, there were acupuncture guidelines and an injection

therapy standard operating procedure, which documented consent requirements for these

treatments. Staff told us that there were forms completed by patients to indicate consent to these

treatments. The forms prompted staff to explain the intervention to patients, exclude any

contraindications to treatment and to discuss any risks of the procedure with patients. We saw

evidence of the use of these forms during our inspection. There were audits of compliance with

completion of consent forms. We asked to see results of these audits and saw that from June

2018 to September 2018 there was 100% compliance with the audit standards.

Mental Capacity Act and Deprivation of Liberty training completion

From April 2017 to March 2018 the trust reported that Mental Capacity Act (MCA) – level two had

been completed by 97.7% of staff within community services for adults, compared to a trust target

of 90%. This demonstrated that the service had exceeded compliance with the trust target for staff

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completion of mental capacity act training. All staff we spoke with during our inspection reported

that they had completed mental capacity act training.

The trust supplied updated MCA training data as of August 2018. By that date the trust had a

single level of MCA training. This had been completed by 94.6% of staff across community adults

as of that date, compared to the trust target of 90%.

The trust did not provide any data prior to inspection, for deprivation of liberty safeguard (DoLS)

training. However, following inspection, some data for DoLS training compliance was provided for

a limited number of community health services for adults. For the services for which data was

provided, this showed 95% of staff had completed it, which was in line with the trust target.

(Source: DR110, Mandatory training compliance August 2018)

Deprivation of Liberty Safeguards

From April 2017 to March 2018 the trust reported that no Deprivation of Liberty Safeguard (DoLS)

applications were made to the Local Authority for community services for adults.

(Source: Universal Routine Provider Information Request (RPIR) – P13 DoLS)

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Is the service caring?

Compassionate care

Staff cared for patients with compassion. Feedback from patients confirmed that staff

treated them well and with kindness.

All patients we spoke with were complementary of the care they had received. Patients and their

relatives told us staff were extremely friendly and helpful. Patients we spoke with used phrases

such as ‘fantastic care’ and ‘excellent service’ to describe their experience. One patient told us

that the staff in the podiatry clinic helped her ‘leave with a smile’ after her visit. The main

concerns patients raised with us were around high car parking charges and some long waits in

clinics, which did not run on time.

We saw thank you cards and letters displayed in many clinical areas which all provided positive

feedback from patients.

During our observations of care, we saw that patients were treated with respect and compassion.

We saw that staff were professional and polite and always introduced themselves by name to the

patients. Staff showed empathy with patients and took time to interact in a considerate and

sensitive manner. Staff took time to explain the service and offered opportunities for patients to

ask questions. Staff respected patients’ social, cultural, and religious needs.

We observed therapists and nurses using an encouraging attitude with patients, for example

praising their efforts with exercises or giving reassurance about their progress with treatments.

We saw a therapist treating a patient following amputation surgery and that the therapist was kind

and reassuring. We observed the therapist bend down to wheelchair height when they spoke with

the patient which demonstrated respect and compassion.

Staff respected patients’ privacy and dignity by ensuring seating in reception areas was far

enough away from the reception desk to maintain confidentiality. However, there was not a

privacy line at every reception for patients to stand behind whilst waiting for other patients to be

dealt with.

In one of the physiotherapy clinics we visited, we saw that cubicle areas had curtains which staff

drew during treatment sessions to maintain patient’s privacy. However, we noted that

conversations could be heard in the corridor, through the curtains which meant that a patient’s

privacy and dignity could be compromised. However, in other clinic areas there were individual

consultation rooms which were more soundproof and could be locked as an additional privacy

measure.

The NHS Friends and Family Test (FFT) is a satisfaction survey that measures patients’

satisfaction they have received. FFT data provided by the service showed from July 2018 to

September 2018 that an average of 98.6% of respondents would recommend the service.

Emotional support

Staff provided emotional support to patients to minimise their distress.

Staff throughout the different services understood the need for emotional support. We spoke with

patients and relatives who all felt that their emotional wellbeing was cared for. Staff had a good

awareness of patients with complex needs and those patients who may require additional support

during their visit to outpatient clinics, or within their home environment.

Patients we spoke with told us they knew who to contact if they had any concerns about their

care. Each patient seen in their own home had a nursing folder which contained information

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about the service they were receiving, which included contact details for the team during working

hours and for out of hours advice and support. We accompanied staff on some home visits and

saw staff took the time to get to know the patients and tailored their care to meet their individual

needs.

During clinic appointments we saw that staff spent time talking about a patient’s condition with

them and provided information and advice about their general health and wellbeing.

Initial assessments in most teams included a screening tool for anxiety and depression which

meant that staff could identify this need and refer patients on for additional assessment or

support as required.

The clinical navigator in the community neurology service was able to signpost patients to local

charities and voluntary organisations who could offer support and advice to patients with complex

or long-term conditions. This included a range of disease specific groups to support carers’

needs. We saw that notice boards in clinics had information on support groups for patients and

carers, for example for lung disease.

Understanding and involvement of patients and those close to them

Staff involved patients and those close to them in decisions about their care and

treatment.

Patients and relatives, we spoke with said they felt involved in their care. They had been given

the opportunity to speak with the staff looking after them and to ask any questions. All patients

we spoke with told us they were provided with a good, clear explanation about their condition. We

saw that patients using physiotherapy services were provided with written information about their

condition. Any recommended home exercises were printed as a personalised exercise

programme from a computer programme which provided patients with a diagrammatic

representation and written description of the recommended exercises.

We observed interactions between therapy staff and patients where exercises were explained

and demonstrated to patients to ensure they fully understood them.

We saw that staff discussed treatment plans with patients so that they were involved in their care

planning. We saw that therapy staff used a goal setting approach with patients and facilitated

conversations around realistic goal setting. Goals were documented in patient’s care plans once

they had been agreed. This approach encouraged patients to be involved in their care, feel

listened to and respected, and to make shared decisions about their treatment.

We observed that staff took time to listen to patients and adapted treatment approaches

considering patient feedback. For example, we saw a physiotherapist change a patient’s exercise

programme as they reported it was too strenuous. Another patient was offered attendance at a

back-pain class rather than one to one therapy as it was agreed they would find this more

motivating.

In the speech therapy clinic, we saw a staff member discuss a patient’s concerns with them at

length and ask questions which demonstrated they understood the impact of the symptoms on

that patient’s wellbeing.

We noted that staff used different methods to support communication in patients with any barriers

such as neurological impairment, or language spoken. We observed a physiotherapist speaking

slowly, using simple language and taking time to clearly explain a treatment to a patient who did

not speak much English. This meant that staff could be sure that patients understood their care

and treatment and could be involved in shared decisions about their care.

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Is the service responsive?

Planning and delivering services which meet people’s needs

The service planned and provided services in a way that met the needs of local people.

The service worked closely with commissioners, stakeholders and other providers to plan and

deliver integrated health and social care in a way that met the needs of local people. Adult

community services began a transformation process in November 2017, developed to meet the

health needs of the population across the county. There was an ongoing programme of work

underway to deliver integrated care through locality based multidisciplinary services.

Community nursing services worked alongside therapists in patch-based teams, where each

team was responsible for specified GP practices within the area and could meet the needs of the

local population. Services were provided across the whole county, although the East and North

Hertfordshire area was commissioned separately to the West of Hertfordshire area, meaning

there was some inconsistency in how services were delivered. There were a number of

integrated care or community adult health services teams across the county which operated as

geographical sub-teams to deliver patient needs led care. This ensured the right staff member

with the right skills was available to support patient care, wherever the patient lived within the

county. Staff in integrated teams visited patients at home to deliver both urgent and planned care.

Patients were prioritised which enabled patients being discharged from hospital or at risk of an

avoidable hospital admission, to be seen urgently. Rapid assessment, treatment and support was

available on the same day to ensure patients received appropriate care and rehabilitation in the

community. These services worked closely with acute hospital wards, GPs and social care to

provide responsive, personalised care. The multi-disciplinary team model was planned to ensure

patients received care tailored to their needs. The trust worked in partnership with local

commissioning bodies to review the demand and capacity of these services to ensure they met

the needs of the local population.

In addition, there were a range of clinic services available for specialities such as podiatry,

diabetes, and leg ulcers. These clinics were held in a variety of locations across the county to

facilitate ease of travel and attendance. This meant there was equity of service provision across

geographical patch based teams.

For speech and language therapy services and community neurology, patients could be seen at

home, in residential or nursing homes, or in a clinic, dependant on what environment was most

suitable to meet their needs. These types of specialist services were able to meet the needs of

patients with complex, long term needs, such as Parkinson’s disease, multiple sclerosis and

stroke.

Staff told us that the local equipment service was accessible, well stocked and responsive and

was able to deliver items of equipment such as hospital beds and hoists without delay when

required.

Staff told us that interpreting services were widely available to support the care of patients whose

first language was not English. The service could provide support over the telephone or could

arrange to do face to face visits to support staff during clinic appointments or home visits.

Meeting the needs of people in vulnerable circumstances

The service took account of patients’ individual needs.

Staff in all areas tailored their services in response to the complex needs of vulnerable patients,

for example, those living with dementia or neurological conditions. Staff in specialist services,

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such as the community neurology service, had additional training to understand the impact of

neurological conditions. They demonstrated knowledge of impairments that patients living with

neurological conditions may experience and used treatment approaches based on this to meet

individual patient’s needs. For example, staff explained how they used communication cards and

pictures to facilitate communication in order to understand patients’ needs.

Staff in the integrated care team told us about a dementia café they could refer patients and

carers to for support. The café was held at a local supermarket and was led by the community

psychiatric nursing team. Staff also reported that there was a mental health service who could be

contacted for advice and support, and who could perform joint home visits with staff, for patients

with complex needs.

We were told that there was a learning disabilities specialist team who were available to offer

support and advice to staff in other teams to support the needs of vulnerable individuals. For

example, staff told us about a purple book that the learning disabilities team could provide to

records patients preferences and individual care needs. This meant that all staff visiting the

patient could be aware of their specific needs. In addition, staff told us how they worked with

carers to ensure patient needs were identified and met.

In clinics we saw information posters entitled ‘information your way’ which advised patients that

information could be provided in different formats on request, for example, braille, large print,

easy read or different languages.

We saw that there was a facility on the electronic patient record system to alert staff to additional

requirements a patient may have, for example if they had a disability or communication support

needs.

We noted that the clinics we visited were accessible to patients with a physical disability, as

patient lifts were available and that there was ramped access to the health centres. However, not

all areas had automatic doors which could impede access for wheelchair users.

We noted that in the clinic rooms we visited, they were equipped with chairs and examination

beds suitable for patients of extreme excess body weight (obesity).

Access to the right care at the right time

Patients could access the service when they needed it. Waiting times from referral to

treatment and arrangements to admit, treat and discharge patients were in line with good

practice.

Referrals – IN RPIR

The trust has identified the below services in the table as measured on ‘referral to initial

assessment’.

The trust met the referral to assessment target in all of the 21 targets listed.

The trust did not provide separate details of the assessment to treatment times but commented

for all services that onset of treatment occurs at initial assessment.

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Name of in-patient ward

or unit

Days from referral to initial assessment Comments,

clarification National / Local

Target Actual (median)

Adult Bladder & Bowel

Care 126 (18 weeks) 49

Onset of treatment

occurs at initial

assessment

Adult Occupational

Therapy Service E&N

(Acute Therapies)

126 (18 weeks) 0

Onset of treatment

occurs at initial

assessment

Adult Physiotherapy

Service E&N (Acute

Therapies)

126 (18 weeks) 0

Onset of treatment

occurs at initial

assessment

Adult Speech & Language

Therapy 126 (18 weeks) 5

Onset of treatment

occurs at initial

assessment

Community Cardiology 126 (18 weeks) 5

Onset of treatment

occurs at initial

assessment

Community Respiratory

Service 126 (18 weeks) 8

Onset of treatment

occurs at initial

assessment

Diabetes 126 (18 weeks) 72

Onset of treatment

occurs at initial

assessment

Heart Failure Service 126 (18 weeks) 1

Onset of treatment

occurs at initial

assessment

ICROPS 126 (18 weeks) 66

Onset of treatment

occurs at initial

assessment

Leg Ulcer Service 126 (18 weeks) 19

Onset of treatment

occurs at initial

assessment

Lymphoedema Services 126 (18 weeks) 10

Onset of treatment

occurs at initial

assessment

MSK Physio & OT West 126 (18 weeks) 26

Onset of treatment

occurs at initial

assessment

MSK Physio E&N 126 (18 weeks) 43

Onset of treatment

occurs at initial

assessment

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MSK Triage E&N 126 (18 weeks) 89

Onset of treatment

occurs at initial

assessment

Neuro Rehab - Community 126 (18 weeks) 68

Onset of treatment

occurs at initial

assessment

Nutrition & Dietetics 126 (18 weeks) 14

Onset of treatment

occurs at initial

assessment

Pain Management &

Chronic Fatigue 126 (18 weeks) 50

Onset of treatment

occurs at initial

assessment

Podiatry MSK Low Risk 126 (18 weeks) 69

Onset of treatment

occurs at initial

assessment

Podiatry Service 126 (18 weeks) 63

Onset of treatment

occurs at initial

assessment

Pulmonary Rehab 126 (18 weeks) 29

Onset of treatment

occurs at initial

assessment

Skin Health Service 126 (18 weeks) 95

Onset of treatment

occurs at initial

assessment

(Source: CHS Routine Provider Information Request – CHS10 Referrals)

Data showed that for all services for which information was provided, there was compliance with

national targets for referral to assessment and referral to treatment times. Patients we spoke with

during our inspection told us they had been offered clinic appointments quickly, for example in

the podiatry, dietetics, and rheumatology services. However, during our inspection, staff in some

services told us that there were long waits for patients to be seen. For example, the tissue

viability service did not have target wait times to see patients as it was not a commissioned

service, however, they reported wait times of up to six weeks for initial assessments. Staff told us

that they had received verbal complaints from patients about the wait time for an appointment. A

nurse in the team explained that the team was very small and capacity was limited. However, the

introduction of dual nurse roles across community nursing and tissue viability was designed to

increase capacity and reduce waits for patients. Therapy staff in the community neurology service

told us that patients who were deemed to be a lower priority, were waiting between 18 and 25

weeks for a therapy assessment. However, there was a prioritisation system through the triage

process in order to identify patients with more urgent needs. Priority patients received a joint

physiotherapy and occupational therapy assessment which meant they had a holistic assessment

without delay, which avoided unnecessary repetition of work. Priority patients were those with an

acute relapse of their condition or those being discharged from residential beds who needed

continued rehabilitation in their own homes. In the physiotherapy clinic at Kingsway, staff told us

that priority three patients, who should have been seen within 14 weeks, were waiting around five

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months for a first appointment at the time of our inspection.

There was a single point of access or referrals hub for community adult services which processed

referrals and signposted them on to the appropriate service in line with service criteria. This

avoided any unnecessary delays in referrals reaching the right service. Clinical staff within

services then triaged referrals and prioritised them. Several services had triage systems in place

which meant that patients with urgent needs were able to be have their care and treatment

prioritised. For example, in the integrated care and community adult health services, patients

could be seen the same day if necessary. These were patients who were at risk of an

unnecessary hospital admission, if responsive care could not be provided in the community. In

the physiotherapy service, those patients with the most severe symptoms were categorised as

urgent and offered appointments within two weeks. Staff in these teams allocated staff to a daily

triage rota to ensure that referrals could be assessed for urgency without delay. Managers in

services that offered rapid response, told us that a system of protecting slots in staff diaries for

new urgent patient assessments, enabled them to be responsive to their care and treatment

needs.

Service leads in community adult health services explained that a daily conference call took place

with each locality team lead to identify any areas of high clinical demand. This call was used to

allocate staff across localities to ensure that caseloads could be safely managed and patients’

care needs could be met across the county.

We saw that in some clinics there was a sign at reception advising patients to contact staff if they

had been waiting beyond their appointment time. Although some clinics such as physiotherapy

and speech and language therapy, usually ran to time, we noted that some clinics had long wait

times beyond appointment times for patients to be seen. In the leg ulcer clinic that we visited,

patients we spoke with told us they had been waiting for up to one hour after their appointment

time. In the ophthalmic clinic waiting times were displayed, however the wait times were dated for

two days prior to the clinic date. The waits on that day had been up to three hours beyond

appointment times.

We asked the service for numbers of cancelled clinics within community adult services between

June 2018 and August 2018. They reported that a total of 2700 clinic rotas had been cancelled

during this time period. They commented that a large number of these clinics had been cancelled

due to a change of time due to appointments being booked in advance. They said that in some

cases another clinic was added to deal with demand, which meant that the original clinic would

show as a cancelled clinic. The service said that these numbers did not represent a failure to

perform agreed clinics and that their systems did not allow for the reason for cancellation to be

recorded.

The service collected numbers of occasions when appointments were not attended. From July

2018 to September 2018 the service reported that an average of 2.6% appointments were ‘did

not attend’ (DNA) appointments. The highest rate of DNAs was in the musculoskeletal

physiotherapy service (23%) and the lowest rate of DNAs was in the integrated community team

(0.05%). We asked the service for any information relating to standard operating procedures or

policies for management of DNAs in clinics but they did not provide any. We spoke with staff in

the physiotherapy service who told us that if patients did not attend appointments they did not

routinely contact them. However, if a patient made contact within two weeks of their appointment

date, a further appointment would be offered to them. If the patient did not get in touch following a

missed appointment, they would be discharged back to the GP and would need a re-referral to

the service in order to access the service.

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In the leg ulcer clinic and speech and language therapy service, staff reported that if patients did

not attend (DNA) for an appointment, they would record this on the electronic record keeping

system and contact the patient to offer them another appointment. If patients missed two

consecutive appointments they would be discharged back to the care of their GP.

In the integrated care services, patients were offered initial appointments by telephone and were

also sent a letter if they could not be contacted by telephone. If the service had not received

contact from the patient within two weeks of sending a letter, they were discharged from the

caseload and referred back to their GP.

The lymphoedema clinic reported that they received high rates of DNAs due to the nature of the

caseload; all patients had a diagnosis of cancer and as a result often had symptoms or side

effects of treatment which meant they could not attend appointments. Staff told us they were

introducing a text message reminder service to try and reduce the rate of DNAs. This system was

already in place in some services such as physiotherapy clinics.

Most clinics were delivered between the hours of 9am to 5pm, Monday to Friday, although the

lead for speech and language therapy told us that they offered evening and early morning

appointments to improve access for patients. Some services were available seven days a week,

such as the community adult health and integrated care team services. Since these services

offered a rapid response option, nursing staff worked on a rota to cover the service every day

from 8am to 10pm. Out of these hours, there was an evening and night nursing service available

for emergencies such as blocked catheters. Although the therapists worked over seven days,

they did not provide a full therapy service at weekends, as a trial of this had resulted in increased

waiting lists. Therapists did complete triage of new referrals and urgent new assessments during

the weekend.

Another way in which services worked to ensure people had timely access to treatments, was by

the use of staff skill mixing. For example, health care assistant staff had been trained to deliver

insulin therapy to stable diabetic patients. This initiative had been introduced to help relieve the

pressure on community nursing caseloads, so that qualified staff time could be released to

perform other nursing care. This meant that the length of time patients had to wait to be seen was

minimised.

The use of technology supported timely access to care and treatment, for example, the ability of

nursing staff in the leg ulcer clinic to access laboratory results through a shared electronic

system. The system was used by GPs to obtain results such as wound swab results. Since the

leg ulcer nurses were able to access these results directly, it meant that they could act on them

immediately. As the majority of staff were nurse prescribers this meant that patients had quicker

access to antibiotics if needed. One of the nursing staff stated that the access to the electronic

system containing laboratory results had improved the team’s productivity.

Learning from complaints and concerns

The service treated concerns and complaints seriously, investigated them and learned

lessons from the results, which were shared with all staff.

Complaints

From April 2017 to March 2018 there were 80 complaints about community services for adults.

The trust took an average of 25 days to investigate and close complaints. This is in line with their

complaints policy, which states complaints should be dealt with within 25 working days.

A summary of complaints within community services for adults by subject is below:

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Community Adults Total

Subject Number of complaints

All aspects of clinical treatment 31

Appointments, delay/cancellation (out-patient) 17

Admissions, discharge and transfer arrangements 9

Communication/information to patients (written and oral) 7

Attitude of staff 7

Others 6

Aids and appliances, equipment, premises (including access) 2

Appointments, delay/cancellation (in-patient) 1

Total 80

(Source: Universal Routine Provider Information Request (RPIR) – P52 Complaints)

The service had a clear process and policy in place for dealing with complaints, staff we spoke to

were aware of the complaints procedure. We saw information about how to raise a complaint was

available throughout community health services for adults, in the form of leaflets and posters. The

hospital website had a section detailing how to make a complaint. Complaints could be made in

person, by telephone, and in writing by letter or email. All patient held treatment folders kept by

patients in their homes contained information on how to make a complaint if they were unhappy

with the service they had received.

We saw that complaints were taken seriously and were investigated at a local level in the first

instance. Verbal complaints would be escalated to service leads who aimed to achieve a

resolution with complainants through a discussion about their concerns, in the first instance.

Managers told us that if patients weren’t happy with their response, they were supported to

escalate their complaint through the patient liaison and advice service (PALS).

Managers told us that they would discuss any complaints with staff at handovers and team

meetings. Staff told us that feedback about complaints and any learning was shared at team

meetings.

Locality leads told us that for their monthly meetings with the deputy general manager for the

business unit, they produced a CLIPPS (complaints, litigation, incidents, PALS, serious incidents

and safeguarding) report. This meant that complaints for all services across the business unit

were logged and discussed at a senior level, including the outcome and any identified learning.

Managers told us that they fed back any shared learning at service team meetings; we saw

minutes of these meetings which confirmed this.

We heard an example of how learning from a complaint had resulted in a change in the hand

therapy clinic. A patient had complained that the phones weren’t always answered if they tried to

call to make a change to their appointment. As a result, a voicemail system had been set up so

that patients could leave messages. There was a process in place for administrative staff to

check for messages regularly and pass them on to relevant staff.

Staff in the integrated care team told us about a complaint about the ordering of unsuitable

equipment for a patient over a weekend. They described how therapy leads had investigated the

complaint and discussed it with the staff members involved. As a result, some additional training

had been provided to the team and a written response was provided to the complainant.

Compliments

From April 2017 to March 2018, the trust received over 12,000 compliments; however, they did

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not provide the data by core service so we are unable to identify how many compliments were

received for community services for adults.

(Source: Universal Routine Provider Information Request (RPIR) – P53 Compliments)

Is the service well-led?

Leadership

The service had managers at all levels with the right skills and abilities to run a service

providing high-quality sustainable care.

There was a clear leadership structure within community health services where individual leaders

had identified responsibilities and reporting structures across the business unit.

Community health services sat in the business unit of adult services, which was sub-divided into

inpatient beds, community and specialist services. Within community services in the business

unit, we saw that services were divided into two areas, one for East and North Hertfordshire and

one for Hertfordshire Valley. This was in line with local commissioning arrangements as services

in the east and north of the county were commissioned by a different commissioning body to

those in the west (Hertfordshire Valley). Both areas had a deputy general manager, reporting to

the associate director of operations, who had oversight of the operational issues across both

areas. Each deputy manager was responsible for several locality managers who managed

integrated care or community adult health multidisciplinary teams, which were patch based. Each

team was aligned to a hub of GP practices for service delivery. The locality managers reported

directly up to the deputy general managers. The specialist services subdivision included clinics,

for example, diabetes and podiatry services, the community neurology service and

musculoskeletal physiotherapy services. We saw that there was a similar management structure

in these services with a deputy general manager across all specialist services. There were

mechanisms in place for the deputy general managers to report information up to senior leaders

in the executive team and to cascade information down to individual teams through the locality

leads. Each locality lead oversaw the therapy and nursing teams in their patch. There were

service leads, and clinical leads within each locality, who had overall responsibility for the day to

day delivery of the clinical services provided.

There was a lead allied health professional (AHP) in post and two clinical quality leads for

physiotherapy and occupational therapy. These posts sat in the quality directorate and provided

support to AHPs across the county. They reported to the director of nursing and quality. These

staff described a networked role responsibility which looked at consistency of practise across the

county and had input into service transformation such as the development of the integrated care

teams.

Integrated care teams had been developed in November 2017 as part of a service redesign and

were set up to deliver planned care, case management and same day response, in order to meet

the needs of the local population. The transformation had been commissioner led and was

necessary to address financial constraints within the local clinical commissioning groups (CCGs).

CCGs are clinically-led statutory NHS bodies responsible for the planning and commissioning of

health care services for their local area, including deciding what services are needed for diverse

local populations, and ensuring that they are provided. Locality leads were responsible for

facilitating integrated working between therapy and nursing services. Leads told us that there had

been a need to deliver services differently in the new integrated care model, in order for quality

services to be delivered sustainably. An example of this was the upskilling of health care

assistant staff to do additional tasks such as deliver insulin therapy, following completion of

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competency based training.

We saw that processes were in place for locality leads to work together across the business unit

and allocate resources flexibly to the area of greatest need. There was a daily conference call in

east and north Hertfordshire and Hertfordshire Valleys between the locality managers which

reviewed staffing levels and caseloads in each team. Staff were allocated to a neighbouring team

in order to facilitate sustainable service delivery.

Staff told us that their local leaders were very visible and approachable and took time to

communicate with them and listen to their concerns.

We heard that representatives of the executive team had attended training sessions delivered by

staff in the tissue viability service. Some staff told us that they had seen senior managers doing

walkarounds in their department which made them visible and approachable. Staff told us how

the senior executive team communicated with them weekly by email and sent video clip

messages out to all staff. We were shown an intranet page which had photographs of all the

executive team with their names and role, to help staff know who they were. One of the deputy

general managers told us that they were aware that staff had struggled with the recent

transformation of services, and recognised that they felt ‘done to’ and not listened to. In an

attempt for staff to feel more engaged, they had set up lunchtime sessions where lunch was

provided alongside a short presentation to update staff on any developments within the trust. At

these events staff were encouraged to identify what was going well and what they would like to

change, in order to make them feel listened to and engaged in change.

All staff we spoke with told us that they were well supported by their line managers and they were

able to meet with them regularly.

Managers told us about various leadership development opportunities within the service. All band

five and six staff worked to competency frameworks and within these were some leadership

competencies. For band seven and eight staff, there was a focus on leadership competencies as

a core part of their development. We were told that a year long ‘foundations in leadership’ course

was delivered internally which 20 staff could attend one day a month to develop leadership

knowledge and skills in preparation for senior posts. There were also masters courses in public

sector leadership and business administration available through local universities, for which

funding could be applied for through the NHS leadership academy.

Vision and strategy

The service delivered care based on the trust’s vision for what it wanted to achieve. The

vision was the focus of each service’s work and was embedded within the business unit.

There were workable plans to turn it into action, developed with involvement from staff,

patients, and key groups representing the local community.

There was a clear trust vision and set of five values which underpinned the work staff did every

day. Most staff were aware of the vision and values. We saw that the trust vision was displayed

as a screensaver on computers. We noted that the vision and values were on display on public

noticeboards in some of the locations that we visited. Staff we spoke with were unclear how the

vision and values had been developed and did not report having had an opportunity to contribute

to their development.

The trust vision was ‘to maintain and improve the health and wellbeing of the people of

Hertfordshire and other areas served by the trust’. As part of developing their strategy, the trust

had identified five top objectives to achieve the vision. These were aligned to the trust values

which managers told us were crucial to the way staff worked. The trust values were ‘care,

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respect, quality, confidence and improve’. All staff in the service received an annual appraisal

which incorporated the trust values when reviewing performance and identifying learning

objectives.

We asked one of the deputy general managers of integrated care services, if there was a local

strategy or set of objectives related to the trust vision and strategy. They told us that there were

not any local objectives but that the trust vision was embedded in the business unit and was the

focus of their work.

Culture

Managers across the service promoted a positive culture that supported and valued staff,

creating a sense of common purpose based on shared values.

All staff we spoke with in community health services said they felt respected and valued by their

managers and colleagues. Staff reported feeling positive about their job roles and feeling proud

to work in the service. Staff morale was high, and individuals described an ethos of working

together as a team to benefit patients. Managers told us they were proud of the staff in their

teams and that there was a culture of ‘growing’ and developing staff. Several managers talked of

teams being ‘great’, ‘fantastic’, ‘lovely’ and ‘committed’. They told us that staff worked together

well and supported each other and commented that staff retention was high.

We heard from one of the locality leads that they had recognised the need to offer staff more

flexible working arrangements in order to recruit and retain staff. They described being supportive

of staff working long days, twilight shifts or weekend working only, in an effort to manage

childcare or other caring commitments.

One staff member who had been off sick due to a long-term condition told us that their manager

had been particularly supportive of their return to work. They described how their role had been

adapted and that their manager had been ‘brilliant’.

One of the diabetes team managers told us that there were two away days held annually to help

with team building and promotion of a positive working culture.

Staff told us they felt safe at work and described lone working processes which had been

established to reduce lone working risks in accordance with the trust lone working policy. In some

teams that saw patients outside of core working hours, they explained that it was standard

practise to visit all new patients in pairs. Staff described tracking processes and buddy systems

within teams which ensured that all staff were accounted for as safe at the end of their working

day. Staff carried mobile phones which could be used to alert other staff if someone felt unsafe

and needed assistance. One team told us they had set up a closed social media group for team

members in order to facilitate tracking and staff safety. The electronic records keeping system on

staff laptops had a panic button facility which could be pressed by staff who felt at risk. This

feature alerted all staff users of the system that someone needed urgent assistance by sending

out a message to all staff through the system.

Staff told us that felt confident to raise concerns with managers and that they would be listened to

and taken seriously. They explained the process for raising and escalating concerns and talked

about the whistleblowing policy. Some staff we spoke with were aware that the organisation had

a freedom to speak up guardian, and could signpost us to finding further information about the

role on the intranet. We saw posters advertising the freedom to speak up guardian role on some

staff noticeboards during our inspection.

Staff at all levels had opportunities for personal and career development. Staff felt supported to

develop and managers told us they supported people to develop.

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Registered nurses and therapists had support to complete requirements for their revalidation or

reregistration.

87

Governance

The service generally used a systematic approach to continually improve the quality of its

services and safeguarding high standards of care by creating an environment in which

excellence in clinical care would flourish. However, there was not an effective approach

for regularly reviewing trust policies or for monitoring compliance with equipment testing

requirements.

There was a structured approach to governance within community adult services. There were

systems and processes in place to ensure regular review and accountability of service delivery.

There were mechanisms for cascading information upwards to the senior management team and

downwards to clinicians and other staff on the frontline. The deputy general managers told us

that they attended meetings with their associate director of operations, and other members of the

executive team, monthly, to review performance reports provided by the organisations business

unit. The deputy general manager then met together with the locality leads on a monthly basis for

a governance meeting to review operational performance. These meetings followed a set agenda

and used the business unit performance reports to review risks, staffing, finance, performance

and outstanding actions. Each locality lead produced a CLIPSS (Complaints, Litigation, Incidents,

PALS, Serious incidents and Safeguarding) report for this meeting which was reviewed and

discussed. Locality leads then met with team leads for each service and reviewed an action log

which served as the meeting agenda. Individual teams met together with their team or service

lead regularly and followed a set agenda for the meetings, which were minuted and shared with

all staff. We saw that the agenda included service updates, operational issues, staffing, risks,

training and a review of the locality CLIPSS reports.

Managers had access to governance systems that enabled them to monitor the quality of care

provided. This included the provider’s electronic incident reporting system and electronic staff

record system (which provided oversight of training and appraisal compliance, and staffing

levels). Service leads used these systems to develop an overview of any recurring themes or

issues that was shared at monthly team meetings. Clinical policies and guidelines were available

for all staff via the intranet. Staff showed they knew how to access relevant policies. However,

during our inspection we saw that two of the policies we reviewed were overdue for review.

These were the resuscitation and management of urinary catheters policies. We asked the

service if there were more up to date versions of these policies and were told that both policies

were under review. They told us that staff were reminded on the trust’s intranet site that all

policies remain applicable for implementation, including those that had an overdue review date.

They also told us that there was a programme of follow-up for all policies including those that

were due and overdue for review. However, since the resuscitation policy was seven years

overdue for review and the management of urinary catheters policy was four years overdue, this

meant that we could not be assured that there was an effective system for regularly reviewing

policies.

During our inspection we found several items of equipment that were overdue for annual testing.

Additionally, information requested following inspection showed that there were large amounts of

equipment on the maintenance log that were overdue for testing. Staff in community adult

services told us that all medical devices were managed by the medical devices team. They told

us that this team had an asset list of all medical devices which was maintained and recorded and

used to schedule and record all maintenance activity performed. However, data provided by the

service did not evidence that this system was effective. The service stated that it had been

recognised there was a need to improve maintenance compliance and ensure that all services

had accurate and timely reporting on the maintenance compliance of medical devices within their

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area. They reported that there was a project underway to provide live reporting of this information

to services and to include summary reports of equipment compliance in all monthly business unit

performance reports. At the time of inspection, we did not find that managers had processes in

place for oversight of equipment maintenance compliance.

All staff had a clear understanding of their roles and understood what they were accountable for

and to whom. Staff were supported in their daily role and were clear of expectations to report

incidents and concerns.

Management of risk, issues and performance

The service had effective systems for identifying risks, planning to eliminate or reduce

them, and coping with both the expected and unexpected.

We saw that the service had systems in place for identifying, recording and managing risks.

Service leads and locality leads were able to tell us what their current risks were and we saw that

these were documented on a local risk registers. Leads reported that the biggest risks were

staffing levels, although there were mitigating actions in place to address this and reduce the

impact on services as far as possible. Local risk registers used a risk assessment framework to

score risks. Identified risks were scored on a five by five matrix for likelihood and severity of the

risk, where the maximum score was 25. These risk scores, were then ‘RAG’ rated to indicate the

severity; RAG rating uses a red, amber green traffic light system to indicate the severity of the

risk score. Serious risks were those scoring 15 to 25, high risks scored eight to 12, moderate

scored four to six risks and low risks one to three. On the community adult service risk registers

we saw that there were three high risks identified, which were around staffing, delayed transfers

of care, and the lack of a skin service clinical specialist lead. Each of these risks had a

description of the risk and likely impact, assurances in place, action to mitigate the risk, and gaps

in assurance, and a target risk level to be achieved with target dates. We were told that the risk

register was reviewed at locality lead meetings and progress against achievement of reduced risk

scores was discussed and documented.

We observed staff in a leg ulcer clinic having to carry out treatments with some level of manual

handling risk due to the environment and equipment constraints of the service. However, we saw

that managers had risk assessed the tasks staff carried out, which documented the level of risk

and mitigating actions to reduce the risk.

Managers told us that there was a serious incident panel responsible for reviewing all serious

incident investigations and monitoring completion of recommended action plans. The panel had

oversight of any themes and learning from serious incidents which could be shared with staff

through locality and service lead meetings.

There were processes for regularly reviewing performance within community adult services.

Locality managers met monthly with the deputy general managers and reviewed service action

logs, staffing, performance and CLIPSS (complaints, litigation, incidents, PALS, serious incidents

and safeguarding) reports. Performance issues were discussed and escalated to the executive’s

team business performance meeting through the deputy general managers. Each service had a

set of key performance indicators to achieve in line with their service contract, for example on

compliance with waiting times or treatment outcomes

Each service completed monthly audits include a ‘dip test’ of records and a snapshot of safety

thermometer data for each caseload one day a month. Results were collated by locality leads

and any themes identified for discussion and sharing. There was an outcome measure used

across all services in the business unit, which measured patient’s functional outcomes. The data

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from this measure was reported and reviewed by each service as an additional method of

monitoring service performance.

There was a winter pressures management plan in place which was based on processes already

in place to review, prioritise and plan consistent delivery of services across the county. We heard

that there was a daily or weekly conference call set up to review caseloads and staffing levels

based on the operational pressures escalation level (OPEL) status declared for each service.

Systems were in place to allocate resources to the areas of greatest need by using the workforce

flexibly. This meant that older people and people in vulnerable circumstances would continue to

receive care at a safe level.

Managers told us that there was always a senior manager on call for the trust who could be

contacted at weekends or evenings for staff to escalate any concerns or potential risks. The

executive on call would be contacted in the event of any major incident.

Information management

The service collected, analysed, managed and used information to support all its

activities, using secure electronic systems with security safeguards.

Information was collected by services as key performance indicators (KPIs) to provide evidence

to commissioning bodies that services were compliant with targets. This information was collated

through electronic care record systems. Performance measures were in place and were routinely

reported and monitored.

We saw that business unit performance reports were compiled for each service, which were used

to share information at monthly operational performance meetings. The reports were used to

identify any service quality issues alongside the CLIPSS report data. Data for the reports was

reported directly from the electronic records system which meant that the data was valid, reliable

and relevant and was easily accessible. Action logs were in place to ensure that any quality

issues were monitored and regularly reviewed.

Information technology systems were used to process referrals and to manage caseloads and

waiting lists. These systems held patient information which could be accessed by clinical staff

across different services through a password protected process. This ensured secure sharing of

patient identifiable data in line with data security standards.

We saw that services participated in a range of national audits, such as the sentinel stroke

national audit programme (SSNAP) and the national diabetes audit, and submitted data to

external bodies in line with requirements.

Engagement

The service engaged with patients, staff and the public to plan and manage appropriate

services, and collaborated with partner organisations effectively.

Services regularly collected friends and family test (FFT) data from patients. We saw FFT

comment cards available at several clinic locations, which patients were encouraged to complete.

We saw ‘tell us what you think’ posters displayed in clinic rooms, to encourage patients to provide

feedback on services.

One of the deputy general managers reported that the last staff satisfaction survey had

highlighted that staff were struggling with recent changes implemented in services as they did not

feel listened to or able to contribute to decisions. This had been recognised and there were now

lunchtime sessions held for staff in each locality with the deputy general manager. These

sessions gave staff an opportunity to hear locality and trust updates and to tell managers about

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what was going well, what they were finding difficult and a chance to share ideas. There was an

output from these sessions to recognise the discussions, in the form of, ‘you said, we did’

posters. Examples were given of changes made as a result of these sessions, including the

introduction of patient satisfaction surveys built into the telephone system for the referral hub, and

the review of safe working systems during nursing twilight shifts. There was a clear agenda from

managers to use these sessions to demonstrate to staff that they were being listened to and to

make them feel engaged in change.

Allied health professional leads explained how they had worked closely with therapy staff during

the transformation of adult services to ensure that staff were engaged and involved in the

changes.

Staff in the tissue viability service told us that they were encouraged to be part of service

improvements and gave an example of how a triage process was being implemented based on

an idea from one of the team.

Therapy staff in the integrated care team told us that they were being supported to develop a falls

clinic and falls class by their manager, following making the suggestion in order to reduce waiting

lists.

Therapy staff in the community neurology service told us that managers were supportive of

service improvements and described how a member of the team had implemented a change in

the type of splinting materials used in the service. The staff member had identified the resource

implications, which they presented to managers who agreed to finance the new equipment

required. Managers were also supportive of additional staff training in order to facilitate

implementation of the change.

We heard that patients were involved in making decisions about their treatment through a joint

goal setting process led by staff. During our inspection we saw that therapists routinely asked

patients what they wanted to achieve and had discussions to agree and set patient centred goals.

We heard about local development boards within the trust which were aimed at engaging patients

in the development of services and to gather service user feedback on any changes

implemented. The boards included representatives from Hertfordshire community NHS trust,

GPs, social care, other local organisations and patient representatives. We were told that he

meetings were held monthly in each locality.

Staff in the community neurology service told us how patients had been involved with staff in the

development of a case of need for a respiratory pathway. Patients had met with staff to evidence

the need for a local pathway, which was being submitted to commissioning bodies.

There was a patient experience group within the trust which met with members of the trust board

in order to seek views, share feedback and shape services.

The community neurology service explained how they invited patients who had previously used

the service to work with them in delivering self-management programmes. Patients were asked to

share their experiences and provide peer support to others. The service had also involved

patients in feedback on the Parkinson’s diseases exercise programme (STABLE) which the team

had developed. They used questionnaires and focus groups to gather feedback which they used

to influence development of the programme. The service hoped to receive funding to complete a

research study of the STABLE programme and had involved two patients in the process, naming

them as research associates on the bid.

Physiotherapists in the musculoskeletal triage service told us how they worked closely with

orthopaedic consultants from the acute trust in order to review complex referrals and ensure they

91

were seen by the most appropriate service. The service told us they were building links with local

gymnasiums so they could advise patients on where they could go to continue self-management

of their condition after therapy sessions had been completed.

The integrated care team met with GP practices in each locality monthly which provided an

opportunity to develop positive and collaborative working relationships across service providers

to deliver patient needs led services. The team invited representatives from social care and the

voluntary sector to case conference meetings which enabled services to work together to identify

and support patient’s needs in the community. The neurological navigator described how they

worked collaboratively with consultants, social care, palliative care services and local charities to

provide information and support to service users.

The trust had an annual staff awards ceremony, where staff were recognised who demonstrated

achievement of the trust values.

Learning, continuous improvement and innovation

The service was committed to improving services by learning from when things went well

and when they went wrong, promoting training, research and innovation.

We heard about a range of service improvements and innovations within community adult

services. For example, in the tissue viability service we were told how the lead was implementing

the use of a new pressure risk holistic assessment tool called PURPOSE -T. This had followed a

pilot of the use of the tool which had received positive feedback. Staff were receiving training and

templates for documenting use of the tool were being developed with the aim of it being fully

implemented in November 2018.

In the diabetes service there had been innovative work to ensure the delivery of the DESMOND

(diabetes education and self-management for ongoing and newly diagnosed) programme was

widely accessible to patients. Increased numbers of programmes were being delivered, including

some on Saturdays to improve access to patients who worked. In addition, a special DESMOND

group for patients with a learning disability, and their carers had been implemented. The diabetes

service held virtual clinics to provide advice and support to GPs about diabetes management.

The clinics reviewed patient’s care records and made recommendations to GPs, which avoided

the need for additional face to face appointments for patients. The service had reviewed the skill

mix required for different tasks within the nursing service and had established a process for

health care assistants to deliver insulin to stable diabetic patients. This released registered nurse

time to deliver more complex care and enabled health care assistants to develop new skills within

their role. The process was competency based and had criteria and standard operating

procedures for staff to follow. The innovation was unique and had been submitted as a

nomination for the trust’s annual leading light awards. These awards had been developed to

celebrate, recognise and reward individual staff or teams going the extra mile for their patients.

There was a culture of improvement and innovation within services. Several staff members had

been supported to complete additional training such as acupuncture and injection therapy

training. Some staff had completed additional training for them to hold nurse prescriber roles

within teams. A number of support staff had completed associate practitioner training

programmes at local universities. There were a number of qualified clinicians who had completed

Master’s level modules at university through the support of the trust.

The community neurology service had developed an exercise programme for Parkinson’s

disease patients which had been nominated for a Parkinson’s UK, Parkinson’s excellence

network award. The service was seeking research funding to do a randomised controlled trial of

92

the programme.

Managers told us that there was a process for learning from reviews such as mortality reviews.

They explained that in the event of an unexpected death, a senior clinician reviewed the care

records and then the information was presented at a mortality review panel led by the director of

nursing. Any learning identified was then shared with teams through the deputy general

managers and locality managers.

93

Community inpatients services

This evidence appendix provides the supporting evidence that enabled us to come to our

judgements of the quality of service provided by this trust. It is based on a combination of

information provided to us by the trust, nationally available data, what we found when we

inspected, and information given to us from patients, the public and other organisations. For a

summary of our inspection findings, see the inspection report for this trust.

Hertfordshire Community NHS Trust provides NHS healthcare services to a population of 1.2

million people in Hertfordshire and West Essex. The trust provides community-based services for

adults and older people, children and a range of ambulatory and specialist care services. They

serve the communities of Broxbourne, Dacorum, East Hertfordshire, Hertsmere, North

Hertfordshire, St Albans, Stevenage, Three Rivers, Watford and Welwyn/Hatfield.

Hertfordshire Community NHS Trust (HCT) manages eight inpatient units situated in five

locations. The inpatient units are geographically spread across Hertfordshire and are

commissioned by three different organisations.

The locations the community inpatient units are based are:

• Bishops Stortford – Hertfordshire and Essex inpatient unit

• Hemel Hempstead – St Peters and Simpson inpatient units

• Potters Bar – Potters Bar community hospital inpatient unit

• Watford – Langley house which includes Holywell and Midway inpatient units

• Welwyn Garden City – Queen Victoria Memorial and Danesbury inpatient unit

The trust provides 185 intermediate care rehabilitation beds and additionally, stroke and

neurological rehabilitation beds. They also deliver a patient pathway under ‘Pathway 3’. Pathway

3 is for patients being discharged home for assessments, and is used for more complex patients,

and particularly for continuing health care assessments which require a multi-agency approach

and involve social care providers. This pathway is organised through Simpson inpatient unit.

Patients in the region are allocated beds via the county community bed bureau, which is a central

access hub for all community hospital bed based units.

We carried out this unannounced inspection 18 – 21 September and 27 September 2018. We

inspected the Hertfordshire and Essex inpatient unit; St Peters and Simpson inpatient units;

Holywell and Midway inpatient units and Danesbury inpatient unit. At Potters Bar, we looked at

medicines management only.

During the inspection, we spoke with 25 staff of various grades including service leads, matrons,

therapy managers, ward sisters, nurses, student nurses, therapists, doctors and housekeeping

staff. We spoke with eight patients and three relatives, observed care and treatment and looked

at 10 patients’ medical and nursing records and 24 patients’ prescription charts. We also looked

at 18 do not attempt cardio pulmonary resuscitation records.

The service was last inspected in April 2016 and at that inspection the community inpatient

service was rated good for safe, effective, caring, responsive and well led. During this inspection,

we looked at the changes and considered any progress that had been made within the

community inpatient services.

94

Facts and data about this service

Information about the sites which offer community inpatient services at this trust, is shown in the

table below. The table only includes the sites to be inspected.

Location site name Team/ward/satellite name Number of inpatient beds

Danesbury Home Adult neurological centre inpatient

unit 1

Hemel Hempstead

General Hospital Simpson ward 21

Hemel Hempstead

General Hospital St Peters ward 20

Hertfordshire and

Essex Hospital Inpatient unit 28

Langley House Holywell neurological rehabilitation

inpatient unit 16

Langley House Langley house inpatient unit

(Midway) 32

Potters Bar Community

Hospital Inpatient unit 29

Queen Victoria

Memorial Hospital Intermediate care inpatient unit 22

Sopwell and Langton wards at St Albans City Hospital, which closed in April and July 2017

respectively, are excluded from the table above and most other data sets in this report where a

site-level breakdown is available.

The trust reported that two clinics are held each month at Danesbury Home. No clinics are held at

the other community inpatient locations.

(Source: Routine Provider Information Request (RPIR) Universal P2 – Sites)

95

Is the service safe?

Mandatory training

While the service provided mandatory training in key skills to staff not all medical staff had

completed all the required mandatory training. Nursing staff across the inpatient units had

completed most of their mandatory training.

The service had a mandatory training programme for all staff. This included topics such as

infection prevention and control, moving and handling, fire evacuation, conflict resolution, and

information governance. The mandatory training programme was tailored to the skill requirement

of staff and was dependent upon their role. For example, clinical staff received training in manual

handling of patients, which non-clinical staff were not required to undertake.

The trust set a target of 90% for completion of mandatory training, except for health and safety

and information governance training, where the target was 95%. During our inspection in April

2016, we saw that most of the inpatient units were at, or close to their mandatory training target,

except the Hertfordshire and Essex hospital where compliance was 78% overall.

Most of the inpatient wards had achieved 90% compliance overall, except Potters Bar where

overall compliance was 85%. Information provided by the service after our inspection showed

there were individual topics at some units where the trust target was not met. For example, at

Potters Bar, resuscitation level two was 52% and conflict resolution was 78%, fire safety at Hemel

Hempstead Hospital was 76% and manual handling people 75%, at Hertfordshire and Essex

hospital.

We were not provided with updated figures for resuscitation level three. Resuscitation level three

was a requirement for all registered nurses, however at Potters Bar only 83% of nurses had this

training. Throughout the service, the overall compliance rate for resuscitation level three was 84%.

The overall compliance for health and safety training was 73%.

Medical staff training targets were not met for three out of six mandatory topics. Compliance to

resuscitation level three training was 77% and equality and diversity training was 33%.

Managers told us their mandatory training figures were higher now than when the information was

provided to us in March, although they could not show us this during our inspection. A senior

manager also told us there was a delay in uploading the training data into the electronic system

and that their learning and development team were aware of this delay and were trying to rectify it.

Some training was provided using e-learning courses, and some training was through face-to-face

sessions. Staff could access e-learning courses at work or at home. If staff completed training at

home in their own time, they were reimbursed for it.

A breakdown of compliance for mandatory courses as of March 2018 for medical/dental and

nursing staff in community inpatient services is shown below:

Mandatory Training completion

The trust set a target of 90% for completion of all mandatory training courses except for health and

safety and information governance, which both had a target of 95%.

Trust wide

The breakdown of compliance for mandatory courses for staff in community health inpatient

services from April 2017 to March 2018 is shown below.

96

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Manual handling - object 27 28 96.4% 90% Yes

Equality and diversity 293 305 96.1% 90% Yes

Conflict resolution 247 269 91.8% 90% Yes

Information governance 282 308 91.6% 95% No

Infection prevention (level 2) 254 279 91.0% 90% Yes

Fire safety 313 353 88.7% 90% No

Manual handling - people 243 275 88.4% 90% No

Resuscitation - level 2 214 253 84.6% 90% No

Resuscitation - level 3 111 133 83.5% 90% No

Health and safety 226 308 73.4% 95% No

In community health inpatient services, the trust’s training targets were met for four of the 10

mandatory training modules for which staff were eligible.

The trust supplied updated mandatory training data as of August 2018. The breakdown by training

module for staff across community inpatients as of that date is shown in the table below. Please

note that the health and safety training module was not included in the updated data. In addition,

some other training modules had been amalgamated or renamed.

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Fire 55 56 98.2% 90% Yes

Infection Control Mandatory 240 268 89.6% 90% No

Information Governance 267 298 89.6% 95% No

Equality and Diversity 266 298 89.3% 90% No

Conflict Resolution 236 271 87.1% 90% No

Fire Evacuation 248 286 86.7% 90% No

Resuscitation 212 265 80.0% 90% No

Moving and Handling 207 259 79.9% 90% No

In community health inpatient services, as of August 2018 the trust’s training targets were met for

one of the eight mandatory training modules for which staff were eligible.

(Source: DR110, Mandatory training compliance August 2018)

Mandatory training completion by module – qualified nursing staff – trust wide

The breakdown of compliance for mandatory courses for qualified nursing staff in community

health inpatient services from April 2017 to March 2018 is shown below.

Name of course

Number of

staff

trained

Number of

eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Manual handling - object 3 3 100% 90% Yes

Resuscitation - level 2 31 32 96.9% 90% Yes

97

Equality and diversity 115 119 96.6% 90% Yes

Infection prevention (level 2) 111 120 92.5% 90% Yes

Conflict resolution 104 113 92.0% 90% Yes

Manual handling - people 106 116 91.4% 90% Yes

Information governance 109 120 90.8% 95% No

Fire safety 121 135 89.6% 90% No

Resuscitation - level 3 72 81 88.9% 90% No

In community health inpatient services, the trust’s training targets were met for six of the nine

mandatory training modules for which qualified nursing staff were eligible. Resuscitation – level 3

had the lowest completion rate with 88.9%, compared to the 90% trust target.

The trust supplied updated mandatory training data as of August 2018. The breakdown by training

module for qualified nursing staff across community inpatients as of that date is shown in the table

below. Please note that the health and safety training module was not included in the updated

data. In addition, some other training modules had been amalgamated or renamed.

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Fire 16 17 94.1% 90% Yes

Infection Control Mandatory 91 98 92.9% 90% Yes

Information Governance 89 98 90.8% 95% No

Fire Evacuation 85 94 90.4% 90% Yes

Equality and Diversity 86 98 87.8% 90% No

Conflict Resolution 85 98 86.7% 90% No

Resuscitation 76 94 80.9% 90% No

Moving and Handling 74 94 78.7% 90% No

In community health inpatient services, as of August 2018 the trust’s training targets were met for

three of the eight mandatory training modules for which qualified nursing staff were eligible.

Mandatory training completion by module – qualified nursing staff – Danesbury Home

community inpatient services

A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for

qualified nursing staff in community health inpatient services at Danesbury Home is shown below:

Name of course

Number of

staff

trained

Number of

eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Conflict resolution 15 15 100% 90% Yes

Equality and diversity 15 15 100% 90% Yes

Infection prevention (level 2) 15 15 100% 90% Yes

Fire safety 29 30 96.7% 90% Yes

Resuscitation - level 2 16 17 94.1% 90% Yes

Manual handling - people 14 15 93.3% 90% Yes

Information governance 13 15 86.7% 95% No

98

At Danesbury Home community inpatient services, the trust’s training targets were met for six of

the seven mandatory training modules for which qualified nursing staff were eligible. Information

governance was the only module where the training target had not been met.

Mandatory training completion by module – qualified nursing staff - Hemel Hempstead

General Hospital community inpatient services

A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for

qualified nursing staff in community health inpatient services at Hemel Hempstead General

Hospital is shown below:

Name of course Number of

staff trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Manual handling - people 24 25 96.0% 90% Yes

Equality and diversity 23 25 92.0% 90% Yes

Infection prevention (level 2) 23 25 92.0% 90% Yes

Resuscitation - level 3 23 25 92.0% 90% Yes

Conflict resolution 21 25 84.0% 90% No

Information governance 21 25 84.0% 95% No

Fire safety 19 25 76.0% 90% No

At Hemel Hempstead General Hospital community health inpatient services, the trust’s training

targets were met for four of the seven mandatory training modules for which qualified nursing staff

were eligible. Fire safety training module had the lowest completion rate with 76.0%, compared to

the 90% trust target.

Mandatory training completion by module – qualified nursing staff - Hertfordshire and

Essex Hospital community inpatient services

A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for

qualified nursing staff in community health inpatient services at Hertfordshire and Essex Hospital

is shown below:

Name of course Number of

staff trained

Number of

eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Conflict resolution 12 12 100.0% 90% Yes

Equality and diversity 14 14 100.0% 90% Yes

Information governance 15 15 100.0% 95% Yes

Manual handling - people 14 15 93.3% 90% Yes

Resuscitation - level 3 9 10 90.0% 90% Yes

Infection prevention (level 2) 13 15 86.7% 90% No

Fire safety 13 15 86.7% 90% No

At Hertfordshire and Essex Hospital community health inpatient services the trust’s training targets

were met for five of the seven mandatory training modules for which qualified nursing staff were

eligible.

Mandatory training completion by module – qualified nursing staff – Langley House

community inpatient services

A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for

qualified nursing staff in community health inpatient services at Langley House is shown below:

99

Name of course Number of

staff trained

Number

of eligible

staff

Completion

rate

Trust

target

Met

Yes / No

Manual handling - people 15 15 100.0% 90% Yes

Equality and diversity 15 15 100.0% 90% Yes

Fire safety 13 15 86.7% 90% No

Resuscitation - level 3 13 15 86.7% 90% No

Infection prevention (level 2) 13 15 86.7% 90% No

Information governance 13 15 86.7% 95% No

Conflict resolution 11 13 84.6% 90% No

At Langley House community inpatient services, the trust’s training targets were met for two of the

seven mandatory training modules for which qualified nursing staff were eligible.

Mandatory training completion by module – qualified nursing staff – Potters Bar

Community Hospital community inpatient services

A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for

qualified nursing staff in community health inpatient services at Potters Bar Community Hospital is

shown below:

Name of course

Number

of staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Fire safety 18 18 100% 90% Yes

Equality and diversity 17 18 94.4% 90% Yes

Infection prevention (level 2) 17 18 94.4% 90% Yes

Information governance 17 18 94.4% 95% No

Conflict resolution 16 18 88.9% 90% No

Resuscitation - level 3 15 18 83.3% 90% No

Manual handling - people 14 18 77.8% 90% No

At Potters Bar Community Hospital community health inpatient services, the trust’s training targets

were met for three of the seven mandatory training modules for which qualified nursing staff were

eligible.

Mandatory training completion by module – qualified nursing staff – Queen Victoria

Memorial Hospital community inpatient services

A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for

qualified nursing staff in community health inpatient services at Queen Victoria Memorial Hospital

is shown below:

Name of course

Number

of staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Equality and diversity 13 13 100.0% 90% Yes

Information governance 13 13 100.0% 95% Yes

Manual handling - people 13 13 100.0% 90% Yes

Fire safety 13 13 100.0% 90% Yes

Conflict resolution 12 13 92.3% 90% Yes

Resuscitation - level 3 12 13 92.3% 90% Yes

100

Infection prevention (level 2) 11 13 84.6% 90% No

At Queen Victoria Memorial Hospital community inpatient services, the trust’s training targets were

met for six of the seven mandatory training modules for which qualified nursing staff were eligible.

Infection prevention was the only module where the completion target was not met.

Mandatory training completion by module – medical staff – trust wide

The mandatory and statutory training data show a small number of medical staff in community

inpatient services. This is not consistent with the vacancy, turnover and sickness data supplied by

the trust, which show no medical staff in community inpatient services.

The data show medical staff working in the community inpatient services at Hemel Hempstead

General Hospital and Potters Bar Community Hospital only.

It should be noted that, because of the small numbers involved, at site level there were only one or

two members of medical staff eligible for each module.

The breakdown of compliance for mandatory courses for medical staff in community health

inpatient services from April 2017 to March 2018 is shown below.

Name of course

Number

of staff

trained

Number

of staff

eligible

Completion

rate

Trust

target

Met

Yes / No

Conflict resolution 2 2 100.0% 90% Yes

Information governance 3 3 100.0% 95% Yes

Infection prevention (level 2) 3 3 100.0% 90% Yes

Resuscitation - level 3 3 4 75.0% 90% No

Fire safety 2 3 66.7% 90% No

Equality and diversity 1 3 33.3% 90% No

In community inpatient services the trust’s training targets were met for three of the six mandatory

training modules for which medical staff were eligible.

Mandatory training completion by module – medical staff - Hemel Hempstead General

Hospital community inpatient services

A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for

medical staff in community health inpatient services at Hemel Hempstead General Hospital is

shown below:

Name of course

Number

of staff

trained

Number

of staff

eligible

Completion

rate

Trust

target

Met

Yes / No

Resuscitation - level 3 2 2 100.0% 90% Yes

Information governance 2 2 100.0% 95% Yes

Conflict resolution 1 1 100.0% 90% Yes

Infection prevention (level 2) 2 2 100.0% 90% Yes

Equality and diversity 1 2 50.0% 90% No

Fire safety 1 2 50.0% 90% No

At Hemel Hempstead General Hospital community health inpatient services, the trust’s training

targets were met for four of the six mandatory training modules for which medical staff were

101

eligible. Only one of the two eligible medical staff had completed the equality and diversity and fire

safety training modules.

Mandatory training completion by module – medical staff – Potters Bar Community

Hospital community inpatient services

A breakdown of compliance for mandatory training courses from April 2017 to March 2018 for

medical staff in community health inpatient services at Potters Bar Community Hospital is shown

below:

Name of course

Number

of staff

trained

Number

of staff

eligible

Completion

rate

Trust

target

Met

Yes / No

Fire safety 1 1 100.0% 90% Yes

Information governance 1 1 100.0% 95% Yes

Conflict resolution 1 1 100.0% 90% Yes

Infection prevention (level 2) 1 1 100.0% 90% Yes

Resuscitation - level 3 1 2 50.0% 90% No

Equality and diversity 0 1 0.0% 90% No

At Potters Bar Community Hospital community health inpatient services, the trust’s training targets

were met for four of the six mandatory training modules for which medical staff were eligible.

Only one of two eligible medical staff had completed resuscitation level 3 training. The one

member of medical staff eligible for equality and diversity training had not completed it.

(Source: Universal Routine Provider Information Request (RPIR) – P40Training)

Staff were responsible for booking and completing their own mandatory training. However, ward

managers told us that they monitored compliance and reminded staff about completing their

mandatory training.

Staff completed mandatory training in dealing with medical emergencies such as resuscitation

level 2 and level 3. Level 2 resuscitation was for healthcare assistant and therapist staff, and level

3 was for registered nursing staff. The resuscitation training included basic life support and

intermediate life support knowledge and automated external defibrillation(AED) training. Not all

nursing and medical staff were compliant with their resuscitation training.

We were told that nursing staff on the community inpatient wards had received education on

recognising sepsis as part of recognising deteriorating patients training. Following the inspection,

the trust provided evidence of education resources that were communicated with staff. However,

we were not provided with the number of staff who were compliant with this. Sepsis is a life-

threatening condition that arises when the body’s response to infection causes injury to its own

tissues and organs. Pathways demonstrate how to recognise sepsis and the steps that are

necessary to treat patients appropriately. Patients suspected of having sepsis were transferred by

ambulance to acute hospitals.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other

agencies to do so. Most staff received safeguarding training on how to recognise and

report abuse.

Processes and practices were in place to safeguard adults and children from avoidable harm,

abuse and neglect that reflected relevant legislation and local requirements.

102

Safeguarding adults and children policies were in date and accessible to staff through the

hospital’s intranet. They included clear guidance on how to manage suspected abuse and

radicalisation, and details of who to contact for further support and guidance. The hospital

received safeguarding support from the local clinical commissioning group (CCG) safeguarding

team.

Safeguarding training completion rates at our inspection in April 2016 were mostly compliant

except at Queen Victoria Memorial Hospital where 68% of staff had up to date safeguarding

training against a target of 90%. Langley house also didn’t meet the 90% target with 87% of staff

having completed safeguarding training. During this inspection, overall safeguarding completion

rates had improved and most were above the 90% target.

Safeguarding training was provided using both e-learning courses, with additional face to face

training. Training covered all aspects of safeguarding adults and children, including professional

responsibilities, the Mental Capacity Act, categories of abuse, safeguarding processes, child

protection. Prevent training was also provided. Prevent training is a national government initiative

which aims to improve awareness of how to protect people who may be a risk of radicalisation.

Staff we spoke with knew how to access and complete safeguarding training.

Nursing staff told us they were aware of their responsibilities to safeguard patients and

demonstrated how they could access the trust policy on the intranet. Staff were aware that there

was a safeguarding lead within the trust and told us they knew how to contact them for advice.

Staff could explain the process for raising concerns.

The trust had a dedicated safeguarding team, which included clinical nursing staff. The team could

support staff across all hospital sites, keep them informed on safeguarding issues and provide

additional training when required. Contact details for the safeguarding team were displayed

throughout the inpatient units.

Staff were aware of female genital mutilation (FGM) and the process to follow should they have

any concerns.

The safeguarding of adults in the service was monitored by the trust’s commissioners who had

carried out an annual review of adult safeguarding across all sites. Findings and recommendations

from the audit were presented to the safeguarding adult forum. This ensured a consistent

approach to safeguarding adults across all services within the area.

Safeguarding Training completion

The trust did not separate their mandatory training data by staff group. Therefore, the data below

includes nursing and midwifery staff, medical and dental staff, allied healthcare professionals and

healthcare assistants/infrastructure support staff in community inpatient services. We asked the

trust to provide this information during the inspection but we didn’t receive this.

The trust set a target of 90% for completion of safeguarding training.

Trust wide

A breakdown of compliance for safeguarding training courses from April 2017 to March 2018 for

staff in community health inpatient services is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Safeguarding adults (level 1) 26 26 100.0% 90% Yes

103

Safeguarding adults (level 2) 276 280 98.6% 90% Yes

Safeguarding children (level 2) 275 281 97.9% 90% Yes

Preventing radicalisation - levels 3, 4 & 5 (prevent awareness) 222 229 96.9% 90% Yes

Safeguarding children (level 1) 25 26 96.2% 90% Yes

Preventing radicalisation - levels 1 & 2 (basic prevent awareness) 58 62 93.5% 90% Yes

In community health inpatient services, the 90% target was met for all six safeguarding training

modules for which medical staff were eligible.

The trust supplied updated safeguarding training data as of August 2018. The breakdown by

training module for staff across community inpatients as of that date is shown in the table below.

Please note that the different levels of safeguarding adults and preventing radicalisation training

had been replaced by a single module for each of these two training subjects by August 2018.

Name of course

Number of

staff

trained

Number of

eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Preventing radicalisation 271 298 90.9% 90% Yes

SAFA Champions 9 10 90.0% 95% No

Safeguarding Adults 287 298 96.3% 90% Yes

Safeguarding Children (Level 1) 32 33 97.0% 90% Yes

Safeguarding Children (Level 2) 246 265 92.8% 90% Yes

Safeguarding Children (Level 3) 1 1 100.0% 90% Yes

In community health inpatient services, as of August 2018 the trust’s training targets were met for

four of the five safeguarding training modules for which qualified staff were eligible.

(Source: DR110, Mandatory training compliance August 2018)

Danesbury Home community inpatient services

A breakdown of compliance for safeguarding training courses from April 2017 to March 2018 for

staff in community health inpatient services at Danesbury Home is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Safeguarding children (level 2) 41 41 100.0% 90% Yes

Preventing radicalisation - levels

3, 4 & 5 (prevent awareness) 41 41 100.0% 90% Yes

Preventing radicalisation - levels

1 & 2 (basic prevent awareness) 4 4 100.0% 90% Yes

Safeguarding adults (level 2) 41 41 100.0% 90% Yes

Safeguarding adults (level 1) 4 4 100.0% 90% Yes

Safeguarding children (level 1) 4 4 100.0% 90% Yes

The 90% target was met for all six safeguarding training modules for which staff in community

health inpatient services at Danesbury Home were eligible.

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Hemel Hempstead General Hospital community inpatient services

A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in

community health inpatient services at Hemel Hempstead General Hospital is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Safeguarding adults (level 1) 4 4 100.0% 90% Yes

Safeguarding children (level 2) 52 52 100.0% 90% Yes

Safeguarding children (level 1) 4 4 100.0% 90% Yes

Safeguarding adults (level 2) 50 52 96.2% 90% Yes

Preventing radicalisation - levels

3, 4 & 5 (prevent awareness) 35 38 92.1% 90% Yes

Preventing radicalisation - levels

1 & 2 (basic prevent awareness) 12 14 85.7% 90% No

The 90% target was met for five of the six safeguarding training modules for which staff in

community health inpatient services at Hemel Hempstead General Hospital were eligible.

(Source: Universal Routine Provider Information Request (RPIR) –P40Training)

Hertfordshire and Essex Hospital community inpatient services

A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in

community health inpatient services at Hertfordshire and Essex Hospital is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Safeguarding adults (level 1) 4 4 100.0% 90% Yes

Safeguarding children (level 1) 4 4 100.0% 90% Yes

Safeguarding adults (level 2) 38 39 97.4% 90% Yes

Safeguarding children (level 2) 37 39 94.9% 90% Yes

Preventing radicalisation - levels

3, 4 & 5 (prevent awareness) 31 33 93.9% 90% Yes

Preventing radicalisation - levels

1 & 2 (basic prevent awareness) 6 8 75.0% 90% No

The 90% target was met for five of the six safeguarding training modules for which staff in

community health inpatient services at Hertfordshire and Essex Hospital were eligible.

(Source: Universal Routine Provider Information Request (RPIR) –P40Training)

Langley House community inpatient services

A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in

community health inpatient services at Langley House is shown below:

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Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Preventing radicalisation - levels

1 & 2 (basic prevent awareness) 15 15 100.0% 90% Yes

Safeguarding adults (level 1) 6 6 100.0% 90% Yes

Safeguarding adults (level 2) 74 74 100.0% 90% Yes

Safeguarding children (level 1) 6 6 100.0% 90% Yes

Preventing radicalisation - levels

3, 4 & 5 (prevent awareness) 55 56 98.2% 90% Yes

Safeguarding children (level 2) 71 75 94.7% 90% Yes

The 90% target was met for all six safeguarding training modules for which staff in community

health inpatient services at Langley House were eligible.

(Source: Universal Routine Provider Information Request (RPIR) –P40Training)

Potters Bar Community Hospital community inpatient services

A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in

community health inpatient services at Potters Bar Community Hospital is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Safeguarding children (level 2) 38 38 100.0% 90% Yes

Preventing radicalisation - levels

1 & 2 (basic prevent awareness) 8 8 100.0% 90% Yes

Safeguarding adults (level 1) 7 7 100.0% 90% Yes

Safeguarding adults (level 2) 37 38 97.4% 90% Yes

Preventing radicalisation - levels

3, 4 & 5 (prevent awareness) 36 37 97.3% 90% Yes

Safeguarding children (level 1) 6 7 85.7% 90% No

The 90% target was met for five of the six safeguarding training modules for which staff in

community health inpatient services at Potters Bar Community Hospital were eligible.

(Source: Universal Routine Provider Information Request (RPIR) –P40Training)

Queen Victoria Memorial Hospital community inpatient services

A breakdown of compliance for safeguarding courses from April 2017 to March 2018 for staff in

community health inpatient services at Queen Victoria Memorial Hospital is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Safeguarding children (level 2) 36 36 100.0% 90% Yes

Preventing radicalisation - levels

3, 4 & 5 (prevent awareness) 24 24 100.0% 90% Yes

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Preventing radicalisation - levels

1 & 2 (basic prevent awareness) 13 13 100.0% 90% Yes

Safeguarding adults (level 2) 36 36 100.0% 90% Yes

Safeguarding adults (level 1) 1 1 100.0% 90% Yes

Safeguarding children (level 1) 1 1 100.0% 90% Yes

The 90% target was met for all six safeguarding training modules for which staff in community

health inpatient services at Queen Victoria Memorial Hospital were eligible.

(Source: Universal Routine Provider Information Request (RPIR) – P38 Training)

Safeguarding referrals

A safeguarding referral is a request from a member of the public or a professional to the local

authority or the police to intervene to support or protect a child or vulnerable adult from abuse.

Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and

institutional.

Each authority has their own guidelines to investigate and progress a safeguarding referral.

Generally, if a concern is raised regarding a child or vulnerable adult, the organisation works to

ensure the safety of the person. In addition, when appropriate, an assessment of the concerns is

conducted to determine whether an external referral to Children’s Services, Adult Services or the

police should take place.

Referrals were provided on a trust wide level so we were unable to break this down to individual

core services. From April 2017 to March 2018 there were 382 safeguarding referrals for adults

made by HCT staff. During the same period the trust made 390 safeguarding referrals for children.

(Source: Universal Routine Provider Information Request (RPIR) – P11 Safeguarding)

Cleanliness, infection control and hygiene

The service mostly controlled infection risk well. Most staff kept themselves, equipment

and the premises clean. They used control measures to prevent the spread of infection.

During our inspection, we found the environment to be clean and most staff followed the

trust policy on infection prevention and control.

There was a nominated trust lead for infection prevention and control (IPC) supported by specialist

nurses and ward based infection prevention link champions to deliver the key objectives.

There were posters on display encouraging staff and visitors to clean their hands using the hand

sanitiser provided. Hand sanitising gel was available throughout the units, and on the end of each

patient bed.

Most staff we observed used hand sanitiser or washed their hands when entering ward bay areas

and before and after each patient contact. This is in line with the National Institute for Health and

Care Excellence (NICE) Quality Statement 61 (Statement 3). Staff had a good knowledge of the

trust hand hygiene policy and knew how to follow the five moments for hand hygiene guidance.

This is defined by the World Health Organisation as the key moments when health-care workers

should perform hand hygiene.

We observed that not all staff on Simpson ward carried out appropriate hand hygiene between

each patient contact, or followed the trust hand hygiene policy of being ‘arms bare below the

elbows’ in clinical areas. Arms bare below the elbows allows clinical staff to wash their hands

thoroughly. We observed one member of staff miss five out of six opportunities for hand hygiene in

a 10-minute observation period. We saw that three doctors had long sleeves and/or were wearing

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wrist watches, and a therapist was wearing nail varnish. Subsequent to our inspection the trust

submitted an action plan detailing the actions it had taken to address these issues including re-

circulating the dress code and personal presentation policy and commencing assurance visits.

In some clinical areas there were no dedicated handwashing sinks to enable compliance with

guidance contained within Health Building Note 00-09: Infection control in the built environment

(Health Building Note 00-09). For example, the clean utility room on Simpson ward did not have a

dedicated handwashing sink for staff to use when preparing medications. The handwashing sink

for staff to use before preparing food, located in the dining room within Danesbury unit was not

compliant with HBN 00-09 guidance. This guidance states that hands should be washed under

running water and the use of mixer taps allows this to be practiced safely in healthcare settings

where water temperatures may be necessarily high. Additionally, hand hygiene sinks should not

have a plug or a recess capable of taking a plug as this allows the sink to be used to soak and

wash equipment. Hand wash sinks should not have an overflow, as these are difficult to clean and

sinks should be wall-mounted with sealed waterproof splash-backs to allow effective cleaning of all

surfaces.

From April 2018 to August 2018 the inpatient services screened 100% of patients for MRSA,

meeting the services screening criteria for MRSA. At the time of our inspection, the MRSA policy

had expired but was under review, and we were told it was due to be re-published in October

2018.

Patients who had a known or suspected infection were nursed in isolation in a side room on the

inpatient units. Staff followed the necessary infection prevention precautions to minimise the risk of

spread to others. Details of the patient’s infection status, treatment and individual care plans were

recorded in their electronic patient record, along with any specialist advice from the IPC team.

There were no cases of MSSA or MRSA blood stream infections from April 2017 to March 2018

and from April 2018 to August 2018. There were two cases of trust apportioned (avoidable)

C.difficile, from April 2017 to March 2018, and from April 2018 to August 2018 there were a further

two cases of avoidable C.difficile.

There had been two outbreaks of Norovirus in the inpatient units from April 2017 to March 2018.

Norovirus can spread rapidly in hospitals and is often difficult to control. The outbreaks were

reported as serious incidents. We saw evidence that these outbreaks were managed by the trust

and fully investigated with an action plan to prevent further outbreaks. Whilst the trust concluded

that neither outbreak could have been avoided, the trust did consider lessons learnt. For example,

delays in obtaining stool samples and communication with the deep cleaning company.

There were separate clean and dirty utility areas which helped minimise the risk of infection.

Clinical and domestic waste was appropriately segregated and there were arrangements for the

separation and handling of high risk used linen. However, on Holywell unit, used clinical waste

bags were temporarily stored in a large low sided, unlidded skip, along with the used linen bags.

Disposal of sharp instruments complied with Health and Safety (Sharp Instruments in Healthcare)

Regulations 2013. Sharps bins we observed were stored away from patient areas and not over

full, were signed and dated, with temporary locks in place. Staff told us how they would respond if

they received a sharps injury, and this was in line with best practice.

Personal protective equipment (PPE), such as gloves and aprons were available in sufficient

quantities on all wards within the community hospitals. Most staff used PPE appropriately when

performing tasks where there was a risk of contamination. However, we observed that a member

of staff on Simpson ward escorted a patient into a bathroom and back while wearing a red

medication round, ‘do not disturb’ apron. The same apron was worn while the staff member

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emptied a urine bottle from another patient and disposed of it in the sluice, before returning to the

medication round.

‘I am clean’ stickers were in use across some units to indicate that equipment had been cleaned

and was ready for use. Stickers were dated. We saw staff cleaning equipment between patient

use.

Audits were carried out regarding infection control compliance. Areas included general

environment, clean and dirty utility rooms, commodes, storage and equipment, waste

management and sharps. Hand hygiene was monitored through regular audits and included the

audit of clinical and non-clinical staff. Hand hygiene audits from June 2018 to August 2018 showed

that the inpatient community units achieved above 90%. Hand hygiene and environment audit

results were displayed in each unit for staff, patients and visitors to see. During our inspection, all

units recorded scores above 90% in each category.

Kitchen areas on units were clean. Food products and patients own food stored in the fridge was

labelled and in date.

Cleaning schedules were displayed in each unit. Domestic staff could explain the different types of

cloths and cleaning products used for patients with an infection.

PLACE Assessments

These self-assessments are undertaken by teams of NHS and private/independent health care

providers, and include at least 50 per cent members of the public, known as patient assessors.

They focus on the environment in which care is provided, as well as supporting non-clinical

services such as cleanliness, food, hydration, the extent to which the provision of care with privacy

and dignity is supported. In addition, assessments are made to consider whether the premises are

equipped to meet the needs of people with dementia against a specified range of criteria.

PLACE scores are only available at site level. However, the trust reported the Holywell

neurological rehabilitation inpatient unit as a separate site for PLACE.

The 2018 PLACE scores for cleanliness at Danesbury Home and Queen Victoria Memorial

Hospital were both lower than the England average for NHS community inpatient services. The

trust’s remaining four sites all scored better than or similar to the England average, and three

scored 100%.

The trust’s overall scores for cleanliness and condition, appearance and maintenance were similar

to the England averages. The trust’s scores for being dementia friendly were both slightly better

than the England averages.

Although the trust scored slightly better than the England average for being dementia friendly,

Danesbury Home, Hemel Hempstead Community Hospital and Potters Bar Community Hospital all

scored worse than the England average for this metric.

Site name Cleanliness

%

Condition, appearance

and maintenance %

Dementia

friendly %

Disability

%

Danesbury Home 95.8% 93.6% 64.6% 81.5%

Hemel Hempstead Hospital 99.1% 83.3% 69.9% 83.5%

Hertfordshire and Essex

Hospital

100.0% 90.3% 86.2% 88.1%

Holywell at Langley House 100.0% 95.0% 92.2% 95.9%

Langley House 100.0% 92.4% 90.8% 94.2%

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Potters Bar Community

Hospital

98.8% 95.5% 76.6% 85.6%

Queen Victoria Memorial

Hospital

92.8% 98.7% 90.8% 89.6%

Trust 98.2% 92.8% 82.4% 88.2%

England average (NHS

community)

98.8% 93.1% 80.3% 86.1%

(Source: NHS Digital)

Environment and equipment

The service generally had suitable premises and equipment and looked after them well.

However, some buildings were old and in need of refurbishment or repair, some units had

insufficient storage space and some units had broken equipment.

Each of the community units we visited were set out slightly differently. Some units, for example,

Danesbury unit and Holywell unit were mostly made up of single side rooms, and some, for

example, Simpson ward, were mostly made up of bays with four patient bed spaces. Each patient

was given an armchair, locker and an over bed table. All accommodation was single sex with

separate male and female bathroom and toilet facilities for each bay area and side room.

We found that most patient rooms and patient furniture was in a good state of repair. However, at

Midway unit we saw damaged flooring in a patient bedroom, with sticky tape being used as a

temporary fix.

Some of the unit environments and pieces of equipment needed repair:

• St Peters unit: we saw that the sluice hopper lid was stuck together with elastoplastic tape.

• Midway unit: we saw chairs at the nurses’ station were fabric coated and ripped.

• Holywell unit: there was a broken cupboard in the patient dining room, with a hand-written

note advising people not to open the door, as it caused electrical shortages.

• Danesbury unit: we saw that most of the bathroom assistance call bell pull-cords had been

snapped off and a plug-in system had been installed to replace them. However, the plug-in

system required the use of long wires which we observed were draped across sinks to

reach the toilet area.

• Holywell unit: we saw chemical ant traps were placed on the kitchen window sill, next to the

hot drinks facilities and at Danesbury unit we saw mousetraps in the dining room.

There was insufficient storage space in some units to store all the required manual handling

equipment, for example, hoists and patient wheelchairs. At Holywell unit we saw patient

bathrooms being used to store hoists. A risk assessment had not been undertaken on the safety of

storing equipment in patient bathrooms. Staff told us that the equipment would be moved out if

patients wanted to use the bathroom for a shower. We saw that the equipment was not moved for

patients using the toilet facilities in these bathrooms. One ward manager told us that lack of

storage was on their risk register.

Emergency medical equipment such as resuscitation trolleys and suction machines were checked

daily. The resuscitation trolleys had a lockable seal which meant that the trolley could not be

tampered with. We saw on Danesbury unit there was one day in August when the resuscitation

trolley had not been checked. In addition, staff had documented the suction machine red light was

not working on one occasion in September 2018. There was no action recorded to state whether

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the suction machine was now working correctly. We highlighted this to the ward manager during

our inspection and they told us they would investigate it.

On Holywell unit, we found the defibrillator pads had expired in August 2018.We highlighted this to

the ward manager during our inspection and they told us they would replace the pads immediately.

There was no water for injection on the resuscitation trolley at Holywell unit, and staff said they

had sachets of water for irrigation instead. We highlighted this with the ward manager and they

told us they would replace these immediately.

On Oakmere ward, at Potters Bar Community Hospital, there was no adult mask to use with the

nebuliser on the emergency trolley on the north side of the ward. The oxygen cylinder on the south

side was only quarter full, and therefore did not comply with the trust policy.

The trust confirmed that the issues with emergency medical equipment had been rectified in an

action plan sent to us subsequent to our inspection.

At Midway unit one suction machine stored in the clean utility, had an electrical test due date of

January 2017. This machine had a sticker on it saying it was not working and had been reported.

Nursing staff we spoke to were unaware of the out of date electrical test, and were unable to say

when it had stopped working.

Hypoglycaemia (low blood sugar) monitoring machines (BM machines) were not always checked

daily and according to trust policy on some units. The BM machine had not been checked on St

Peters for two days in August 2018, and one day in June 2018 and one day in July 2018. Simpson

ward staff told us they did not carry out daily checks on the BM machine as they believed this was

done by the acute trust who owned the equipment. On the Midway unit, there were three identical

BM machines in use, with only one log book, which indicated one of the machines had been

checked. However, the log book only had one date recorded for a check which was carried out on

6 September 2018. There was no record book for the other two machines.

BM test strips should be discarded 3 months after opening. Some units did not record the date of

opening. We saw on Midway unit there was a ‘’discard day’’ written on the test kit of 7 July 2018.

Staff were unclear if this was the discard date, or if it was the date of opening the packet of strips.

The trust advised us subsequent to our inspection that all equipment associated with BM

machines and been checked and assurance visits to monitor ongoing compliance had

commenced.

Emergency call bells were located by each patient bed space throughout the service, and some

units had piped oxygen and suction in each bed space. Portable oxygen cylinders and suction

were available on the units we inspected. Portable oxygen cylinders were stored away from public

areas however we saw that they were not always stored securely. On Danesbury unit and

Simpson ward some cylinders were freestanding, but were secured to the wall or other

immoveable object.

Suitable equipment was available to prevent patients sustaining pressure ulcers, in line with Royal

College of Nursing for the management of pressure ulcers. Patients identified at being at risk of

developing pressure ulcers had access to pressure-relieving support surfaces and strategies for

example, mattresses and cushions 24 hours a day. Patients assessed as having a grade 1-2

pressure ulcer could be placed on a high-specification foam mattress or cushion with pressure-

reducing properties. Patients assessed as having grade 3-4 pressure ulcers, or at high risk of

developing pressure sores, were provided with an alternating pressure mattress or a continuous

low-pressure system. On St Peters ward there were five alternating pressures mattresses,

however four of these were on the wrong setting for the patient. We drew attention to this with staff

during our inspection.

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Disposable items and consumables, for example syringes, needles, dressings and hand gels were

within their expiry dates.

Hazardous chemicals were not always locked away and stored in line with the Control of

Substances Hazardous to Health (COSHH) regulations. In the dirty clinical room on St Peters

ward, we found bleach cleaning tablets in a locked cupboard with the key attached to a hanger on

the outside of the locked door. The dirty clinical room was not locked and patients and visitors had

access to it. This was highlighted to the trust and subsequent to our inspection they took action to

alert staff to the risk assessments for all COSHH items and assurance visits to commenced to

monitor compliance to the regulations.

We also found diluted bleach in dirty utility rooms on Simpson ward and Holywell unit which were

not locked away. We saw that an incident had occurred that had been discussed at the

Hertfordshire and Essex team meeting in August 2018, in which hazardous chemicals had not

been locked away and had resulted in a patient safety incident.

Electrical equipment throughout the inpatient units had been tested and had yearly expiry dates

that were visible and clearly written.

We observed a wide variety of mobility equipment used and stored within the units. Systems were

in place to remove broken or faulty equipment.

Some bariatric equipment was available, for example, a larger sized chair and hoist and a larger

size commode. Staff told us that extra bariatric equipment could be ordered in if required.

Hoists were available within all the ward areas which meant staff could provide safe and effective

manual handling processes. This was in line with the Manual Handling Operation Regulations

2002. Some bed spaces within the ward areas had overhead hoist equipment, so that a patient

could be moved safely while reducing any unnecessary risk to the patient or the staff member.

All inpatient units at the community hospitals had access to fire escapes. Staff told us that fire

tests were routinely carried out. Fire exits were clearly signed and not blocked.

Assessing and responding to patient risk

Although there were effective systems in place to recognise and respond to deteriorating

patients’ needs, not all risks in the service had been identified, assessed and monitored.

Not all staff were aware of local risk registers.

The National Early Warning System (NEWS) is used to identify deteriorating patients in

accordance with NICE Clinical Guidance (CG) 50: ‘acutely ill adults in hospital: recognising and

responding to deterioration’ (2007). The trust used standardised NEWS charts to document patient

observations, such as blood pressure, pulse, oxygen levels, and temperature. Staff we spoke with

said the system worked well and staff responded appropriately to patients with an elevated NEWS.

Compliance to NEWS escalation and frequency of observations was audited and we saw in June

2018, all inpatient community areas scored between 92% and 100%, except Holywell which

scored 37%. Action plans for non-compliance included re-audit, change of handover design,

further training and discussions with relevant staff to ensure improvements. The service also had a

NEWS trigger sheet, which staff were required to complete when a patient’s NEWS score was

raised above zero. The sheet had a space to record what action had been taken and by who.

During our inspection in April 2016 we found that repeat patient observations had not always been

completed within agreed timeframes for all patients at Danesbury Neurological Centre and

Hertfordshire and Essex Hospital. During this inspection we found that NEWS scores had been

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accurately assessed and escalated appropriately, and that the NEWS trigger sheets had been

completed for each patient.

Staff had an awareness of sepsis and received training in recognising the signs of sepsis. Patients

suspected of having sepsis were transferred to an acute NHS hospital provider by ambulance.

Risk assessments were carried out on patients when they were admitted to the community

services. This included risk assessments for falls, malnutrition, and pressure ulcers. These were

documented in the patient’s records and included actions to mitigate any identified risks.

Assessments were updated weekly or following any changes, such as a new fall. The service used

nationally recognised risk assessments such as the Malnutrition Universal Screening Tool (MUST)

and Morse falls scale. MUST is a five-step screening tool to identify patients, who are

malnourished, at risk of malnutrition (under nutrition) or obese. The Morse Fall Scale is a rapid and

simple method of assessing a patient’s likelihood of falling.

Falls assessments were completed on each patient on admission and updated following a fall or a

change in the patient’s condition. The trust had recently updated its falls policy which was due for

release October 2018. Staff were aware of the updated policy and told us falls link nurses had

received extra training about the new policy. Patient falls alarms were in use for those patients

deemed to be at a high risk. Falls care was in line with the National Service Framework (NSF) for

Older People – Standard 6, which requires hospitals to reduce the number of falls which result in

serious injury, and to ensure effective treatment and rehabilitation for those that have fallen. The

trust falls policy and falls risk assessments were available on the intranet and staff knew how to

access these. Patients who had fallen or at risk of falling were placed on a 30 minute observation

chart for three days after a fall. This required staff to check the patient every 30 minutes and to

document that the patient was safe and had everything they needed. We found evidence that 30

minute checks were in place for three days for patients following a fall or at risk of falling.

However, at Danesbury unit we saw two falls 30 minute observation charts had been completed

retrospectively, and at Midway unit we saw that one 30 minute observation chart had been

completed retrospectively. We fed this back to the trust who after our inspection put measures in

place to alert staff to the importance of regular observation of patients as risk of falls, and

assurance visits were arranged to ensure this learning had been embedded.

During our inspection we did not see any patients who had a ‘position chart’ or turn chart. Position

charts are used for patients who have difficulty in moving and repositioning themselves whilst in

bed, to help patients avoid pressure damage to their skin. Nurses at St Peters and Simpson wards

told us they did use turn charts, however during our inspection there were no patients who

required assistance with moving. We saw that most patients on these wards appeared quite

dependant, and were mostly in bed wearing hospital pyjamas. Some staff told us that positions

were checked during the two hourly comfort rounds. However, the comfort round chart did not

record the position of the patient, or that staff had moved them, for example, from right side, to left

side. During our inspection in 2016, we found turn charts were used but that they were not always

completed regularly. Therefore, there had been little improvement in this area.

Emergency buzzers were available by patient bed spaces. Staff we spoke to were unaware if

these had been tested or whose responsibility this was.

Some patients had ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions made in

their notes. The DNACPR was recorded electronically in the electronic system, and a paper

version was kept in the patient’s medical file. DNACPR status was not recorded on the nurse

handover sheets. However, most agency nurses working in the units did not have access to the

electronic system. There was a risk to patients in that they might not get the correct response,

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should they collapse while in hospital because staff may be unaware of the patient’s DNACPR

status.

During our inspection in April 2016 we reported that at the Queen Victoria Memorial Hospital and

Midway unit there wasn’t a policy outlining the frequency that patients should receive therapy or

how soon after admission their assessment should be made. Patients at Queen Victoria Memorial

Hospital and Midway unit were not always seen daily by a therapist, which may have delayed their

rehabilitation and progress. This was raised with senior staff at the time of that inspection. During

this inspection we found that there was still no policy on how often patients should receive therapy

and not all units provided therapy at a weekend. Staff told us that some patients who were

admitted on a Friday, were not assessed by the therapy team for three or four days, which could

delay their recovery.

Staffing

The service did not always have enough nursing staff with the right qualifications, skills,

training and experience. The service did not report any incidents of harm due to staff

shortages.

Staffing levels, skill mix and caseloads were planned and reviewed so patients received safe care

and treatment at all times, in line with relevant tools and guidance.

The Safer Nursing Care tool (SNC) was used by the community hospitals to calculate staffing

requirements across the inpatient services. The SNC tool determined acuity and dependency

levels of patients in hospitals; it was used to assess the care needs of patients, estimated care

hours and suggested care arrangements. This meant that appropriate skill mix and staffing levels

were planned, which met the Royal College of Nursing safe staffing guidance.

Each unit displayed a board which showed the number of nurses that should have been on duty

and the actual number of nurses on duty. The number of therapy staff was not displayed. During

our previous inspection in April 2016 we found that most wards had the required amount of staff

on duty, each shift. During this inspection, most wards had the correct amount of staff on duty,

except Simpson ward on 19 September 2018, where they were one registered nurse short, and

Midway unit on 18 September 2018 where they were also one registered nurse short. However,

ward managers told us they were regularly short staffed and often had shifts without the required

number of nurses. For example, on Midway unit, in August 2018, there had been 32 unfilled nurse

shifts; 17 unfilled healthcare assistant (HCA) shifts; 12 occupational therapy unfilled shifts; four

physiotherapy shifts short and 32 rehabilitation shifts unfilled. On Holywell unit, from 4 September

to 17 September there had been eight unfilled nurse shifts and seven unfilled HCA shifts.

Where qualified nursing staff availability was lower than required, unqualified staff, healthcare

assistants (HCAs) made up the staffing numbers if possible. However, on Holywell unit, from 4

September to 17 September there were five days when both the nurse staff actual number and the

HCAs actual number fell below planned staffing. Ward managers told us they worked clinically

when they were short staffed and that staffing numbers were escalated every day at management

meetings and to the bed bureau. If possible, staff would move from one unit to another, to support

each other. We were told this was particularly easy to arrange on sites where there was more than

one unit, for example at Langley House, Holywell and Midway units where staff were shared. We

were told that rehabilitation assistants sometimes assisted with nursing duties and shared work

with the HCAs.

Monthly staffing reports were produced which considered unit staffing, linking shortages to events

on the ward, to look for any impact because of having reduced staff. Reports recorded the number

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of complaints, the number of falls, pressure ulcers and infections. Reports from April 2018 to June

2018 indicated there had been no avoidable moderate or severe harm because of staff shortages.

Most units had above 90% staffing for day and night shifts.

The ward manager told us that Midway unit had five nurse vacancies and one member of staff on

long term sickness. The ward manager at Danesbury unit told us there were four nurse vacancies.

Staff of all grades told us they sometimes had insufficient numbers of staff. During our inspection,

we did not see any evidence of patient care being compromised. However, two patients told us

they had waited a long time for call bells to be answered, one on Holywell unit and one on

Simpson ward.

Nursing staff and managers told us it was the trust policy to report staff shortages as incidents.

The trust had a safe staffing reporting and escalation Standard Operating Procedure (SOP). The

SOP outlined safe staffing ratio’s and was in place to help inpatient unit staff manage staff

shortage and minimise the risk to patient safety. The SOP set out a clear escalation process that

staff should follow to notify senior management and the bed bureau. Where the staff shortage is

unresolvable, an incident notification should be completed on the trust’s electronic reporting

system which all staff had been trained to use. From September 2017 to August 2018, the service

had reported one incident due to staff shortages. This was reported as no harm. Managers were

unable to say why there had only been one incident reported.

The service was actively trying to recruit new staff and developing new roles to increase the skills

of their existing staff. For example, therapy assistants were helping patients washing and dressing.

HCAs were learning basic skills in physiotherapy to help patients mobilise safely and increase the

rehabilitation opportunities for patients when a physiotherapist was not available.

The unit managers told us that recruitment was a priority and that they used targeted recruitment

drives which were bespoke to each unit. Managers planned to offer staff flexible working as much

as possible and to use incentives for difficult to fill roles, such as occupational therapists.

Safer staffing levels

Staff fill rates compare the proportion of planned hours worked by staff (nursing, midwifery and

care staff) to actual hours worked by staff (day and night). Community health trusts are required to

submit a monthly safer staffing report and undertake a six-monthly safer staffing review by the

director of nursing. This is to monitor and in turn ensure staffing levels for patient safety. Hence,

an average 70% fill rate in January 2018 for nursing staff during the day means; In January 2018,

70% of the planned working hours for daytime nursing staff were actually ‘filled’.

Details of staff fill rates within community inpatient services for registered nurses and care staff in

May 2018 for each site published on their website by the trust are below:

For community inpatient services, there is information for seven locations. These are:

• Danesbury Home

• Hemel Hempstead General Hospital

• Potters Bar Community Hospital

• Hertfordshire and Essex Hospital

• Holywell

• Queen Victoria Memorial Hospital

• Langley House

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Community inpatient services – Danesbury Home

Registered nursing staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,227 1,116 713 713

Care staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,426 1,719.58 713 1,104

Registered nursing staff at Danesbury Home had an average fill rate of 85.6% for day shifts and

a 100% average fill rate for night shifts. Care staff had an over-establishment of 20.6% for day

shifts and an over-establishment of 54.8% for night shifts.

Over-establishments are when there are more staff on duty than planned. Over establishments

are often required when there are patients, who require one to one care.

Community inpatient services – Hemel Hempstead General Hospital

Ward/unit

Registered nursing staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

St Peters ward 1,227 1,163 713 713

Simpson ward 1,227 1,116 713 713

Total 2,454 2,279 1,426 1,426

Ward/unit

Care staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

St Peters ward 1,426 1,695.5 1,069.5 1,426

Simpson ward 1,265 1,374.25 1,265 1,252.92

Total 2,691 3,069.75 2,334.5 2,678.92

Registered nursing staff in St Peters ward at Hemel Hempstead General Hospital had an average

fill rate of 94.8% for day shifts and a 100% average fill rate for night shifts. Care staff had an

over-establishment of 18.9% for day shifts and an over-establishment of 33.3% for night shifts.

Registered nursing staff in Simpson ward at Hemel Hempstead General Hospital had an average

fill rate of 91% for day shifts and a 100% average fill rate for night shifts. Care staff had an over-

establishment of 8.6% for day shifts and an average fill rate of 99% for night shifts.

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Community inpatient services – Potters Bar Community Hospital

Oakmere

Registered nursing staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,940 1,933.58 1,426 1,425.75

Care staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,426 1,458.83 713 713

Registered nursing staff in Oakmere ward at Potters Bar Community Hospital had an average fill

rate of 99.7% for day shifts and a 100% average fill rate for night shifts. Care staff had an over-

establishment of 2.3% for day shifts and an average fill rate of 100% for night shifts.

Community inpatient services – Hertfordshire and Essex Hospital

Cambridge/

Oxford ward

Registered nursing staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,940 1,933.58 1,426 1,425.75

Care staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,426 1,458.83 713 713

Registered nursing staff in Cambridge/Oxford ward at Hertfordshire and Essex Hospital had an

average fill rate of 97.5% for day shifts and a 95% average fill rate for night shifts. Care staff had

an over-establishment of 11.2% for day shifts and an over-establishment of 20.1% for night shifts.

Community inpatient services – Holywell

Holywell

Registered nursing staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,227 1,234 713 712

Care staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,069.5 1,510.75 713 1,058

Registered nursing staff in Holywell had an over-establishment of 0.6% for day shifts and a

99.9% average fill rate for night shifts. Care staff had an over-establishment of 41.3% for day

shifts and an over-establishment of 48.4% for night shifts.

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Community inpatient services – Queen Victoria Memorial Hospital

Rehabilitation

unit

Registered nursing staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,227 1,164.17 713 713

Care staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,426 1,408.53 1,069.5 1,069.25

Registered nursing staff in the rehabilitation unit at Queen Victoria Memorial Hospital had an

average fill rate of 94.9% for day shifts and a 100% average fill rate for night shifts. Care staff had

an average fill rate of 98.8% for day shifts and an average fill rate of 100% for night shifts.

Community inpatient services – Langley House

Langley

Registered nursing staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,583.5 1,644.67 713 713

Care staff

Day Night

Required shifts Filled shifts Required shifts Filled shifts

1,782.5 2,312.75 1,426 2,023

Registered nursing staff Langley House had an over-established fill rate of 3.9% for day shifts

and a 98.9% average fill rate for night shifts. Care staff had an over-establishment of 29.7% for

day shifts and an over-establishment of 41.9% for night shifts.

(Source: Safer Staffing Data – Trust website)

Planned v Actual Establishment

Year 1 section:

Details of staffing levels within community health inpatient services by staff group as at March

2018 are below.

Community inpatient services total

Staff group Planned staff

WTE

Actual Staff

WTE

Staffing

rate (%)

NHS infrastructure support 24.3 18.9 77.9%

Other Qualified Scientific, Therapeutic &

Technical staff (Other qualified ST&T) 5.4 5.4 100.0%

Public Health & Community Health Services 2.9 1.7 57.9%

Qualified Allied Health Professionals

(Qualified AHPs) 46.5 33.2 71.3%

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Qualified nursing & health visiting staff

(Qualified nurses) 145.9 105.3 72.1%

Support to doctors and nursing staff 144.8 118.9 82.1%

Support to ST&T staff 17.8 12.7 71.2%

Total 387.7 296.0 76.4%

Year 2 section:

Details of staffing levels within community health inpatient services by staff group as at March

2018 are below.

Community inpatient services total

Staff group Planned staff

WTE

Actual Staff

WTE

Staffing

rate (%)

NHS infrastructure support 27.1 16.7 61.6%

Other Qualified Scientific, Therapeutic &

Technical staff (Other qualified ST&T) 5.4 4.0 74.6%

Public Health & Community Health Services 2.3 2.7 116.4%

Qualified Allied Health Professionals

(Qualified AHPs) 42.8 37.5 87.7%

Qualified nursing & health visiting staff

(Qualified nurses) 140.1 110.4 78.8%

Support to doctors and nursing staff 131.3 108.0 82.2%

Support to ST&T staff 17.5 15.8 90.2%

Total 366.4 295.1 80.5%

(Source: Universal Routine Provider Information Request (RPIR) – P16 Total Staffing)

Vacancies

The trust set a target of 10% for vacancy rate, that is no more than 10% of posts were vacant.

From April 2017 to March 2018, the trust reported an overall vacancy rate of 22.1% in community

health inpatient services. This did not meet the trust’s target. Across the trust overall vacancy

rates for nursing staff were 22.4% and for allied health professionals were 51.9%.

A breakdown of vacancy rates by staff group in community health inpatient services at trust level

is below:

Community inpatient services total

Staff group

Total number

of

substantive

staff

Number of

substantive

vacancies

Total % vacancies

overall

(excluding

seconded staff)

Other Qualified Scientific,

Therapeutic & Technical staff (Other

qualified ST&T) 9.1 12.2 74.8%

Support to ST&T staff 136.6 261.3 52.3%

Qualified Allied Health Professionals

(Qualified AHPs) 160.9 310.2 51.9%

NHS infrastructure support 25.1 64.7 38.8%

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Qualified nursing & health visiting

staff (Qualified nurses) 255.3 1,138.4 22.4%

Support to doctors and nursing staff 157.1 1572.8 10.0%

Public Health & Community Health

Services -0.3 7.1 -4.8%

All staff 743.8 3,366.7 22.1%

The trust set a target of 10% for vacancy rate, that is no more than 10% of posts were vacant. From April 2017 to March 2018, the trust reported an overall vacancy rate of 19.5% in community health inpatient services. This did not meet the trust’s target. Across the trust overall vacancy rates for qualified nursing staff were 21.2% and for allied health professionals were 12.2%. A breakdown of vacancy rates by staff group in community health inpatient services at trust level is below:

Staffing group

Total number of

substantive staff

Total number of

substantive vacancies

Vacancy

rate (%)

NHS Infrastructure Support Staff 10.41 27.1 38.4%

Other Qualified Scientific,

Therapeutic, Technician Staff 1.36 5.36 25.4%

Public Health and Community Health

Services -0.38 2.32 -16.4%

Qualified Allied Health Professionals 5.23 42.75 12.2%

Qualified Nursing and Health Visiting

Staff 29.69 140.06 21.2%

Support to doctors and nursing staff 23.23 131.34 17.7%

Support to Scientific, Therapeutic and

Technical Staff 1.76 17.51 10.1%

Total 71.3 366.44 19.5%

(Source: Universal Routine Provider Information Request (RPIR) – P17 Vacancy)

Turnover

All nurses leaving the service were given the opportunity of an exit interview with the senior

matron. This helped identify any themes to understand why staff left. Some staff left due to

promotion within the organisation or for promotion to another healthcare provider.

The trust set a target of 12% for turnover rates. From April 2017 to March 2018, the trust reported

an overall turnover rate of 14.7% in community health inpatient services. This did not meet the

trust’s target. Across the trust overall turnover rates for nursing staff were 14.9% and for allied

health professionals were 27.9%.

A breakdown of turnover rates by staff group in community health inpatient services at trust level

is below:

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Community health inpatient services total

Staff group

Total number

of

substantive

staff

Total number of

substantive

staff leavers

in the last 12

months

Total % of

staff

leavers in

the last 12

months

Qualified Allied Health Professionals 36.6 10.2 27.9%

Qualified Nursing and Health Visiting

Staff 109.6 16.4 14.9%

Support to Doctors and Nursing Staff 128.1 11.9 9.3%

NHS Infrastructure Support Staff 3.9 0.0 0.0%

Public Health and Community Health

Services 2.3 0.0 0.0%

Support to Scientific, Therapeutic and

Technical Staff 15.4 4.4 28.6%

Other Qualified Scientific, Therapeutic,

Technician Staff 4.5 1.4 31.5%

Grand Total 300.3 44.3 14.7%

(Source: Universal Routine Provider Information Request (RPIR) – P18 Turnover)

Sickness

Staff who had a period of sickness absence had a return to work/welfare interview immediately

upon their return. The purpose of the interview was to ensure the staff member was fit to be back

at work, and to ensure any reasonable assistance required was identified. Sickness and absence

rates were monitored and there were policies in place to ensure that absence monitoring was

carried out correctly. Monthly staff sickness days were displayed on units in public areas.

The trust set a target of 3.6% for sickness rates. From April 2017 to March 2018, the trust reported

an overall sickness rate of 5.9% in community health inpatient services. This did not meet the

trust’s target. Across the trust overall sickness rates for nursing staff were 5.4% and for allied

health professionals were 2.1%.

A breakdown of sickness rates by staff group in community health inpatient services at trust level

is below:

Community inpatient services total

Staff group Total % permanent staff sickness

overall

NHS Infrastructure Support Staff 17.8%

Support to Doctors and Nursing Staff 7.2%

Support to Scientific, Therapeutic and Technical Staff 6.9%

Qualified Nursing and Health Visiting Staff 5.4%

Qualified Allied Health Professionals 2.1%

Other Qualified Scientific, Therapeutic, Technician

Staff 1.9%

Public Health and Community Health Services 0.0%

All staff 5.9%

(Source: Universal Routine Provider Information Request (RPIR) – P19 Sickness)

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Nursing – Bank and Agency Qualified nurses

From April 2017 to March 2018 the trust reported bank and agency usage for qualified nurses in

community health inpatient services as below:

Type of shift Total number of shifts

Shifts available 5,881

Filled by bank 2,941

Filled by agency 2,092

Shifts not filled 848

The trust reported that the following community health inpatient wards/units had among the

highest bank usage and agency usage across all core services:

Ward/unit Bank use (shifts) Agency use

(shifts)

Plans in place to address overuse

of temporary staffing

Rehabilitation unit

Cambridge Oxford

ward

975 2,242 Escalation beds have now been closed.

Recruitment to vacancies is ongoing.

There have been a large number of

health care assistants required to

provide one to one care for at risk

patients, but this has now reduced

Langley House 1,625 1,361 Escalation beds have now become

permanent so permanent staffing has

increased. Escorts and one to one

carer has been required, but this has

now reduced. On-going recruitment to

vacancies.

St Peters ward 1,357 674 Escalation beds have now been closed.

Recruiting to vacancies on-going.

One to one care has been required

for some patients, but this is now

being managed more carefully.

Holywell unit 1,331 643 Actively recruiting to all vacant posts.

However, highest proportion used to

manage patients requiring 1:1

supervision, as this is identified in the

enhanced care risk assessment.

These patients lack capacity and also

have a DOLs in place, are at higher

risk of falls and lack insight into their

level of need

(Source: Universal Routine Provider Information Request (RPIR) – P20 Nursing Bank Agency)

Nursing - Bank and Agency Non-Qualified nurses

From April 2017 to March 2018 the trust reported bank and agency usage for non-qualified

nurses in community health inpatient services as below:

Type of shift Total number of shifts

Shifts available 11,625

Filled by bank 6,154

Filled by agency 4,559

Shifts not filled 912

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(Source: Universal Routine Provider Information Request (RPIR) – P20 Nursing Bank Agency)

Medical locums

From April 2017 to March 2018 the trust reported agency usage for speciality doctors in

community health inpatient services as below:

Staff group Shifts available Agency shifts filled Not filled

Speciality doctor 1,343 844 499

The trust states that they do not currently have a medical bank due to low usage; however, one is

being set up via National Health Service Professional (NHSP) in 2018.

(Source: Universal Routine Provider Information Request (RPIR) – P21 Medical Locum Agency)

Suspensions and supervisions

During the reporting period from April 2017 to March 2018, community health inpatient services

reported that there was one case where a staff member is under supervision at Langley House.

(Source: Universal Routine Provider Information Request (RPIR) – P23 Suspensions or

Supervised)

Quality of records

Staff did not always keep appropriate records of patients care and treatment, not all patient

records were kept in secured areas. Several staff had difficulties navigating a new

electronic notes system, and not all records were completed in line with best practice.

During our inspection in April 2016 we found that patient records were not always

comprehensively completed for all patients, particularly at Danesbury Neurological Centre.

During this inspection we found that records we reviewed were not always comprehensively

completed or securely stored. We found some records were not completed contemporaneously

and some paper records did not contain the patient’s identity details.

On Simpson ward we found two patient’s NEWS observation charts did not contain patient

identification. At St Peters ward, used nursing handover sheets were collected in a tray left by the

nurse’s station and could be accessed by unauthorised people, and at Midway unit we found a

handover sheet on top of an unattended nursing station. Handover sheets were between six and

15 pages long and contained full patient identifiable details plus full clinical condition and social

circumstances. On St Peters ward, notes trolleys were lockable, but unlocked during our

inspection and were kept in the ward reception area. We highlighted these issues with staff during

our inspection.

The community hospitals had recently implemented an electronic record system. The system used

was one of the accredited systems in the government's programme of modernising IT in the NHS.

Nursing staff told us they had received training in the new system and managers told us extra

training was available to everyone, alongside a ward based ‘superuser’ who was confident in using

the system and could assist staff on duty. Some staff said they found it difficult to use the system

despite extra training and we saw this when they showed us patients records. Some nursing staff

said the system involved a lot of duplication and some units were still using paper based records

for some things, as well as the electronic version.

Therapy staff had used the electronic notes system before the nursing teams and most therapists

said they found the system helpful to them.

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Managers told us the electronic notes system would allow for greater quality and safety because it

could easily identify when patients’ risk assessments were carried out. Managers could identify

when there were gaps in patient assessments, and provide feedback to individual staff when

necessary.

All staff had access to patients’ notes which were written on the electronic system. This led to a

greater understanding of the patient’s condition because all documentation was stored together.

For example, nurses could view the therapists’ assessments and could check if doctors had

completed patient discharge letters, or referred the patient on to other services.

Compliance with record storage and documentation was audited. Documentation was reviewed

and monitored by senior staff. Audits carried out from December 2017 to March 2018, had

considered 25 sets of notes. The audits demonstrated that compliance had improved from 84% to

100%.

Care pathways were mostly completed in line with recommendations. We looked at 10 patient

records and found one patient did not have a fully completed care pathway for nutrition. The aim of

a care pathway is to enhance the quality of care by improving risk-adjusted patient outcomes and

promoting patient safety.

We reviewed 18 DNACPR forms in the inpatient units. A DNACPR form is a document issued and

signed by a doctor, after ensuring the patient can understand its implications, which tells the

medical team not to attempt cardiopulmonary resuscitation if the patient collapses. However, we

found that 10 DNACPR forms had not been completed in line with British Medical Association,

Resuscitation Council (UK) and the Royal College of Nursing, October 2014 guidance. Gaps in

form completion were largely due to a failure to document the decision of an indefinite DNACPR

and a failure to document the consultant review.

On Simpson and St Peters wards, the DNACPR forms were not reviewed following patient

transfers from local acute hospitals. The trust resuscitation policy stated that all documentation

should be reviewed and communicated to staff. Not all copies of the decisions regarding the

DNACPR status of each patient had been recorded in both the paper and electronic notes. During

our inspection we asked staff about patient’s resuscitation status. We were told that several

patients were for resuscitation however, their hospital records showed that DNACPR forms had

been completed. This was escalated to the inpatient ward sisters at the time of our inspection.

DNACPR forms were kept as paper copies in the patient notes and recorded on the electronic

notes system. DNACPR status was not recorded on the handover sheet which meant that some

staff may not have been able to access the information easily, for example agency staff. This may

have resulted in the wrong treatment being given.

There had been four incidents reported from September 2017 to August 2018 which related to

patient records, including one which related to a DNACPR form. There had been no themes

identified from the incidents reported.

Medicines

The service did not always prescribe, give, record or store medicines in line with best

practice. Patients did not always receive the right medication, at the right dose, at the right

time.

During our previous inspection in April 2016 we found there had been some anomalies in

medicines management, particularly at the Hertfordshire and Essex Hospital where there had

been three occasions where the Controlled Drugs (CD) checks had not been recorded. During this

inspection we found medicines management across the inpatient services had got worse.

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Pharmacy services provided to the inpatient units were under service level agreements with the

local NHS providers or with local private pharmacies, depending on unit. At Holywell and Midway

units, medications were supplied on individual prescriptions only, and a pharmacist visited the

units four days per week. At Hertfordshire and Essex hospital, medications were supplied by a

local NHS provider, and a pharmacist visited the units for half a day per week. We were told a

pharmacist visited each unit once per week to check patient prescriptions and ensure patients had

sufficient medication for their hospital stay. Nursing staff told us the pharmacy service were very

responsive and could supply medicines on the same day if required urgently. However, medicines

were generally not available out of hours. Nurses told us they would ring duty managers if a

medicine was required urgently.

Some of the inpatient units only had ‘patient own’ medications. This meant that all the medicines

were stored separately in individual boxes for each patient. Some wards had a limited availability

of stock medicines which could be used when required, for example Simpson ward. However,

there were no stock drugs on Holywell unit or Midway unit. This meant that staff did not have

access to routine medications such as simple analgesia, or laxatives and indigestion remedies.

The service used medication trolleys when carrying out medication rounds. At Hertfordshire and

Essex hospital there were nine medicines found across two trolleys which belonged to patients

who had been discharged between July and September 2018.

Nursing staff at the Hertfordshire and Essex Hospital told us they could administer some

medicines against a patient group direction (PGD). PGDs are written instructions which allow

healthcare professionals who are not prescribers, to supply or administer medicines to defined

groups of patients. This meant they could offer simple analgesia, for example, Paracetamol and

other medicines, to patients without waiting for a doctor to write a prescription. However, there was

no record available to state which staff had received training in PGDs and who was authorised to

administer medicine against the PGD. Staff on Holywell unit told us they did not use PGDs and

were unable to supply and administer simple medications without a written prescription from a

doctor. Staff told us most patients had simple analgesia prescribed as an ‘on request’ medication.

Following our inspection, we requested information from the service on the use of PGDs and we

were told that none of the inpatient units used PGDs.

Medicines used in the inpatient units were mainly stored in locked clinical rooms. On St Peters

ward there was no lock on the clinical room door, however, all medicines within the room were

locked inside cupboards. On Simpson ward, there was a lock on the clinical room door, however

we witnessed the door not being locked, slightly open and accessible to unauthorised people.

Medicines inside this room were not locked away in cupboards. We found Aspirin, Glycerine

Trinitrate, Naloxone, and Diazepam rectal suppositories in a box on the counter top. We

highlighted the open door to staff during our inspection and it was then locked. The medicine room

on Holywell unit was on the ground floor. We noted that the window to this room was large and

fully open. Metal bars were across the window; however, these were quite wide apart which

enabled the room contents to be fully observed. This lack in security was raised with the trust,

who alerted ward managers and pharmacists and added safe storage of medicines to the weekly

inpatient check list.

Medicines were all within their expiry date, except for one bottle of reconstituted antibiotics which

we found in the fridge on Simpson ward. This had been opened on 25 August 2018, with a use by

instruction of seven days from reconstitution. Staff disposed of this medicine during our inspection.

Controlled drugs (CDs) were stored in the medicines cupboard, there was a separate key for this

cupboard which was kept by the nurse in charge. CDs were mostly stored correctly according to

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the Misuse of Drugs (Safe Custody) Regulations 1973 and usage of CDs was recorded in secure

records, checked and administered by two nurses. CDs had been checked daily in line with trust

policy on all units except for Holywell unit where we found they had not been checked on 3 or 17

Sept 2018. We found on Oakmere ward south at Potters Bar hospital, the CD cabinet was made of

wood, which did not comply with the Misuse of Drugs (Safe Custody) Amendment 2007. This was

replaced shortly after our inspection.

Some medications can become less effective if exposed to heat and it is good practice to monitor

the temperature where medicines are stored. Most inpatient units monitored the ambient

temperature in the main drugs rooms daily, except for Hertfordshire and Essex Hospital where

there were frequent omissions, and from 1 to 11 September 2018, there were no temperatures

recorded. Room temperatures were largely within expected ranges across all units.

Temperature sensitive medicines were stored in fridges. However, fridge medicines were not

always stored within the required temperature range. Fridge temperatures had exceeded the

maximum in Holywell unit on 15,16,17, and 18 September 2018 and for 15 days in August 2018.

The only action recorded was to ‘reset’ the temperature.

At Midway unit, fridge temperatures exceeded their recommended range from 3 September 2018

through to 6 September 2018 with no actions logged.

At Hertfordshire and Essex hospital, fridge temperatures were not being monitored at the

weekends and when the housekeeper was away. The maximum fridge temperatures had gone

above 8 degrees on several occasions, however no actions or escalation were recorded. The ward

manager did not know what action had been taken.

After our inspection the trust informed us that processes had been put in place to monitor and

escalate any deviances from recommended temperatures for the storage of medicines.

Emergency medicines were readily available, were stored securely and checked regularly.

However, on Holywell unit we saw that the supply of water for injections in the resuscitation trolley

was in a sachet format and was not in an ampoule. This meant that water for injections, required in

the event of an emergency was not available. We highlighted this as a concern during our

inspection and we were told this would be rectified immediately.

Not all patients received all the medicines they had been prescribed.

We looked at prescription charts at all the sites we inspected as follows.

• Hertfordshire and Essex Hospital:

o We looked at four prescription charts. Not all medicines had been signed for.

Nurses we spoke with said they were unsure if the medicines had been

administered and suggested staff may have given it, but had forgotten to sign to say

they had.

• Danesbury unit:

o We looked at six prescription charts. Three of them had not always been signed to

indicate medicines had been administered. This included one patient with 15

unsigned medications. We highlighted this to the ward manager during our

inspection. Holywell unit:

o We looked at two prescription charts and saw one unsigned medication.

• St Peters unit:

o We looked at two prescription charts and saw one unsigned medication.

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• Simpson ward:

o We looked at three prescription charts and saw two unsigned medications.

• Potters Bar hospital:

o We looked at six prescription charts and found that five had gaps in medicines

administration. The ward sister told us the gaps were due to a shortage of staff on

26 September 2018, when there were only two nurses on duty and no health care

assistants, however we didn’t find an incident report to correspond to this.

Unsigned for medications included antibiotics, analgesics, anti-epileptics, anti-hypertensives, and

deep vein thrombosis prophylactics.

Not all patients received the medicines they had been prescribed in a timely manner. On

Simpson ward the 8am medication drugs round was still ongoing at 10.30am and at the

Hertfordshire and Essex Hospital we saw that one medicine, out of stock from 15 September

2018, had not been ordered until 18 September following our intervention.

Not all patients had been prescribed the correct medicine. At Danesbury unit we saw a

prescription for an antiretroviral medicine which had been prescribed incorrectly (wrong dose).

This had not been noticed for 20 days when it was identified by the pharmacist and corrected.

We also saw a prescription for an antidepressant which had been prescribed at a dose of 150mg,

instead of 30mg. On investigation, we found that this patient was self-administering their

medication, and was in fact taking the correct dose. However, nurses had signed to say 150mg

had been taken each day. We saw a prescription for paracetamol which had been prescribed in

such a way, that if all had been given, the patient would have exceeded the recommended daily

dose. However, a nurse had recognised this error, so it had not been given.

Following our inspection, the trust told us it did not do audits that checked patients had received

the correct medication and at the time in was prescribed, although it had carried out some audits

including controlled drugs management, high-risk medicines, and antibiotics use. The audit gap

had been identified and was raised for discussion, however, due to a lack of pharmacy capacity,

the audits had not been undertaken. After this was raised by us this was added Trust Risk

Register.

Patients’ weights had not been recorded on medication charts which is best practice to ensure

correct doses of medication were prescribed, although they were recorded on the electronic

records system. After our inspection the trust implemented weekly assurance checks to ensure

patients weights were recorded on medication charts on admission and if a new weight was

recorded.

Prescription charts we checked contained details of patients known allergies.

The community hospitals had reported 40 medication incidents from September 2017 to August

2018. Most of these were due to medication errors. There were 13 incidents reported which

related to medication charts – either missing charts, or charts which were confusing due to

transcribing errors, or to duplicate charts. Nursing staff told us it was difficult to get prescriptions

changed or written out of hours.

We observed nursing staff administering medicines in line with the Nursing and Midwifery Council

Standards (NMC) for Medicines Management. Staff ensured they checked the patient identity

confirming the patients name and date of birth verbally, as well as checking their wrist band.

Nurses carrying out the medication round wore a red tabard. This identified them to other staff,

patients and members of the public not to disturb the nurse while they were administering the

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medication. This is a recognised national approach to improve the effectiveness of a drug round

and reduced incidence of medication errors. However, on Simpson ward the nurse was called to

carry out additional tasks several times during the drug round. This included taking patients to the

bathroom, and assisting with personal hygiene.

Medicines management training was not part of the services mandatory training programme.

Ward managers told us new staff were assessed to ensure they were competent to administer

medications before being allowed to carry out the medication rounds, and that following an error,

extra training and support had been provided.

Incident reporting, learning and improvement

Staff recognised incidents and reported them, but not all incidents where categorised

correctly. It was difficult to ascertain the correct number of each type of incident.

Staff understood their responsibilities regarding reporting incidents. The trust used an electronic

reporting system that all staff had been trained to use. Teams and the organisation learnt from

incidents and there was evidence of clear action planning following reviews.

Managers investigated incidents and shared learning with the whole team and the wider service.

Examples of incidents that were reported included medication errors, pressure ulcer incidents and

falls.

From September 2017 to August 2018 there had been 781 incidents reported across the inpatient

services. We were unable to break the number of incidents down by hospital site. 492 incidents

had been reported as no harm and 268 incidents had been reported as low harm. Five incidents

had resulted in severe harm and 12 had resulted in moderate harm. Most incidents, 223 were

reported due to patient falls.

The type of incident was not consistently recorded. For example, in addition to the 223 patient

falls, recorded under ‘patient falls’ type of incident, there was a further 162 incidents reported as

‘patient accidents’ which were also mostly patient falls. Four incidents were recorded as ‘other’

which were also patient falls. We saw that 31 incidents had been classed as ’infection control’ type

incidents, however there were also 16 instances of patient infection which had been reported

under ‘delay or failure to monitor’. We asked staff about this during our inspection and they told us

categories of falls were often changed by the investigating team. Staff had undergone training to

use the electronic online incident reporting system, however, this did not include training on

categorising incidents. Following our inspection, we requested further information from the trust

about incident categorisation. They told us when an incident is reported staff categorise the

incident according to where the most significant risk lies. The incident is then escalated to the

manager to review the incident and at this point the incident category may be amended if

necessary.

Incidents were discussed at team meetings and we saw evidence of this. Nurses told us about an

incident which involved a patient falling. Changes in practice as a result of the fall included the

introduction of 30 minute observation checks for each patient who had fallen to be carried out for

three days, or longer if there were still concerns about the patient’s safety.

Staff we spoke with understood their responsibilities regarding duty of candour. Ward managers

explained that if any incident caused harm to a patient, a formal letter was issued by the service

and the incident was discussed with the patient and their family. Patients would be advised about

the root cause of any errors and would be provided with copies of the investigation if required.

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Never events

Never events are serious patient safety incidents that should not happen if healthcare providers

follow national guidance on how to prevent them. Each never event type has the potential to cause

serious patient harm or death but neither need have happened for an incident to be a never event.

From August 2017 to July 2018, the trust reported no never events in its community health

inpatient services.

(Source: Strategic Executive Information System (STEIS))

Serious Incidents

Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).

These include never events (serious patient safety incidents that are wholly preventable).

In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents

(SIs) in its community health inpatient services which met the reporting criteria set by NHS

England from August 2017 to July 2018.

There was one SI each of the following types:

• Abuse/alleged abuse of adult patient by staff

• Slips/trips/falls.

(Source: Strategic Executive Information System (STEIS))

Serious Incidents (SIRI) – trust data

From April 2017 to March 2018, trust staff within community health inpatient services reported

five SIs. Note the earlier time period compared to the previous section.

Despite the earlier time period, these include the two SIs reported through STEIS that are listed

in the previous section.

Of these, none involved the unexpected death of a patient.

The breakdown by incident type was as follows:

• Slips/trips/falls: two

• Abuse/alleged abuse of adult patient by staff: one

• Healthcare associated infection/infection control incident: one

• Sub-optimal care of the deteriorating patient: one

The breakdown by site and incident type is detailed below.

Danesbury Home

One “slips/trips/falls”. incident in May 2017 that resulted in hydrocephalus diagnosed post fall.

Hertfordshire and Essex Community Hospital

One “healthcare associated infection/infection control incident” incident in March 2018 when

outbreak of norovirus resulted in some bed closures.

Langley House

One “abuse/alleged abuse of adult patient by staff” in September 2017.

Potters Bar Community Hospital

Two SIs. These was one SI each of the following types:

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• Slips/trips/falls in September 2017 resulting in fractured neck of femur

• Sub-optimal care of the deteriorating patient in June 2017 relating to burns and

management of a category 3 pressure ulcer.

(Source: Universal Routine Provider Information Request (RPIR) – P29 Serious Incidents)

Prevention of Future Death Reports (Remove before publication)

The trust has not had any deaths requiring Coroner's Inquest in the last 12 months for community

health inpatient services.

(Source: Universal Routine Provider Information Request (RPIR) – P76 Prevention of future

death reports)

Safety performance

The service used safety-monitoring results well. Staff collected safety information and

shared it with staff, patients and visitors. The service used information to improve safety.

The senior hospital staff explained the actions they took to minimise the risk of avoidable harm.

They monitored the use of patients’ risk assessments and the use of the NEWS observation charts

and post falls checklists.

Each unit displayed safety information in the public areas using a ‘safety cross’ system. The

information included: the number of falls; the number of pressure ulcers; the number of bed days

lost to diarrhoea and vomiting (D&V); cleanliness audit results; the number of complaints and staff

sickness. For example, on Simpson ward in August 2018, there had been zero days lost to D&V,

zero cases of new pressure ulcers, and zero cases of falls. On Midway unit in August 2018, there

had been two falls, zero acquired pressure ulcers and zero days lost to D&V.

Safety Thermometer

The Safety Thermometer is used to record the prevalence of patient harms and to provide

immediate information and analysis for frontline teams to monitor their performance in delivering

harm free care. Measurement at the frontline is intended to focus attention on patient harms and

their elimination.

Data collection takes place one day each month. A suggested date for data collection is given but

wards can change this. Data must be submitted within 10 days of suggested data collection date.

From June 2017 to June 2018 the trust reported 14 new pressure ulcers, 97 falls with harm and

100 new urinary tract infections in patients with a catheter within all community inpatients wards.

There were peaks in prevalence of both new pressure ulcers and falls with harm in September

2017, while there was a peak in prevalence of new Urinary Tract Infections (UTI’s) in patients with

a catheter in August 2017. There were peaks in prevalence of new UTI’s in patients with a

catheter and new pressure ulcers in February and March 2018 respectively.

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Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter urinary tract infections at Hertfordshire Community NHS Trust – all community inpatients wards

(Source: NHS Safety Thermometer: https://www.safetythermometer.nhs.uk/index.php/classic-

thermometer)

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Is the service effective?

Evidence-based care and treatment

The service provided care and treatment based on national guidance and evidence of its

effectiveness. Managers checked to make sure staff followed guidance.

Policies were up to date and followed guidance from the National Institute for Health and Care

Excellence (NICE) and other professional associations. Local policies, such as the infection

control policy were written in line with national guidelines. Policies were available on the trust

intranet and clinical staff we spoke with knew how to access them.

Relevant NICE guidelines, quality standards and other good-practice guidance, for example

prevention and management of pressure ulcers and stroke rehabilitation were used. This provided

patients with long-term conditions a clear personalised care pathway and aimed to improve the

rehabilitation for people who have had a stroke. Patients had a personalised treatment plan which

was underpinned by evidence based healthcare. Treatment plans contained realistic patient

reported outcome measures.

Patients were assessed using recognised risk assessment tools. For example, the risk of

developing pressure damage was assessed using the Waterlow Score, a nationally recognised

practice tool. Staff undertook falls risk assessments using the Morse fall score and completed

post-fall check lists following patient falls. Patients’ dependency was measured using the

Northwick Park dependency score, and patients’ balance was assessed using the Berg balance

scale. These assessment measures allowed staff to provide each patient with the right amount of

support and supervision to keep them safe while in hospital.

The service was working towards the11 standards in the National Service Framework for Long

Term Conditions and was currently following NICE Guidance for Parkinson’s Disease and Multiple

sclerosis in the neurological rehabilitation units.

Nutrition and hydration

Staff gave patients enough food and drink to meet their needs and improve their health.

Adjustments were made to take into account patients’ religious, cultural and other

preferences.

Nursing staff completed nutrition and hydration assessments using the Malnutrition Universal

Screening Tool (MUST) on admission, for each patient. Dieticians assessed all patients whose

nutritional needs were highlighted as a risk. Danesbury unit had a full-time dietician based on site

and other units had dieticians who visited daily or when required following a patient referral. Staff

had access to advice from speech and language therapists (SALT) and we saw that the SALT

team worked closely with nurses and other therapy staff to ensure patients received appropriate

food, for example softened diets, to meet their needs.

Patients who required their nutrition through a tube into their stomach (enterally) had their needs

assessed by a dietician. We saw that enteral nutrition was provided for patients on the stroke and

neurological rehabilitation units. Alternative texture meals were available for people with

swallowing difficulties and thickeners were added to drinks for some patients to allow them to drink

fluids safely.

Food and fluids were placed within patients’ reach and those who required assistance with eating

and drinking were identified in the initial care assessment, and provided with red trays at

mealtimes. Fluid balance charts were completed for patients whose hydration was an identified

issue. Hydration was monitored during the two-hourly care rounds and recorded in the patients’

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records. We looked at food records and found these were mostly completed and up to date. Fluid

balance charts were not always comprehensively completed and that totals at the end of the day

were not normally added up to indicate either a positive or negative fluid balance.

Specific food care plans were available for patients with certain medical conditions, for example,

those undergoing kidney dialysis. We saw that the food charts suggested safe alternative food

types which enabled patients to achieve the right amount of nutrition without compromising their

health.

Pain relief

Patients’ pain was assessed, we saw evidence that analgesia prescribed was administered.

Patients told us that their pain was adequately controlled. They told us that pain relief was offered

and given when it was requested. Pain scores were recorded using a numeric rating scale on the

NEWS record sheet. We saw this was being used correctly. Staff also recorded pain scores on the

electronic notes system.

The Abbey pain scale is a pain assessment tool for patients who cannot express how they are

feeling, for example, patients who have dementia or communication difficulties. Staff we spoke

with were aware of this pain assessment.

Patients were offered analgesia before therapy sessions. This provided patients with pain relief to

enable them to complete their rehabilitation sessions. This meant that they continued their therapy

and increased their long-term mobility.

Patient outcomes

The service monitored its effectiveness of care and treatment and used the findings to

improve them. They compared local results with those of other services to learn from them.

All patients admitted to the service for rehabilitation underwent the Patient Specific Functional

Scale (PSFS). The PSFS is a measure which allows staff to know if is making a difference to each

patient. The PSFS was based on a patient’s self-assessment of their ability on admission, and

then continued self-reassessment on their abilities throughout their hospital stay, to see if set

goals had been achieved. Therapy staff told us these outcomes were not audited and therefore

they were unaware of how effective overall patients’ treatment and rehabilitation had been.

We asked how effectiveness was measured. We were told that patients outcomes were measured

in relation to percentage of days of harm free care, For example percentage of days without a

pressure ulcer or a reduction in falls with harm. We were not provided with the results of these

audits, or of evidence that the service compared its results with other similar providers.

Some monthly data was collected and audited by the service. This included hand hygiene and

cleanliness audits. Each ward manager collected monthly data for their business unit performance

review (BUPR). This reported on quality, workforce, performance and finance. Senior staff told us

the BUPR provided a dashboard of data that was used to identify trends and improve the service

by altering polices or working practices.

The community inpatients service told us they were on target to meet their Commissioning for

Quality and Innovation National targets(CQUIN) for 2017- 2019 in the following areas:

• Personalised Care and Support Planning

• Improving the assessment of wounds

• Preventing ill health by risky behaviours

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• Pro-active and Safe Discharge

• Introduction of health and wellbeing initiatives- Option B

• Improving the Uptake of Flu Vaccinations for Front Line Clinical Staff

• Healthy food for NHS staff, visitors and patients.

Therapy staff told us they encouraged all patients to get out of bed and wear their own clothes

while in the rehabilitation units. They were taking part in promoting the end PJ Paralysis

Campaign, which was a campaign launched by National Health Service Improvement (NHSi) in

Spring 2018.The campaign aimed to improve patient outcomes by getting them out of bed, into

their own clothes, and get moving to boost their recovery. We saw that patients were mostly

dressed in their own clothes and out of bed, except on Simpson and St Peters wards, where most

patients remained in hospital nightwear and were in bed.

Therapy leads told us they used length of patient stay as a measure of their effectiveness, and

that at Danesbury and Holywell units, length of stay had been reduced from 42 days, to 32 days.

Audits – changes to working practices

The trust did not participate in any clinical audits in relation to community health inpatient services

as part of their Clinical Audit Programme.

(Source: Universal Routine Provider Information Request (RPIR) – P35 Audits)

The trust participated in 12 clinical audits in relation to this core service as part of their Clinical

Audit Programme.

Audit name Area covered Key Successes Key actions

National

Parkinson's Audit

NCAPOP Quality

Account Audit

2017/18

Neurological

Service

100% cases

submitted -

minimum of 10

responses for

Speech and

Language Therapy,

Occupational

Therapy and

Physiotherapy.

Full report still to be

issued, so cannot

yet demonstrate

where practice has

been changed.

Report yet to be

presented.

National Sentinel

Stroke National

Audit Programme

(SSNAP) NCAPOP

Quality Account

Audit 2017/18

Community

Hospitals and

all Integrated

Community

Teams

Ongoing data

collection from 1

November 2013 -

data submitted for

737 in 2017/18.

As part of the

Sentinel Stroke

National Audit

Programme

(SSNAP) our Acute

No key actions.

134

Therapy Services

(Occupational

Therapy and

Physiotherapy) at

the Achieving the

rating of ‘A’ puts the

Service in the top

23% out of 215

stroke services

across the country.

SSNAP audit

results [Q3 2017]

(released to the

public in March)

show that

Danesbury have

maintained their `A`

rating and Holywell

have achieved their

first `A` rating.

National COPD

Rehabilitation Audit

NCAPOP Quality

Account Audit

2017/18

Pulmonary

Rehabilitation

Service

Data submitted for

118 eligible

patients’

Organisational

questionnaire

completed.

Full report is to be

presented to

Clinical

Effectiveness

Group in August

2018, so cannot yet

demonstrate where

practice has

changed.

Report yet to be

presented.

ANNUAL NHS

Safety

Thermometer

(Pressure Ulcers,

Falls, Catheters,

Urinary Tract

Infections and

Venous

Thromboembolism)

National. (12)

Community

Hospitals and

all Integrated

Community

Teams

• For the year

2017/18 there has

been a significant

decrease in the

number of

avoidable category

2 pressure ulcers.

• Increased scrutiny

of all avoidable

pressure ulcers has

demonstrated that a

high percentage of

those patients with

• Record all harms

documented are

accurately recorded

as ‘new’ or ‘old’ in

line with Safety

Thermometer

criteria.

• Continue to meet

and discuss actions

at the Pressure

Ulcer/Tissue

Viability Forum to

maintain the focus

135

avoidable pressure

ulcers receive joint

care, either from a

carer at home or in

a residential home.

• Analysis of data

has also highlighted

that the majority of

patients referred

onto HCT’s with an

existing pressure

ulcer are either in

their own home or a

residential home.

on pressure ulcer

prevention.

• Work in

partnership with

Princess Alexandra

Hospital and a

commercial

dressings company,

to deliver a training

programme for

residential home

and home-care

providers to upskill

the local workforce.

• A train-the-trainer

programme will also

be delivered to

managers to

provide

sustainability of

knowledge.

• Employ a staff

member to be

seconded into the

Community

Equipment Service

to support

equipment provision

and training thereby

maintaining close

working

relationships.

• Task and Finish

Project to review

the use of the

Waterlow risk

assessment tool to

evaluate whether it

meets the needs.

An alternative,

PURPOSE T, is

being considered.

• Continue to focus

on the reduction of

pressure ulcers and

the improvement of

wound care

136

management as a

Quality Priority.

National Audit of

Intermediate Care -

NAIC NCAPOP

Quality Account

Audit 2017/18 (4)

Bed Based IC,

home based IC

and re-

enablement

services

Intermediate Care

Teams/Community

inpatient units: 65

questionnaires

submitted

Community ICT

Teams: 52

questionnaires

submitted

• Dependency

levels recorded

were 31% for

homebased, 35%

for bed-based and

36% for re-

ablement services.

• The dependency

levels of people on

admission, and the

improvements

made during their

stay, were similar to

the 2015 results for

home and re-

ablement services.

• Over 96% of

service users

replied ‘yes –

definitely’ to the

question ‘I was

aware of what we

were trying to

achieve’.

• Over 91% of

people felt they had

been treated with

dignity and respect.

Evidenced that we

are treating people

with respect and

kindness.

It is suggested that

the audit content is

reviewed in the light

of the NICE

Guidelines issued in

2017: NICE

guideline, NG74

Intermediate care

including re-

ablement.

• Share results at

the Operational

Senior Management

Team

(OSMT)/Operational

Services at HCT to

identify whether

there is any learning

to be shared

(feedback at CEG

meeting in October

2018 once this work

stream has been

undertaken).

• Work with

Operational Teams

to improve the

Average Length of

Stay in hospital.

Work has been

done with the

CCGs, in particular

Hertfordshire Valley

to address this and

improve practices.

• Work with the

Acute Trusts and

the local CCGs to

improve the winter

pressure planning

and ensure

admission criteria

are being followed.

Falls and Fragility

Fracture Audit

Programme:

Bed Bases • 73% of

Trusts/Community

Hospitals report all

• National report

findings discussed

at the Falls Working

137

National audit of

inpatient falls.

NCAPOP Quality

Account Audit

2017/18 (5)

severe harm

incidents. 92% said

there is an

executive director

who has specific

roles/responsibilities

for leading falls

prevention.

• 97% answered

that the information

on the number of

falls is routinely

presented and

discussed at most

falls prevention

working group

meetings.

• Lying and

standing Blood

Pressure (BP)

results [Q3

2017/18] showed

that 27% of patients

(41/151) had their

lying-standing BP

monitored. Potters

Bar Community

Hospital (63%) and

Langley House

(59%) were the

units where most

patients had been

monitored whilst

Holywell,

Danesbury and

Hertfordshire and

Essex Hospital

were the units

where fewest

patients had been

monitored (all 0%).

This shows how the

majority of falls are

reported, acted on

and learning is

disseminated.

Group (FWG).

• Collaborated with

West Hertfordshire

Hospital Trust, East

and North

Hertfordshire Trust

and Hertfordshire

Partnership

Foundation trust, to

share good practice

and learning –

actioned 8th

December 2017.

• Guidance and

training for the

assessment of lying

and standing BP

Rolled out.

• Inpatient falls

policy aligned with

NICE guidance.

Policy due to be

ratified 25th June

2018 at the Patient

Safety and

Effectiveness

Group.

• Monitor

improvements as

part of quarterly

snapshot audits. (In

progress).

An Audit on the

MUST Score and

Adult

Community

• The MUST Score

was recorded in

• SystmOne used to

ensure that the

138

Use of Oral

Nutritional

Supplements

(ONS) - Re-audit

(14)

Hospitals:

Nutrition &

Dietetics

91% of patient

notes.

• In 86% of cases,

the MUST score

was calculated

correctly.

• In 94% of cases,

the weight had

been calculated.

• The height was

calculated in 64% of

cases, and

estimated only in

30% of cases.

• MUST is being

completed correctly

by ward staff in

86% of patients in

the HCT bed based

units. 21 patients

had a score that

was incorrect. On

two comments

made this was

related to the

incorrect calculation

of the % weight

loss.

Highlighted the

need for further

nurse training to

ensure MUST score

is calculated

correctly.

software used for

MUST calculations

reflects a realistic

time frame to report

% weight loss.

• Patients who are

admitted to an

inpatient unit and

have a MUST score

of less than 2 have

their prescribed

ONS discontinued

and the patient

encouraged to

choose high protein,

high energy option

snacks between

their meals.

• MUST training

(face to face) is

facilitated by the

Dietitians across the

Community

Hospitals to

empower the ward

staff to promote a

food first approach

and is an important

component of

nursing care. MUST

training is available

as e-learning for

staff working on the

wards to be

undertaken at an

agreed time period.

Infection Control

(IPC) (40)

Environment/Safety

Audit - includes

Sharps Safety (I)

Hand Hygiene (ii)

MRSA Screening

(iii) Urinary

Catheter Care (1)

Insertion and (2)

Continuing Care

(iv) Peripheral

Bed Bases

monthly audits:

Integrated

Community

Teams quarterly

audits: Health

Visitors, MIU

(HEH) RAU

(SACH) Dental

service.

All audits reported at the Infection Prevention

and Control Forum.

139

Vascular Catheter

(v) Enteral Feeding

(vi) Commode (vii)

a) Hand Hygiene

Urinary catheter

care insertion and

continuing care.

Vascular devices b)

Hand Hygiene

Environment/safety

audit (and specific

dental service

audits).

Oral Care Audit -

Hyper Acute /

Acute Stroke Lister

(56)

Adult Speech

and Language

Therapy

• 147 oral hygiene

assessments in

total were done

over the two week

period (excluding

refusals or where a

patient was

unwell/unable to

tolerate)

• Of these, 14

dysphagia

assessments were

unable to be carried

out due to poor oral

hygiene

(approximately

10%)

Only 2% (4/147)

assessments were

rated as 'Severe,'

with 70% (103/147)

being rated as 'Mild

Need'.

• Patients have a

documented record

of receiving oral

hygiene received

(prioritising at risk

patients).

• Increased

education of Nurses

and Health Care

Assistant’s (HCA's)

in the East and

North Hertfordshire

Oral Hygiene

Assessment Tool is

required.

• Sponges are

withdrawn – Trial

and pilot of

replacements e.g.

Moutheze (re-

usable) brushes in

the next month.

Community

Hospital Catheter

Passport Audit (80)

Bed Bases • 100% of patients

have a catheter

care pathway in

place

• 68% (13/19) of

patients with an

indwelling catheter

had a catheter

passport

• 61% (11/18) of the

patients had a plan

for discharge in

• Training on the

revised Syringe

Pump Policy

(including the

importance of why

the patient and

family should be

provided with the

patient information

leaflet) – ongoing as

all staff have to

attend an annual

140

place

100% (19/19) of the

patients had a

catheter care

pathway in place

update.

• Training on the

Individualised Care

Plan for the Dying

Patient (to ensure

that staff

understand why this

is used and when to

implement it).

Continual training

now introduced via

several different

training sessions

offered to HCT staff.

• Ensure all new

Band 5 and 6 staff

have palliative care

competencies

(within the

competency

booklet) and signed

off within 3 months

of starting with

HCT. Band 6 and

Band 7 mentors

now review

competency booklet

to provide

assurance of

completion. (Action

complete).

• Report findings at

the CEG meeting in

February 2018.

(Action complete).

• Monitoring via re-

audit by the Clinical

Professional Lead

(Nursing).

Community

Hospital Catheter

Passport Audit (81)

Re-audit

Bed Bases • Over 60% of the

Community

Hospitals wards

had details of the

date and time of

Catheter recorded

for initial insertion.

100% of Wards had

plans in place to

• Ensure details of

insertion completed

in the catheter

passport

• If there was no

discharge plan,

ensure information

is recorded

141

inform the District

Nurse/GP/Care

Agency when the

patient was

discharged.

• Re--audited again

3 months later.

Plus size patients

management audit

(46)

East & North &

Hertfordshire

Valleys (adult

bed bases,

ICTs and clinic-

based services

- leg ulcer,

podiatry,

diabetes,

bladder & bowel

• 90% (18/20) of

staff were aware of

the management of

plus-size patients

policy

• 70% (14/20) were

aware of the risk

assessment tools

for plus size

patients.

• 95% of staff were

aware of how to

report an incident

related to the

moving and

handling of a

patient.

• 90% (18/20) staff

would know how to

report moving and

handling equipment

if it is not fit for

purpose.

• In response to the

question, ‘Are you

aware of how to

access moving and

handling and other

specific equipment

for plus-size

patients?’, 18

responded

positively (90%).

Over 90% of staff

were aware of how

to manage and

handle plus-size

patients effectively,

in accordance with

HCT's management

of plus size patients

policy (2015).

• Re-launch of the

plus size patients

policy following

review with a

requirement for

managers to ensure

that staff are aware

of the content of the

policy, specifically

relating to the risk

assessments,

patient pathway and

processes to be

taken when

accepting plus size

patients on referral.

• There was an

apparent lack of

awareness of which

trust director is the

nominated

responsible person

for risk and health

and safety. This

was addressed

through the re-

launch of the policy

and training.

• All staff who

provide care for

plus size patients

should be aware of

how to order

appropriate

equipment; this is

addressed through

raising awareness

of the policy and

through manual

handling training

sessions.

(Source: Universal Routine Provider Information Request (RPIR) – P35 Audits)

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Competent staff

Staff were sufficiently qualified and had the right qualifications, skills, training and

experience to keep people safe from avoidable harm and abuse and to provide the right

care and treatment. Managers appraised staff’s work performance and held supervision

meetings with them to provide support and monitor the effectiveness of the service.

Role specific training requirements were allocated to staff for example, registered nurses were

expected to complete resuscitation training level 3, and healthcare assistants received

resuscitation level 2; clinical staff received manual handling, people and non-clinical staff received

training manual handling, object.

Managers had oversite of the staff training compliance. The community hospitals provided a list of

competencies that were non-compulsory. Staff we spoke with said they had completed extra

training sessions to provide evidence of ongoing professional development. For example,

continence and male and female catheterisation.

Some senior nursing staff had attended, or were currently attending leadership and management

training programmes. Managers told us the course had helped them to develop their leadership

skills and to carry out the necessary tasks needed to manage a community inpatient ward. This

included sessions such as difficult conversations with staff, return to work interviews and appraisal

training. Band six nurses were encouraged to attend training workshops specific for their role,

including staff appraisals. Band five staff nurses attended mentorship training so that they could

train nursing students while they were on their practical placement from university.

Therapy staff we spoke with said that the trust supported them in the learning beyond their

registration. This allowed the therapy teams to access both inhouse and external training updates

and conferences. Some therapy staff had completed masters training, for example in stroke

patient rehabilitation.

Clinical Supervision

Nurses told us clinical supervision was available if required. Clinical supervision is an activity that

brings skilled supervisors and practitioners together to reflect upon their practice. At Holywell unit,

we saw a poster with dates listed for the forthcoming clinical supervision sessions for therapy staff.

The trust provided the following information about their clinical supervision process:

Supervision is delivered in line with the clinical supervision framework policy; supervision

happened in groups - action learning sets; individual supervision and informal support to enable

staff to reflect on their practice. There was no formal prescription of either frequency or percentage

compliance.

Supervision was managed and monitored, however, there was a variation in the robustness of

processes and recording. Data from 2017 identified gaps where supervision did not happen or was

incorrectly recorded.

Further work was being undertaken in the trust to enable improved access to supervision,

including development of formal groups within services by the locality quality leads and more

robust monitoring systems.

(Source: CHS Routine Provider Information Request (RPIR) – CHS4 Clinical Supervision)

Appraisal rates

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From April 2017 to March 2018, 92.3% of staff within the community health inpatient services had

received an appraisal compared to the trust target of 90%.

(Source: Universal Routine Provider Information Request (RPIR) – P39 Appraisals)

During our inspection in April 2016, we found most staff had received an appraisal in the previous

12 months, except at Langley House and Hertfordshire and Essex Hospital where the rate was

78%, against the trust target of 90%. During this inspection we found appraisal rates across the

inpatient units were 92%. We were not provided with a breakdown of appraisal rates at each site.

At Simpson ward, the manager told us their appraisal rate was 99%.

The trust’s appraisal policy stated that all staff were required to have an annual appraisal. Staff we

spoke with told us their appraisal had been useful, and that they had been given agreed objectives

for the following year.

Multidisciplinary working and coordinated care pathways

Most staff of different disciplines worked together as a team to benefit patients. Doctors,

nurses and other healthcare professionals supported each other to provide good care.

Relevant professionals were involved in the assessment, planning and delivery of patient care. We

observed good working relationships between a range of health professionals within the service.

Members of the multidisciplinary team (MDT) had access to each other’s notes and assessments.

We observed good working relationships between staffing groups and comprehensive MDT

working practices. We observed a close working relationship between the allied health and nursing

leads. The staff included nursing staff, rehabilitation assistants, occupational therapists,

physiotherapists, and doctors. Updates regarding specific patients were shared, specific patient

care needs were discussed and any relevant incident learning was shared during ward handovers.

Some staff in different units told us that nurses and therapists did not always work together for the

benefit of patients. A physiotherapist told us they believed it was not their job to assist patients to

the bathroom during or after their therapy session. A nurse told us that not all therapy staff were

willing to help with basic patient care when nurse staffing was short. A therapist told us that some

nurses failed to carry out their therapy recommendations for each patient on a weekend.

Therapy leads told us they were providing training for nursing staff to increase their confidence

provide weekend therapy. Therapy assistants were also being developed to assist with some

health care assistant roles.

We observed the consultant ward round at Simpson ward. There was positive interaction between

the doctor, patient and nursing staff. There was a communication book to ensure doctors reviewed

relevant patients, received results from investigations and updated medication charts. Nursing

staff escorted the doctor when they visited patients and care was planned and agreed

There were weekly multidisciplinary team (MDT) meetings involving all disciplines of staff at the

inpatient units. We observed an MDT meeting at Holywell unit and found it was well attended and

carried out to the benefit of patients using the service. Medical, therapy and nursing staff were

joined by social workers and unit managers. The goal of the MDT meeting was to promote the

patient’s care sufficiently so they could be discharged from the unit as soon as safely possible.

There was an emphasis on maintenance at home and admission avoidance strategies.

Documented discussions were held around patient’s care needs.

Health promotion

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Patients and their relatives were supported to manage their own health and well-being, and to

maximise their independence wherever possible.

We saw a wide range of health promotion material available to patients during our inspection.

Posters were displayed throughout the units which promoted healthy living, including, for example,

dietary advice, exercise advice, alcohol and smoking advice.

The units provided a range of health information leaflets for patients and relatives, including

dementia information, pressure ulcer and falls prevention.

Notice boards contained contact details for support services, including for dementia support

service, stroke community groups, as well as details of care agencies and where to obtain advice

about welfare benefits and financial assistance.

The smoking status of patients was recorded in the service’s electronica data system and in April

2018, 95% of all patients had a smoking status documented in their care records.

In December 2017 the trust rolled out, ‘my health plan’ which specifically helped to support

patients to identify their own personal health goals. Alongside this, 90% of patient facing staff

received training in how to have conversations with patients that promoted self-care.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the

Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health

and those who lacked the capacity to make decisions about their care. However, policy and

best practice was not always followed when a patient lacked capacity to make their own

decisions.

Staff understood their roles and responsibilities regarding the Mental Capacity Act 2005. Staff we

spoke with described the process they would follow should someone be found to not have mental

capacity to agree to treatment or be able to make decisions in relation to their care.

Nursing and therapy staff understood the trust’s process for completing the necessary

assessments and referrals when they suspected a patient might be experiencing mental ill health.

Nursing staff told us the assessments were undertaken by two staff together, and usually involved

a band six nurse or above and a therapist or social worker.

Staff could demonstrate where to access guidance on the Deprivation of Liberty Safeguards policy

(DoLS) and Mental Capacity Act (MCA) using the trust’s electronic database. DoLS is the

procedure prescribed in law when it is necessary to deprive the liberty of a resident or patient who

lacks capacity to consent to their care and treatment to keep them protected from harm.

Staff demonstrated an understanding of fluctuating capacity and ensuring patients were in the best

environment to enable them to make informed decisions about their care. We were shown the

assessments which had been carried out on a patient in Danesbury unit and saw that they

followed guidance. Ward managers explained that they would apply for a DoLS if there was a

confused patient who needed to be kept on the unit for their own safety. We saw a patient under a

DoLS who was nursed with one to one support.

Some patients with a DNACPR form were deemed to have lacked capacity. However, there was

no evidence of a documented MCA assessment being carried out in the patient’s notes. Mental

capacity assessment guidance recommends that where long-term or significant decisions are

made in relation to a person who may lack capacity, professional staff must keep a record of how

capacity was assessed and of how any decisions about that person have been made. Out of the

eighteen DNACPR forms reviewed, nine patients were deemed to be lacking in capacity. Out of

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the nine patient records, no MCA forms were documented in either paper or electronic records.

This was escalated at the time of our inspection.

Mental Capacity Act and Deprivation of Liberty training completion

The trust did not separate their mandatory training data by staff group. Therefore, the data below

includes nursing and midwifery staff, medical and dental staff, allied healthcare professionals and

healthcare assistants/infrastructure support staff in community inpatient services.

The trust did not provide completion rates for Mental Capacity Act (MCA) level 1 training.

The trust set a target of 90% for completion of MCA level 2 and Deprivation of Liberty Safeguards

training.

From April 2017 to March 2018 the trust reported that MCA training had been completed by 98.6%

of staff within community health inpatient services.

Deprivation of Liberty Safeguards (DoLS) training had been completed by 98.7% of staff.

Trust level

A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in

community health inpatient services is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Deprivation of Liberty Safeguards 147 149 98.7% 90% Yes

Mental Capacity Act level 2 276 280 98.6% 90% Yes

The 90% target was met for both courses for staff in community health inpatient services.

The trust supplied updated MCA and DoLS training data as of August 2018. By that date the trust

had a single level of MCA training. The breakdown of compliance for MCA and DoLS courses for

staff across community inpatient services as of August 2018 is shown in the table below.

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Deprivation of Liberty Safeguards 130 138 94.2% 90% Yes

Mental Capacity Act 258 265 97.4% 90% Yes

Again the 90% target was met for both courses for staff in community health inpatient services.

Danesbury Home

A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in

community health inpatient services at Danesbury Home is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Deprivation of Liberty Safeguards 24 24 100.0% 90% Yes

Mental Capacity Act level 2 41 41 100.0% 90% Yes

The 90% target was met for both courses for staff in community health inpatient services at

Danesbury Home.

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Hemel Hempstead General Hospital

A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in

community health inpatient services at Hemel Hempstead General Hospital is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Deprivation of Liberty Safeguards 26 26 100.0% 90% Yes

Mental Capacity Act level 2 48 52 92.3% 90% Yes

The 90% target was met for both courses for staff in community health inpatient services at Hemel

Hempstead General Hospital.

Hertfordshire and Essex Hospital

A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in

community health inpatient services at Hertfordshire and Essex Hospital is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Mental Capacity Act level 2 39 39 100.0% 90% Yes

Deprivation of Liberty Safeguards 18 19 94.7% 90% Yes

The 90% target was met for both courses for staff in community health inpatient services at

Hertfordshire and Essex Hospital.

Langley House

A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in

community health inpatient services at Langley House is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Mental Capacity Act level 2 74 74 100.0% 90% Yes

Deprivation of Liberty Safeguards 38 39 97.4% 90% Yes

The 90% target was met for both courses for staff in community health inpatient services at

Langley House.

Potters Bar Community Hospital

A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in

community health inpatient services at Potters Bar Community Hospital is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Deprivation of Liberty Safeguards 22 22 100.0% 90% Yes

Mental Capacity Act level 2 38 38 100.0% 90% Yes

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The 90% target was met for both courses for staff in community health inpatient services at

Potters Bar Community Hospital.

Queen Victoria Memorial Hospital

A breakdown of compliance for MCA and DoLS courses from April 2017 to March 2018 for staff in

community health inpatient services at Queen Victoria Memorial Hospital is shown below:

Name of course

Number of

staff

trained

Number

of eligible

staff

Completion

rate

Trust

Target

Met

(Yes/No)

Deprivation of Liberty Safeguards 19 19 100.0% 90% Yes

Mental Capacity Act level 2 36 36 100.0% 90% Yes

The 90% target was met for both courses for staff in community health inpatient services at Queen

Victoria Memorial Hospital.

(Source: Universal Routine Provider Information Request - P38 Training)

Deprivation of Liberty Safeguards

From April 2017 to March 2018 the trust reported that 114 Deprivation of Liberty Safeguard

(DoLS) applications were made to the local authority for community health inpatient services.

Three applications were approved and three had direct notifications sent to CQC.

(Source: Universal Routine Provider Information Request (RPIR) – P13 DoLS)

Routine patient consent was not always documented. For example, nurses wrote in patient care

records that they had assisted the patient with a wash, but did not write that they had obtained

consent first. Nurses told us they always asked the patient before carrying out any procedure,

including assisting a patient with a wash. Therapy staff often documented that they had received

consent to carry out their therapy.

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Is the service caring?

Compassionate care

Staff continually cared for patients with compassion. Feedback from all patients confirmed

that staff treated them well and with kindness.

Staff interacted with patients and relatives in a respectful and considerate manner. They respected

patients’ privacy and dignity. Staff knocked on doors before entering rooms and ensured care and

treatment was provided behind curtains or closed doors. We observed all staff speaking with

patients in a kind, compassionate and sensitive way in a variety of situations.

We spoke with eight patients and three relatives across the community inpatient units. Patients

and relatives, we spoke with told us staff were kind and caring and that they had received care

they were happy with.

Patients praised the work of staff looking after them including nurses, therapists, cleaners and the

domestic staff who provided patient’s meals and hot drinks.

We saw many positive examples of nursing staff and patient interaction, for example, we heard

staff talking about shared hobbies and interests, including pets and gardening.

Patients told us they felt listened to by staff and that they were given choices about their care.

Patients told us they had been treated with dignity and respect. For example, staff knocked on

bathroom doors before entering, and asked patients if they needed assistance with dressing.

We observed examples of allied health professionals and patient interactions, for example,

physiotherapy staff actively engaging patients to achieve their goals. We saw a patient who was

having difficulty standing up from a seated position in a chair. We heard the physiotherapist

providing encouragement which slowly resulted in the patient standing safely.

Two patients told us staff sometimes took a long time to respond to their call bells. However, both

said this had been mainly at night. One patient said they had waited over half an hour to go to the

bathroom.

Danesbury unit used a therapy dog one day per week. Staff told us this was a huge benefit to their

patients. Staff understood the benefit patients received from being close to or touch the therapy

dog.

All the units we visited provided single sex accommodation. This was either in single or double

rooms or in bays of four to six patients. Bays were spacious, with curtains between each bed

space to enable privacy and dignity.

Some units had day rooms which allowed patients to watch TV or play games together. Families

could visit patients any time during the day or evening, except during protected mealtimes and told

us staff always made them feel welcome.

PLACE - data in relation to privacy, dignity and wellbeing

PLACE self-assessments are undertaken by teams of NHS and private/independent health care

providers, and include at least 50 per cent members of the public (known as patient assessors).

They focus on the environment in which care is provided, as well as supporting non-clinical

services such as cleanliness, food, hydration, the extent to which the provision of care with privacy

and dignity is supported and whether the premises are equipped to meet the needs of people with

dementia against a specified range of criteria.

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The 2018 PLACE score for privacy, dignity and wellbeing at the trust was 85%. This was slightly

better than the England average for NHS community services of 83.5%.

Although the trust achieved scores better than the England average overall, Hemel Hempstead

Hospital’s score of 65.7% was worse than the England average. All other trust locations scored

better than the England average.

Site Name Privacy, dignity and wellbeing score 2018

(%)

Danesbury 91.2%

Hemel Hempstead Hospital 65.7%

Hertfordshire and Essex Hospital 83.9%

Holywell at Langley House 86.8%

Langley House 88.3%

Potters Bar Community Hospital 89.7%

Queen Victoria Memorial Hospital 88.2%

Trust 85.0%

England average (NHS community) 83.5%

(Source: NHS Digital)

Emotional support

Staff provided emotional support to patients to minimise their distress.

We observed that staff constantly provided emotional support to patients when they displayed

anxiety during their rehabilitation activities. Therapy staff actively provided emotional support to

patients to help them achieve their individual care goals. We saw therapists talking with patients

before their therapy sessions, asking them how they were feeling and if they needed any pain

relief.

Staff actively listened to their patient’s wishes. For example, we heard a patient asking the nurse

to come back later to assist with their morning wash, as they were too tired at that time. Individual

preferences and needs were reflected in how patient care was delivered.

The inpatient units did not have a carers’ overnight room where they could be accommodated

while visiting inpatients. However, they did provide the names and addresses for local

accommodation where rooms could be booked when required.

There were arrangements that supported the emotional and spiritual needs of patients. Patients

and their relatives had access to religious services and chaplains. Patients from all faiths were

accommodated.

Counselling services within the community hospitals were available by a referral system. NICE

clinical guidance (CG 162) suggests that a stepped approach to psychological care is

recommended for rehabilitation patients. This meant that extra provision was in place to consider

patients’ emotional needs and the management of depression.

We observed staff caring for a patient living with dementia who became distressed. They

displayed appropriate and calming behaviour to the patient to ease their distress.

Understanding and involvement of patients and those close to them

Staff involved patients and those close to them in decisions about their care and treatment

150

Patients and relatives told us, and we saw, that nursing staff kept patients fully informed about

their treatment and they felt included in the decisions about their care. We saw evidence in patient

records and observed staff involving patients in shared decision making.

Staff communicated with patients so that they understood their care, treatment and condition. We

saw staff explaining a treatment process to a patient. Staff recognised when people who used

services needed additional support to help them understand and be involved in their care and

treatment and enable them to access this. We observed staff speaking to patients so they

understood their treatment options.

The inpatient ward teams ensured that all patients and relatives felt they could contribute to

individualised care pathways. This encouraged patients and relatives to understand and manage

the care requirements needed to maintain independence. We saw a specific care plan for a patient

who could become very angry because of their illness. The care plan addressed the specific

concerns of the patient to enable their care needs to be met, as well as keeping staff safe. For

example, the care plan advised staff not to try and touch the patient while they displayed signs of

anger, as this was likely to upset them further. The care plan had been written with assistance

from the patient’s family.

Patient feedback notice boards were present on the inpatient units. We saw cards from both

patients and relatives who expressed thanks for the support the service had provided to them and

their loved ones.

Staff demonstrated understanding of different communication needs. We saw that communication

aids such as picture books, writing pads, language interpreters and sign language interpreters

were available to support patients during care.

Is the service responsive?

Planning and delivering services which meet people’s needs

The trust planned and provided services in a way that met the needs of local people.

The inpatient services reflected the needs of the local population and ensured continuity of care.

The service worked closely with the acute NHS trusts, local authorities, social workers and

commissioners to meet the needs of patients in the area, particularly those with complex needs,

long-term conditions and life-limiting conditions.

The design, maintenance and use of facilities and premises were appropriate. Patient areas were

mostly at ground level with easy access for people with wheelchairs or walking aids. Lifts were

available where required. Parking, including disabled parking spaces was available. There was

signage throughout the units which allowed people, including those with a cognitive impairment, to

navigate their way around with ease.

Information boards were provided for each of the community inpatient units. This displayed

guidance on visiting times, mealtimes, telephone numbers and displayed pictures of staff uniforms

so patients and relatives knew healthcare professionals’ nursing grades. All staff wore name

badges to help visitors and patients clearly identify who they were talking with. Some units had

pictures of each individual member of staff alongside their name and job role.

The inpatient units were open to visitors for most of the day. The wards had protected mealtimes

to ensure patients could eat their meals without interruption, however family members were

encouraged to attend at lunchtime if the patient required assistance with eating so that they could

provide support.

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The different requirements of the local people were understood as planning, design and delivery of

services were done with this in mind. Services were planned in a way which ensured flexibility and

choice. For example, patients discharged from acute hospitals were placed in units as close to

their own homes and families whenever possible. This increased the likelihood that friends and

relatives would visit the patient more often.

The service responded to patient feedback. We saw the inpatient units had, ‘you said we did’

notice boards. At Holywell unit, patients had requested that their nails were cut. Following this,

staff had training on cutting patient nails and were carrying this out when required.

Danesbury unit had had self-contained rooms which had been set up like a home, including

separate living and sleeping areas and a kitchen where patients could prepare their own food.

These rooms were used for patients living with long term neurological conditions and supported

patients in their rehabilitation and a return to independent living where possible.

Patients had access to drinks and snacks at any time of the day. Some units had large

kitchen/dining rooms available for patients and relatives to make hot drinks. A hairdresser was

available on some of the units regularly, and we saw this during our inspection on St Peters ward.

Patients were provided with a wide range of information on discharge including details of their

continued care and treatment, health promotion and a contact number to call if they experience

any problems or required advice.

Ward moves

The trust was asked to detail ward moves for a non-clinical reason during the last 12 months. For

example, if a patient had to move wards several times because there was no room in the speciality

ward they should have been on.

From April 2017 to March 2018, 2,049 individuals (98.3%) in community health inpatient services

did not move wards during their admission, and 36 individuals (9.2%) moved once or more.

A breakdown by ward/unit is shown below:

Potters Bar Hospital – Oakmere ward

Number of ward moves Number of patients % share of all patients

0 360 98%

1 5 1%

2 1 0%

3 0 0%

4+ 0 0%

Total 366 100%

Langley House – Midway ward

Number of ward moves Number of patients % share of all patients

0 292 98%

1 6 2%

2 0 0%

3 0 0%

4+ 0 0%

Total 298 100%

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Langley House – Holywell ward

Number of ward moves Number of patients % share of all patients

0 166 99%

1 1 1%

2 0 0%

3 0 0%

4+ 0 0%

Total 167 100%

Hemel Hempstead General Hospital – St Peters ward

Number of ward moves Number of patients % share of all patients

0 196 96%

1 8 4%

2 0 0%

3 0 0%

4+ 0 0%

Total 204 100%

Hemel Hempstead General Hospital – Simpson ward

Number of ward moves Number of patients % share of all patients

0 143 94%

1 9 6%

2 0 0%

3 0 0%

4+ 0 0%

Total 152 100%

Danesbury ward

Number of ward moves Number of patients % share of all patients

0 167 99%

1 1 1%

2 0 0%

3 0 0%

4+ 0 0%

Total 168 100%

Queen Victoria Memorial Hospital

Number of ward moves Number of patients % share of all patients

0 412 99%

1 3 1%

2 0 0%

3 0 0%

4+ 0 0%

Total 415 100%

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Hertfordshire and Essex – Oxford and Cambridge Wards

Number of ward moves Number of patients % share of all patients

0 313 99%

1 2 1%

2 0 0%

3 0 0%

4+ 0 0%

Total 315 100%

The trust has stated that the above data represents non-clinical and clinical related moves of

patients within the adult HCT bed base. Non-clinical related moves were mainly due to patient

choice with patients and families preferring their care to be delivered within the locality that they

live. HCT tried to accommodate this.

Clinical reasons for moves can be due to patients needing to be observed closely due to

mental/physical deterioration, and this not being able to be provided on their current ward.

The data shows moves were minimal across all units. Simpson ward had the highest number of

moves due to the type of patients accepted onto this ward. This ward is predominately continuing

healthcare (CHC) assessment and other patients who required complex discharge planning from a

local acute trust. These patients often were admitted to Simpson ward in the first instance, then

transferred to one of the rehabilitation wards/units for further treatment.

The Hertfordshire community bed bureau is a central access hub for all community hospital bed

based units. There are well established triage processes to ensure that patients are placed into

community hospital settings appropriate to their clinical needs to minimise the need for future

transfers. The bed bureau team had an understanding of the differences between the units which

included their location, layout and clinical competencies of the staff.

(Source: Universal Routine Provider Information Request (RPIR) Universal P43 – Ward moves)

Moves at night

The trust was asked to list ward moves between 10pm and 8am for each core service for the most

recent 12 months

From April 2017 to March 2018, the trust reported that transfers were planned. It was not expected

that moves will be undertaken between 10pm and 8am. Data that the trust provided showed that

there had been only one night move in 12 months. This was in February 2018 at Hemel

Hempstead General Hospital in St Peters ward.

(Source: Universal Routine Provider Information Request (RPIR) Universal P44 – Moves at night)

Mixed sex breaches

Mixed sex breaches are defined by CQC and the NHS Confederation as members of the opposite

sex having to share accommodation. Whilst these are specifically for mental health providers the

same definitions apply to community and acute providers. Included in the definition is the need to

provide gender sensitive care, which promotes privacy and dignity, applicable to all ages, and

includes children’s and adolescent units. This means that boys and girls should not share

bedrooms, bed bays or toilets and washing facilities. An exception to this might be in the event of

a family admission on a children’s unit, in which case brothers and sisters may, if appropriate,

share bedrooms, bathrooms or shower and toilets.

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The trust reported that there have been no mixed sex breaches in any of Hertfordshire Community

Trust adult inpatient units at any time night or day since 2015.

(Source: Universal Routine Provider Information Request (RPIR) P47 –Mixed sex)

Meeting the needs of people in vulnerable circumstances

The service took account of patients’ individual needs. Patients were assessed on

admission to identify any additional support needs.

Services were planned to take account of the needs of different people, for example, on the

grounds of age, disability, gender and race. Staff could access interpreting services for patients

who did not speak or understand English. Patient information leaflets were readily available,

including information on how to raise a concern or complaint, and could be translated into

languages other than English as required. Access to the wards was sensitive to the needs of those

patients living with a disability.

We saw reasonable adjustments were made to consider the needs of different people on the

grounds of religion, disability, gender, or preference. Patients living with a learning disability or

other cognitive impairment were flagged on the electronic patient record system and an, ‘all about

me’ booklet was used to identify their individual needs. This ensured that staff were aware of any

adjustments that might be required.

Patients living with dementia were not routinely visible flagged by different coloured wristbands or

a symbol in their bed space. For example, by using a recognised scheme, such as the Butterfly

Scheme. Flagging systems allow all staff to instantly recognise patients who may require extra

assistance. Nurses told us there was a symbol added electronically to the notes of patients living

with dementia. The trust has a process for recognising dementia. Each patient has a ‘this is me

document’ that helps staff understand individual patient needs and preferences. It also helps staff

to easily identify a patient with dementia as the document is placed in the patient’s paper file and

recorded on system one. Nursing and therapy staff had a good understanding of managing and

helping patients living with dementia and patients with delirium. There was a specialist dementia

nurse available, and staff had access to dementia link nurses for advice and support.

The trust’s overall 2018 PLACE scores for being disability and dementia-friendly were both slightly

better than the England average. However, the dementia friendly scores at Danesbury Home,

Hemel Hempstead Community Hospital and Potters Bar Community Hospital were all lower

(worse) than the England average. The service told us that ongoing action plans in place had

resulted in some improvements.

Patients had access to therapy rooms and gym areas. Therapy sessions included physical

exercise, relaxation therapy, breakfast clubs and craft sessions. This provided holistic care to

Site name Dementia friendly

PLACE score % Disability PLACE score %

Danesbury Home 65 82

Hemel Hempstead Hospital 70 84

Hertfordshire and Essex Hospital 86 88

Holywell at Langley House 92 95

Langley House 91 94

Trust average 82 88

UK average 80 86

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patients helping them achieve maximum independence in daily living activities and improving their

wellbeing.

Dayrooms were available on most units and this made it easier for patients to socialise together.

Some therapy sessions were carried out in groups and this increased opportunities for patients to

mix with others.

Social workers attended the wards regularly for multidisciplinary meetings and assisted patients to

make informed decisions. Nurses told us that the social work team worked closely with them to

ensure that patients had access to the required support for their physical and psychological needs.

Transport services were available externally for service users with mobility problems. The booking

team provided patients with contact details of an external transport organisation when required.

Where delays in transport were encountered staff would record this as an incident and share

learning.

There was a range of patient information leaflets in all the inpatient units, including advice on

diabetes, stroke, dementia, meningitis, smoking cessation and mental health and wellbeing. We

also saw leaflets clearly displayed which informed patients and visitors on the processes to report

compliments, concerns and complaints.

Access to the right care at the right time

Although arrangements to admit, treat and discharge patients were in line with good

practice, people could not always access the service when they needed it.

The service was trying to improve access for patients. There was a centralised bed bureau which

showed where the available inpatient unit beds were. This was updated daily and enabled staff to

offer beds nearest to the patients preferred location whenever possible. It also ensured beds did

not remain empty when there was a patient waiting to be admitted. Clinical leads were regularly

attending units to join daily sweeps, looking at individual patient pathways. Where required, a local

‘situation report’ was used to determine the bed position in individual services. There were daily

assurance calls by senior managers with each unit manager in which any delays were discussed

and escalated. In addition, the trust performance team had produced an improvement plan, which

all therapy leads and ward managers were aware of, and understood their individual areas of

responsibility.

The service declared its bed escalation status twice per day and had an adult bed capacity

escalation plan which categorised bed pressures based on Operational Pressures Escalation

Levels 1- 4 (OPEL). For example, OPEL 1 was business as usual; OPEL 3 meant the ability of the

hospital to provide all agreed services was compromised.

The multidisciplinary team at each of the services’ inpatient units held ‘red to green’ meetings

every morning to improve patient flow. The use of ‘red and green bed days’ are recommended by

NHS Improvement as a visual management system to assist in the identification of wasted time in

a patient’s hospital stay. A green day is a day when everything planned, gets done, and a red day

is for example, when a planned investigation or assessment, does not occur. The aim is to reduce

internal and external delays as part of the SAFER patient flow bundle which the community

hospitals had implemented.

There was an action plan in place to reduce delayed transfers of care and to get patients home

sooner. The action plan included the use of red to green days and daily assurance calls. The

action plan had been circulated to ward managers along with a short video demonstrating effective

red to green day board rounds. Ward managers and therapy staff were actively involved in

promoting red to green days.

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Records were updated daily to provide effective discharge planning. The electronic record system

had a discharge planning tab which was updated by the MDT teams. On admission, targets for

discharge planning were allocated: patients admitted for rehabilitation were targeted with specific

timeframes for discharge, depending on specific pathways. For example, patients admitted to

Danesbury unit were given 42 days for rehabilitation, and patients admitted for general

rehabilitation at Hertfordshire and Essex Hospital were targeted with 19 days.

Nurses and doctors told us some patients were transferred into their service that did not meet their

admission criteria regarding their rehabilitation suitability. We were told some patients were too

unwell to be rehabilitated within the given timeframes, and that local commissioning teams

sometimes insisted the service accept patients to remove them from the acute hospital trusts. We

asked how many inappropriate transfers they had received and we were told that this information

was not recorded. However, we saw that from June to September 2018, 18% of all discharges

(121 patients) were discharges to an acute trust.

The service was actively trying to reduce inappropriate admissions through an ‘in-reach’ team.

This was a team of experienced nurses and therapists who went into the acute hospitals and

reviewed prospective patients before they were discharged. Patients suitability and requirements

for rehabilitation were assessed by the team. The in-reach team knew the admissions criteria for

each of the inpatient units, aiming to improve appropriate admissions.

The service was actively trying to get patients home sooner, and had an established ‘discharge to

access’ service. This involved discharging patients home sooner, so they could be assessed by

therapy teams in their home environment and supported for a few days at home by community

staff.

Inpatient unit nursing staff told us they had waiting lists for admission, and that waiting times

varied from a few days to several weeks. We were not provided with average length of delays

during the inspection, however after the inspection the trust confirmed that the current length of

wait for admission was three days for St Peters, Langley House and Holywell units. Hertfordshire

and Essex and Danesbury units had zero days wait for admission at the time of the inspection.

The trust told us that patients waiting from acute trusts remain in patients with clinical responsibility

remaining with the acute trust until a bed becomes available in the community. Priority is given to

patients who are deemed to be ‘prevention of admission’ to acute trust, for example, patients

being admitted from their own home. These patients continue to be assessed and managed by

community teams until the bed becomes available.

Weekly conference calls were undertaken to review all new referrals into the service and to

discuss any clinical risk to the patient as a result of any admission delays. Managers and quality

leads looked at the reason for any delays, for example staffing capacity and incorrect triage at

referral. However, despite several measures to improve the flow of patients through the hospital,

some units still reported a high number of patients experiencing delays to their discharge. This

included for example, from April 2017 to March 2018, 47% of patients on St Peters ward and 43%

of patients on Simpson ward had delayed discharges. Overall, 2085 patients, or 36% of all

patients leaving the inpatients services experienced a delayed discharge.

Accessibility

Bed occupancy

The breakdown of average bed occupancy levels from April 2017 to March 2018 by site for

community health inpatient services below:

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Site Average bed occupancy

St Peter’s ward, Hemel Hempstead General Hospital 97.3%

Simpson ward, Hemel Hempstead General Hospital* 96.1%

Holywell neurological rehabilitation unit, Langley House 95.0%

Inpatient unit, Langley House 94.7%

Danesbury Home 94.1%

Potters Bar Community Hospital 93.8%

Hertfordshire and Essex Hospital 89.9%

Queen Victoria Memorial Hospital 88.0%

*Opened in October 2017. Therefore, data are for October 2017 to March 2018 (eight months)

only.

(Source: Community Routine Provider Information Request (RPIR) Community CHS7 – Bed

occupancy & LOS)

Average length of stay data

The breakdown of average length of stay by the site for community health inpatient services for

the period from June 2017 to May 2018 is shown below:

Site Average length of stay

Danesbury Home 33.0

Hemel Hempstead Hospital 52.5

Hertfordshire and Essex Hospital 29.5

Holywell neurological rehabilitation unit, Langley House 36.1

Langley House inpatient unit 37.2

Potters Bar Community Hospital 28.2

Queen Victoria Memorial Hospital 16.6

St Albans City Hospital 27.0

Invalid site code 28.8

Overall 28.6

(Source: Hospital episode statistics)

Referrals

The trust did not identify any community health inpatient services as measured on ‘referral to initial

assessment’ and ‘assessment to treatment’.

(Source: CHS Routine Provider Information Request – CHS10 Referrals)

Delayed discharges

Langton and Sopwell wards, which closed in April and July 2017 respectively, are excluded from

the charts below. To aid comprehension the trust reporting units have been spread over three

charts. Data are only available for Simpson Ward from August 2017. The trust note that this ward

was transferred to this trust from another in October 2017.

From April 2017 to March 2018, there were 2,085 delayed discharged in community health

inpatient services. This amounts to 36.0% of the total discharges.

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Delayed discharge trends from April 2017 to March 2018, Hertfordshire Community NHS

Trust

159

Delayed discharge trends from April 2017 to March 2018, Hertfordshire Community NHS

Trust

A breakdown of delayed discharges by reporting unit for community health inpatient services is

shown below:

Ward Total

Discharges

Total Delayed

Discharges

% Delayed

Discharges

St Peters ward 204 95 46.6%

Inpatient unit, Langley House 298 129 43.3%

Simpson ward 152 65 42.8%

Queen Victoria Memorial Hospital 415 155 37.3%

Potters Bar Community Hospital 366 129 35.2%

Holywell neurological rehabilitation

inpatient unit, Langley House

167 52 31.1%

Hertfordshire and Essex Hospital 315 96 30.5%

Danesbury Home 168 29 17.3%

Total 2,085 750 36.0%

(Source: Universal Routine Provider Information Request (RPIR) Universal P49 – DTOC)

Delayed transfers of care had been consistently high for over a year despite various initiatives to

address this. The most significant cause of delayed discharge is due to a lack of care packages in

the community or residential or nursing home placements.

The inpatient teams were actively using Red to Green methodology to improve patient flow and to

reduce the average length of stay for patients who are appropriate for rehabilitation.

Addressing patient flow was the biggest priority and they were in the process of finalising an action

plan with the local acute trust and was working with CCGs and partners to review patients who are

inpatients but do not meet the trust criteria.

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Learning from complaints and concerns

Although the service treated concerns and complaints seriously, investigated them and

learned lessons from the results, they did not always do so in a timely manner.

Patients knew how to make a complaint or raise a concern, and were encouraged to do so.

Information about the complaint process was clearly displayed within the inpatient units. Staff we

spoke with could describe the complaints process and explain how they would advise patients to

raise a complaint.

Nursing staff understood the process for receiving, handling and responding to concerns and

complaints.

Patients told us the nursing staff were approachable and if they wished to raise a concern they

would do this by speaking with the nurses who were caring for them at that time.

The hospital had a patient advice and liaison service (PALS) and complaints team.

All feedback received was reviewed. Each unit had a learning poster to display their, ‘you said –

we did’ actions. The ward managers updated the ‘you said – we did’ action posters each month.

Complaints

From April 2017 to March 2018 there were 22 complaints about community inpatient services. The

trust took an average of 33.7 working days to investigate and close complaints. This is not in line

with the trust’s complaints policy, which states that complaints should be dealt with within 25

working days.

A summary of complaints within community health inpatient services by subject and site is below:

Community inpatient services total

Subject Number of complaints

All aspects of clinical treatment 13

Admissions, discharge and transfer arrangements 3

Communication/information to patients (written and oral) 2

Attitude of staff 2

Patients' property and expenses 1

Others 1

Total 22

Community inpatient services – Danesbury Home

Subject Number of complaints

All aspects of clinical treatment 1

Community inpatient services – Hemel Hempstead General Hospital

Subject Number of complaints

All aspects of clinical treatment 2

Attitude of staff 1

Total 3

Community inpatient services – Hertfordshire and Essex Hospital

Subject Number of complaints

All aspects of clinical treatment 4

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Admissions, discharge and transfer arrangements 2

Attitude of staff 1

Total 7

Community inpatient services – Langley House

Subject Number of complaints

Patients' property and expenses 1

Communication/information to patients (written and oral) 1

Total 2

Community inpatient services – Potters Bar Community Hospital

Subject Number of complaints

All aspects of clinical treatment 2

Admissions, discharge and transfer arrangements 1

Total 3

Community inpatient services – Queen Victoria Memorial Hospital

Subject Number of complaints

All aspects of clinical treatment 2

Communication/information to patients (written and oral) 1

Total 3

Community inpatient services – St Albans City Hospital

Other 1

All aspects of clinical treatment 1

Total 2

In addition, there was one complaint about “all aspects of clinical treatment” that was not mapped

to a location. This concerned the St Albans, Harpenden and Hertsmere neurological rehabilitation

service.

(Source: Universal Routine Provider Information Request (RPIR) – P52 Complaints)

Compliments

From April 2017 to March 2018, the trust received over 12,000 compliments; however, they did not

provide the data by core service so we are unable to identify how many compliments were

received for community health inpatient services.

(Source: Universal Routine Provider Information Request (RPIR) – P53 Compliments)

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Is the service well-led?

Leadership

Although some managers at all levels had the right skills and abilities to run a service

providing high-quality sustainable care, some leaders were very new to their role and were

developing their leadership skills.

The service had recently introduced a new management structure in order clarify escalation routes

for staff and commissioners. Some ward managers and leaders were very new in post. There was

a lack of oversight of medicines management however, the trust had recently appointed a new

chief pharmacist who recognised that the pharmacy service needed improvement.

The inpatient service was headed by an associate director of operations with two divisional

general managers (DGM) leading the service. Each DGM worked with a clinical service manager.

Clinical service managers were responsible for several wards and ward managers, and were

present in the clinical environment daily. Uniforms had recently been introduced, rather than

business clothes, for the clinical service managers, to improve the recognition of leaders in the

clinical environment. Both clinical service managers were new in post.

Each ward was managed by a ward manager, several wards had more than one manger due to

part time working arrangements. Some ward managers were new in post. Ward managers were

not rostered to work clinical shifts, however, they often did so, due to staffing shortages.

Ward managers and clinical service managers told us they had attended leadership training or

were currently on leadership courses. Mangers told us the training was effective in enabling them

to acquire the skills necessary for their role.

Inpatient service leaders and managers attended regular ‘trust leaders’ and ‘senior leaders’ forums

to share and promote good practice across the trust. During these meetings, staff showcased

examples of successful changes or improvements, which they called ‘glimpses of brilliance’. For

example, we were told about how the therapy team had promoted the ‘red to green days’ across

the service.

Extra leadership skills training was planned by the trust learning and development department for

ward managers, which was due to be rolled out in October 2018. Individual targeted leadership

was also being delivered for specific managers.

Most nursing staff we spoke with said they felt supported, recognised and valued by their

managers and reported good communication between senior management and staff working in

the clinical areas.

Clinical service managers and ward managers were visible throughout our inspection, and staff

said they regularly saw senior staff in the inpatient units.

Vision and strategy

The service had a vision for what it wanted to achieve and workable plans to turn it into

action developed with involvement from staff, patients, and key groups representing the

local community.

The community hospitals did not have local strategy; however, the trust’s vision and strategies

were embedded within the community hospitals.

The trust’s vision was ‘to maintain and improve the health and wellbeing of the people of

Hertfordshire and other areas served by the trust'.

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The trust strategy was to focus on:

• Health and Wellbeing – working with other organisations to develop local, community

approaches to maintaining health and wellbeing

• Self-management – supporting people with health conditions and disabilities to manage

their own care as far as possible

• Coordinated Care – providing well-co-ordinated, personalised, multi-agency care for people

with complex needs

The trust worked with their staff and other service users to develop its strategy, although the staff

we spoke with said they had not been involved in developing the strategy. The strategy and

approach to change was communicated to staff through a series of roadshows.

The trust values were:

• Care - We put patients at the heart of everything we do

• Respect - We treat people with dignity and respect

• Quality - We strive for excellence and effectiveness

• Confidence - We do what we say we will do

• Improve - We will improve through learning and innovation

Staff employed within the service knew and understood the trust values and most staff we spoke

with could describe the trust’s vision and values and how they would apply them to their role. Staff

were less familiar with the trust’s overall strategy. We saw staff demonstrating the values of the

trust in all areas we visited.

Individual objectives for each staff member had been created to support delivery of the vision and

values and were managed through individual staff appraisals. This enabled staff to understand the

vision and values and their role in achieving this.

The service worked closely with local clinical commissioning groups (CCGs) and had agreed

pathways for patients leaving the acute hospitals. The CCGs had carried out recent inspections of

the services and had provided the organisation with feedback. The local health watch team were

actively involved in the trust and attended board meetings and provided feedback to the service.

Culture

Managers across the trust promoted a positive culture that supported and valued staff,

creating a sense of common purpose based on shared values.

During our focus groups we held with staff before our inspection, we were told that staff culture

within the inpatient units had been a challenge. However, the service had recognised this and put

some actions in place to improve the culture. This included; an away day supported by the leaning

and development team to identify and embed change; increased assistance from the human

resources department for ward managers to manage staff where appropriate; improving

consistency of communication with team leaders to ensure expectations were fully understood.

Staff across all areas of the inpatient units said they were committed and passionate about the

care they provided to patients. They reported feeling proud to work within the community hospitals

and were positive about the job they did. Staff told us they felt listened to and supported by each

other and the trust.

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Most staff we spoke with said they felt respected and valued by managers and by each other, and

that the culture within their unit was improving. Some staff said there were difficulties when the

units were short staffed, and everyone felt under pressure. Some staff told us that therapy and

nursing staff did not always help each other to provide seamless care for patients. Weekly ward

manager and therapy leads meetings had been recently introduced to drive shared accountability.

During our inspection we saw therapy leads and ward managers working together closely.

There were mechanisms in place for providing staff at all levels with the professional development

they needed. This included training, support with revalidation, appraisals, one to one feedback and

clinical supervision. Staff also gave examples of how they had been promoted into new roles

within the service. We were also told that 360 review processes were being introduced, which was

aligned to staff appraisals. The 360 review involves leaders asking staff of all grades to provide

feedback on their performance. It was hoped that the culture amongst leaders would be improved

by using this approach.

There was a freedom to speak up guardian (FSUG) in the trust, and some staff in the inpatient

units had accessed this service. We saw evidence that concerns raised by staff had been

investigated and actions had been put in place as a result. However, most staff we spoke with

were not aware there was a FSUG, or who they were.

Governance

Although the trust used a systematic approach to continually improve the quality of its

services and safeguarding standards of care, they did not always create an environment in

which excellence in clinical care flourished.

There were processes and systems of accountability in place. Staff were clear about their roles

and what they were accountable for. Senior leaders, ward managers and clinical staff across the

inpatient services demonstrated awareness of the trust’s governance arrangements. They

described the actions taken to monitor patient safety and risk. This included a quality dashboard,

incident reporting and the undertaking of audits.

Performance monitoring was done through a newly implemented quality dashboard, called

business unit performance reports (BUPR). Ward managers had been made responsible for

completing these monthly reports to improve ownership of the units, which included data on

performance, quality, workforce and finance.

BUPR data was shared with ward staff at team meetings and at governance meetings to ensure

local actions were undertaken. However, we found that not all aspects of quality and safety was

being monitored in a sufficiently robust way. For example, we found several issues with medicines

managements across the inpatient units, and in particular we found issues with medications

prescribed but not administered. We highlighted this to clinical service leads during our inspection

and we were told that each month ward managers audited 10 patient records and this included

scrutiny of medication charts. However, as this audit had not identified any issues with medicines

management, we were not assured of the robustness of this process.

The trust had an audit programme which was reported to the audit committee. This provided

oversight of the governance arrangements and systems of internal control.

Mortality review meetings were held four times a year with the medical director and included

medical and nursing staff. The meetings were used to discuss deaths and to identify any learning

as a result.

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Management of risk, issues and performance

The trust did not have effective systems for identifying risks, planning to eliminate or

reduce them, and coping with both the expected and unexpected.

At the time of our inspection, the community hospital inpatient units did not all have an individual

risk register which was used to identify the risks in each unit. Two ward managers we spoke with

were confused by the term, risk register, and could not identify any specific risks in their area,

other than staffing. We highlighted these concerns to clinical service managers during our

inspection and we were told that the local risk register was new and was currently being

implemented as part of increasing local ownership of individual units.

Local risks had not been identified, for example:

• The storage of clinical waste bags in the unit corridors and storage of equipment in patient

bathrooms at Holywell unit.

• The long call bell wires in the patient bathrooms at Danesbury unit.

• The damaged kitchen cupboard door leading to possible ‘electrical shortages’ at Holywell.

There was an electronically maintained high level risk register and risks were discussed at the

healthcare governance committee meetings. Risks on the high level risk register were reviewed

regularly and we saw that actions had been recorded to mitigate the risks where possible.

However, we saw that the high level risk register did not contain the risks of delayed discharges,

the risks of nurse vacancies, or the lack of frequent pharmacy provision at some sites.

The service had a continuing problem of high numbers of delayed discharges, despite several

initiatives which had been introduced to reduce delays.

The service participated in local audits which provided a systematic approach to processing

information. The actions required from the completed audits were shared at team meetings and

staff we spoke with were aware of the audits undertaken in their areas. Information about incidents

was also discussed at ward meetings to ensure any learning was shared and minutes we

reviewed, confirmed this.

There clear lines of accountability including clear responsibility for cascading information to the

senior management team, nursing staff and MDT teams. During our inspection we saw evidence

in meeting minutes that quality and risk information was reviewed and actioned.

There were business continuity plans in place detailing the actions to be taken by ward staff in the

event of a major incident, for example disruption to staffing or facilities. Staff we spoke with were

aware of major incident policies and contingency plans and gave recent examples of when these

had been implemented.

Information management

While the trust collected, analysed, managed and used information to support its activities,

some information was not accurately recorded, some information was not stored securely,

and some information collected was duplicated and/or difficult to access.

The trust had an information governance policy which managed and controlled information through

the trust’s policies and protocols. The policy identified measures to ensure the security of

information held on patients and staff and identified measures to be implemented in the event of

an information governance breach. There had been no breaches in information governance

reported within the community hospitals over the past year.

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Information on service performance measures including falls, pressure ulcers, staffing, infections

and patient feedback were reported monthly and displayed in public areas.

The service had recently implemented an electronic patient record system which was accessible

to all employed staff. The new system improved the quality and accuracy of the services data

collection. This data was used to monitor performance and produce clinical data quality reports.

Examples of data collected included, the number of patients having their NHS numbers recorded

(100%), patient ethnicity recorded (96%), and smoking status (95%). The system was also used to

monitor response times to referrals for treatment and for collecting patient outcomes.

Not all staff were proficient in using the new electronic system and we were told some information

recorded electronically was also collected on paper. This had led to a duplication of work. Some

information recorded on paper was different to that recorded electronically, for example DNACPR

forms. Some staff had difficulty assessing information electronically, this included patients’

electronic records. Agency staff could not access the electronic records. We highlighted our

concerns around staffs’ ability to use the electronic notes system and we were told that extra

training was available for all.

Not all information had been stored securely and we saw patients’ notes outside their rooms in

corridors, which were accessible to the public. Notes trolleys were not always locked.

Nurse handover sheets were generated by the electronic notes system and contained full patient

identifiable data and were up to 15 pages long. These were not always stored securely. Some

ward managers and sisters told us that the ward handover sheets were too long, and this meant

they were difficult to refer to quickly while working in the clinical environment. We were told that

this had been raised with senior managers, however, no solution had been found.

An electronic patient safety reporting system was in place to ensure that information about

incidents could be collected, and any themes identified. However, we found that there were

inconsistencies in the categorisation of incidents and therefore we were not assured about the

robustness of this data. For example, some staff categorised a patient with diarrhoea and vomiting

incident as an ‘infection’, and some staff reported it as ‘delay or failure to monitor’. This made it

difficult to get a true picture of how many incidents were happening in each category.

We saw that an incident had occurred that had been discussed at the Hertfordshire and Essex

team meeting in August 2018, in which hazardous chemicals had not been locked away and had

resulted in a patient safety incident. We were not provided with details of this incident prior to the

inspection and cannot be assured that the incident had been reported as an incident and fully

investigated.

Engagement

The trust engaged well with patients, staff, the public and local organisations to plan and

manage appropriate services, and collaborated with partner organisations effectively.

Patient and relatives’ views concerning the community inpatient wards were actively encouraged

by the staff. Ward staff worked closely with relatives and patients to improve the services provided.

Staff, patients and relatives on some of the inpatient units raised money to improve facilities for

patients.

Patients and members of the local community had opportunities to get involved in the

improvement of the services and were encouraged to become volunteers or members of

Hertfordshire Community Trust. PLACE inspections took place regularly using locally sourced lay

people.

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Staff were encouraged to improve services through a variety of ways including the staff survey,

involvement with working groups, and through staff training. Staff engagement was also

encouraged by regular sessions, which involved staff meeting the senior clinical team in an

informal setting.

The trust ran a quarterly pulse survey as part of its ongoing engagement with staff. This covered

16 core questions, plus a small number of ‘hot topic’ questions to get more detailed feedback.

Staff were also able to provide free text comments. We were not provided with individual results

for the impatient units, however we were told that generally, the trust had saw an overall trend of

improvement, particularly on staff recommending the trust as a place to work, staff health and

wellbeing questions and the quality of appraisals. The trust had actions for areas of the survey

where staff had reported concerns. For example, to improve staff morale, a health and wellbeing

programme had been introduced, along with resilience training and improved use of technology.

Staff excellence was celebrated through an annual awards ceremony, ‘Leading Lights’ and to

celebrate the NHS’s 70 birthday this year, the trust introduced ‘NHS70 star’ awards, where

individuals nominated colleagues for their outstanding work. A star badge and certificate was then

presented to them by the CEO or senior manager.

Engagement with staff from the CEO was through Keeping in Touch visits, as well as recording

briefing videos which were cascaded to all staff. Board members also visited the inpatient units to

speak to staff and patients.

In response to the staff survey we were told that the inpatient services had recognised the level of

pressure staff were under and several initiatives had been introduced to reduce workloads. This

included the launch of a new e-scheduling tool and improvements to electronic staff rostering. It

was hoped this would enable staff to make more effective use of their time. They had also

introduced new service models and increased the use of new technology, including electronic

patient records.

Staff working in the inpatient units had access to workshops on ‘building personal resilience’ and

‘managing change’ which the trust had introduced as part of their new focus of health and

wellbeing.

The service engaged with the public through engagement meetings. We were told about an

engagement meeting held with the public prior to the closure of a community unit in St Albans.

There had also been two events to provide information and obtain feedback on the redevelopment

plans for Harpenden Memorial Hospital. This included joint working with community groups to

deliver a joint communications and engagement plan. Events had also taken place with the local

health watch team to gain feedback from potential service users in the Hertfordshire Valley area

as a result of service redesign proposals.

Learning, continuous improvement and innovation

The trust was mostly committed to improving services by learning from when things go

well and when they go wrong, promoting training, research and innovation.

The service was committed to improving care for patients. It had invested in a new electronic

patient records system which would allow for greater scrutiny of patient care plans. Current and

future performance, including patient outcomes was regularly reviewed and improved through

ward safety dashboards, audits, and clinical patient assessment tools. For example, in response to

delayed discharges and patient flow blockages, the inpatient units developed and implemented:

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• Red to green days to identify patient flow blockages. This was managed in the daily ward

rounds and there was an escalation process to management should patients care not

achieve care plan targets.

• A progress chaser had been employed, who managed each patient’s discharge.

• An in-reach team at the acute hospitals to assess patients’ suitability for the inpatient units.

However, not all issues highlighted in our 2016 inspection had been resolved: Medications were

not always administered as prescribed; there was no policy which set out specifically how often all

patients should receive therapy; turn charts were not routinely used for patients and fluid balance

charts were not always comprehensively completed.

While the service demonstrated it had learned from incidents, incidents were not always

categorised appropriately. Therefore, the full number of each type of incident, could not be

accurately determined.

Managers and staff told us they had access to training courses and were encouraged to attend

extra training to extend their roles and increase their skills wherever possible.

The trust wide audit programme included standardised national audits, for example the stroke

rehabilitation audit, and audits like the Patient Led Assessments of the Care Environment

(PLACE), infection prevention and control audits and documentation audits. Results of audits were

shared and plans for improvement were made. Changes as a result of an audit include the

rationalisation of care plans used in the integrated community teams and community inpatient

hospitals. Following the audit, the number of care plans was reduced from 196 to 58, based on

best practice using a recognised framework. This enabled staff to personalise each care plan

according to individual patient needs and benefits included standardisation and a reduction in

variation, reduced duplication, and ensured that care plans better reflect patient needs.

Accreditations

NHS trusts are able to participate in a number of accreditation schemes whereby the services they

provide are reviewed and a decision is made whether or not to award the service with an

accreditation. A service will be accredited if they are able to demonstrate that they meet a certain

standard of best practice in the given area. An accreditation usually carries an end date (or review

date) whereby the service will need to be re-assessed in order to continue to be accredited.

There were no services reported within community health inpatient services that have been

awarded an accreditation.

(Source: Universal Routine Provider Information Request (RPIR) – P66 Accreditations)

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Community health services for end of life care

Facts and data about this service

Hertfordshire community trust (HCT) is responsible for delivering a wide range of community and

inpatient health services across Hertfordshire. The trust serves the communities of Broxbourne,

Dacorum, East Hertfordshire, Hertsmere, North Hertfordshire, St Albans, Stevenage, Three

Rivers, Watford and Welwyn/Hatfield.

HCT was commissioned by two clinical commissioning groups (CCGs). East and North

Hertfordshire CCG, commission HCT to provide specialist palliative care (SPC) and end of life

care as part of the community and inpatient nursing provided in North Hertfordshire, Stevenage

and Royston localities. In Hertfordshire Valleys CCG, HCT provide SPC nurses within Watford

and Hertsmere localities. Hospices within the area provide care for the St Albans, Harpenden and

Dacorum localities.

The trust’s vision for end of life care is to ensure health and wellbeing is maximised in the last

year of life and that patients and carers are supported to access appropriate services and jointly

plan treatment with a preferred place of death. The community trust aims to increase the number

of patients identified to be in the last year of life and for all patients at the end of their life to

ensure they received high quality, personalised care.

During our inspection we visited community inpatient areas at Queen Victoria Memorial Hospital,

Danesbury House, Potters Bar Community Hospital and Hemel Hempstead Hospital. We also

visited community adult services within the HCT localities. During our inspection we were told

that there were seven patients undergoing end of life care within the community setting and that

there were no inpatients within the trust’s community hospitals, requiring end of life care. We

attended four home visits with both SPC nurses and community nurses. We reviewed six care

records including six medicine charts, and reviewed 22 do not attempt resuscitation (DNACPR)

forms within the community inpatient and community settings. We also reviewed ten patients’

Mental Capacity Act (MCA) documentation.

We spoke with 18 staff including, specialist palliative care nurses, community end of life

champions, ward inpatient end of life champions, a palliative care medical consultant, a specialist

Macmillan clinical education manager and locality managers within HCT. In addition, we spoke

with a range of staff including ward and community nurses and sisters, medical staff and allied

healthcare professionals and clinical nurse specialists. We also spoke with four patients and six

relatives.

The trust was last inspected in April 2016. At that inspection it was rated requires improvement

overall.

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Is the service safe?

Mandatory training

Although the service provided mandatory training in key skills to all staff and made sure

end of life specialist nurses, community and inpatient staff had access to it, not all staff

had completed mandatory training.

Staff received mandatory training on a rolling annual programme which was provided through a

mix of classroom based sessions and e-learning.

Mandatory Training completion

The trust did not separate their mandatory training data by staff group. Therefore, the data below

includes nursing and midwifery staff, medical and dental staff, allied healthcare professionals and

healthcare assistants/infrastructure support staff in community inpatient services.

The trust set a target of 90% for completion of all mandatory training courses except for health and

safety and information governance, which both had a target of 95%.

From April 2017 to March 2018 the breakdown of compliance with mandatory training for staff in

community services for end of life care is shown below.

Name of course Staff

trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)

Infection Prevention (Level 1) 3 3 100% 90% Yes

Equality and Diversity 5 5 100% 90% Yes

NHS |CSTF| Resuscitation - Level 2 3 3 100% 90% Yes

Information Governance 5 5 100% 95% Yes

Manual Handling - Object 5 5 100% 90% Yes

NHS |CSTF| Fire Safety 5 5 100% 90% Yes

Conflict Resolution 2 3 67% 90% No

Health and safety 2 5 40% 95% No

The trust met the target for six of the eight courses.

Medical device training had been completed and updated in line with trust policy. Medical devices

included; medication pumps, vital signs monitoring equipment and syringe drivers, all of which

were used within the community and inpatient settings.

Staff had received additional training to the mandatory topics dependant on their specific roles. For

example, end of life care training was offered to all staff within the inpatients and community

settings. Additional training was given which included, how to ask difficult questions, holistic

assessments for patients and carers and how to implement the Gold Service Framework (GSF).

The trust supplied updated mandatory training data as of August 2018. The breakdown by training

module for staff in community services for end of life as of that date is shown in the table below.

Please note that the health and safety training module was not included in the updated data. In

addition, some other training modules had been amalgamated or renamed.

Name of course Staff

trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)

Information Governance 4 5 80.0% 95% No

Fire 4 5 80.0% 90% No

Conflict Resolution 3 4 75.0% 90% No

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Resuscitation 3 4 75.0% 90% No

Infection Control Mandatory 3 4 75.0% 90% No

Equality and Diversity 3 5 60.0% 90% No

In community health inpatient services, as of August 2018 the trust’s training targets were not met

for any of the six mandatory training modules for which staff were eligible.

(Source: DR110, Mandatory training compliance August 2018)

Safeguarding

Staff understood how to protect patients from abuse and the services worked well with

other agencies to do so.

Staff showed an awareness of safeguarding procedures and how to recognise if someone was at

risk or had been exposed to abuse. Staff had access to the trust’s safeguarding policy and knew

how to escalate concerns to the wider trust safeguarding team.

Specialist palliative care, inpatient and community nurses demonstrated a good understanding of

safeguarding and their responsibilities in relation to reporting and escalating concerns. For

example, nursing staff had raised a safeguarding alert for a patient at the end of life, who was at

home in vulnerable circumstances and did not want to be admitted to hospital. This led to a

multidisciplinary approach to ensure they were able to stay at home safely.

Staff received equality and diversity training as part of their required mandatory training. Staff we

spoke with were aware of the adaptations necessary when caring for patients with cultural and

physical requirements. For example, we were told of an incident where a patient would only let a

male nurse care for him, therefore, arrangements were made to ensure this need was met, which

ensured their protected belief had been listened to and complied with.

Safeguarding Training completion

The trust set a target of 90% for completion of safeguarding training.

From April 2017 to March 2018 the breakdown of compliance for mandatory courses for staff in

community services for end of life care is shown below.

Name of course Staff

trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)

Safeguarding Adults (Level 1) 2 2 100% 90% Yes

Safeguarding Children (Level 1) 2 2 100% 90% Yes

Safeguarding Adults (Level 2) 3 3 100% 90% Yes

Safeguarding Children (Level 2) 3 3 100% 90% Yes

NHS |CSTF| Preventing - Radicalisation - Levels 1 & 2 (Basic Prevent Awareness)

2 2 100% 90% Yes

NHS |CSTF| Preventing Radicalisation - Levels 3, 4 & 5 (Prevent Awareness)

2 3 67% 90% No

The trust met the target for five of the six courses.

SPC nurses safeguarding training was at 75% within the East and North Hertfordshire localities

and 100% within the Hertfordshire Valleys team. This did not meet the trust target of 90%.

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The trust supplied updated safeguarding training data as of August 2018. The breakdown by

training module for staff in community services for end of life as of that date is shown in the table

below. Please note that the different levels of safeguarding adults and preventing radicalisation

training had been replaced by a single module for each of these two training subjects by August

2018.

Name of course Staff

trained Eligible

staff Completion

rate Trust

Target Met

(Yes/No)

Safeguarding Children (Level 1) 1 1 100.0% 90% Yes

Safeguarding Adults 4 5 80.0% 90% No

Safeguarding Children (Level 2) 3 4 75.0% 90% No

Preventing radicalisation 3 5 60.0% 90% No

In community health inpatient services, as of August 2018 the 90% target was met for one of the

four mandatory training modules for which staff were eligible.

(Source: DR110, Mandatory training compliance August 2018)

Safeguarding referrals

A safeguarding referral is a request from a member of the public or a professional to the local

authority or the police to intervene to support or protect a child or vulnerable adult from abuse.

Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and

institutional.

Each authority had their own guidelines relating to investigating and progressing a safeguarding

referral. Generally, if a concern was raised regarding a child or vulnerable adult, the organisation

worked to ensure the safety of the person. In addition, an assessment of the concerns was

conducted to determine whether an external referral to children’s services, adult services or the

police should take place.

Referrals were provided on a trust wide level so we were unable to break this down to individual

core services.

(Source: Universal Routine Provider Information Request (RPIR) – Safeguarding)

Cleanliness, infection control and hygiene

The service controlled infection risk in line with best practice.

Staff kept themselves, equipment and the premises clean. Staff complied with the trust’s infection

prevention and control policy.

During our inspection, we found the community inpatient environments we visited to be visibly

clean. There were posters on display encouraging staff and visitors to clean their hands using the

hand gel provided, which was available within the inpatient ward corridors and the community

nursing areas.

We observed community and inpatient staff groups complying with the arms ‘bare below the

elbow’ policy. This is an infection prevention and control plan to prevent the transfer of infection

from clothing that could be contaminated, and allows clinical staff to wash their hands thoroughly.

We accompanied SPC nurses and community nurses on home visits, with the patient’s

permission. We saw that staff adhered to good practice regarding hand washing in patients’

homes. We observed that community nurses and the SPC nurses carried personal protective

clothing, for example, gloves and aprons when providing care for patients. These were also

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available within the patient’s home surroundings. All clinical waste was disposed of according to

trust policy using the appropriate clinically coloured bags.

There was a mortuary at Hemel Hempstead hospital that was used by the community inpatient

wards. The mortuary was run by a local acute trust. Porters were responsible for cleaning the

specific trolley used following a patient’s death. We were assured that the trolley was cleaned

following each patient transfer. We noted on our inspection that the trolley was maintained and the

wipeable cover over the trolley was kept in good condition, with no obvious tears.

Environment and equipment

The service generally had suitable premises and equipment and equipment was serviced

according to the manufacturer’s instructions.

Patients admitted for end of life care within the community inpatient wards were cared for in single

rooms. This provided the patient and relatives with privacy and ensured a quiet peaceful

environment. In Hemel Hempstead hospital, St Peters ward had two beds specifically allocated to

patients who required end of life care. Occasionally these beds were allocated to patients not

requiring end of life care. We were assured by the staff that if a dying patient required a side room,

adjustments would be made to facilitate the needs of that patient and their relatives.

Equipment or aids required by patients in their own homes, was accessed from Hertfordshire

Equipment Services. Types of equipment that were required to help patients at home included

hoists, commodes, hospital beds and special mattresses to prevent pressure ulcers. We were told

by community nurses that equipment was accessible and delivered within a timely manner.

Medical devices such as syringe drivers were used within both the community inpatient wards and

community settings. A syringe driver is a small, portable, infusion device and is used to provide a

continuous delivery of pain killers, sedatives or anti sickness drugs. They are suitable for patient

use in the hospital and at home. The syringe drivers we saw, had all been electronically tested and

were sealed in a locked clear box. Each syringe driver used in the community was maintained and

tracked within the specific locality of the patient. During our inspection we saw that all syringe

drivers being used were renewed appropriately in line with the recommended National Institute for

Health and Care Excellence (NICE) guidance CG140 -palliative care for adults.

Community nurses undertook risk assessments to ensure sharps containers were stored safely

within the patient’s home environment. A sharps container is a hard-plastic container that is used

to dispose of needles and other sharp medical consumables. Used sharps containers were

disposed of by the community nurses by placing the sealed container in a plastic bag and

disposing it within the clinical waste area allocated at the main locality base.

Assessing and responding to patient risk

The service had systems in place to ensure the safety of patients.

Comprehensive risk assessments were carried out, and risk management plans were developed

in line with national guidance. These included assessments of patients’ susceptibility to pressure

ulcers, dehydration and malnutrition where it was appropriate. In accordance with the end of life

care planning, these assessments were adapted according to the patient’s needs.

During our inspection the community nurses and specialist palliative care nurses described how

they would implement specific risk assessments for example, when using home oxygen. They

showed us an initial home assessment form which would be completed prior to arranging delivery

and consent to use oxygen within the patient’s home. Home oxygen risk mitigation assessments

were completed to eliminate and prevent incidents happening within the community setting.

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In inpatient areas and community settings, staff worked proactively to ensure they could meet the

needs of patients requiring end of life care. They were prepared for times when less medical

support was available. Specialist palliative care support was available seven days a week and an

out of hours advice line service was available from one of the local hospices. The community

nursing facility also provided a 24-hour service, nurses prioritised patients who had required

advanced pain control and management of associated symptoms. The trust was in the process of

approving a new policy on ‘deferred visits guidance’ to assist with the decision making around

responding to patient’s needs.

During our inspection we observed a team meeting with the specialist palliative care nurses. The

palliative care team discussed the patients receiving end of life care within the specific locality.

Discussions took place amongst the locality manager, the palliative medical consultant and SPC

nurses regarding new patients and ongoing needs of the patients within the community.

Staffing

The service generally had enough staff with the right qualifications, skills, training and

experience to keep patients safe from avoidable harm and abuse and to provide the right

care and treatment.

Staffing levels, skill mix and caseloads were planned and reviewed so patients received safe care

and treatment, in line with relevant national guidance. NHS England specialist level palliative care

April 2016, suggests that to provide a safe and effective specialist level palliative care service it

must be adequately resourced to meet the characteristics of the service commissioned, taking into

account the need for 24hour cover seven days a week and cover for study leave, holidays and

other absences. During our inspection we were assured that this had been achieved.

There was no dedicated team delivering end of life care either in the community setting or in the

trust’s bed bases. Care was provided by teams, for example community nurses, who also gave

care to other patient groups. Advice was available from the SPCT. The trust captured data for this

staffing group. Within the inpatient and community settings there were end of life care champions

based in each locality. These champions were multi-disciplinary practitioners that had received

enhanced end of life training. During our inspection we spoke with end of life champions in all the

localities we visited.

Where necessary staff were doubled up to ensure safety within the community. Staff we spoke

with were aware of the lone working policy and would complete a risk assessment if they felt more

than one practitioner was required during a patient visit.

Staffing - Planned v Actual

Details of staffing levels within community services for end of life care by staff group as at March

2018 are below.

Community end of life care total

Staff group Planned WTE Actual

WTE Staffing rate (%)

NHS Infrastructure Support Staff 3.8 1.6 42%

Other Qualified Scientific, Therapeutic,

Technician Staff 0.81 0 0%

Public Health and Community Health

Services 2.14 1 46.7%

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Qualified nursing & health visiting staff

(Qualified nurses) 2 2 100%

Total 8.75 4.6 52.6%

(Source: Routine Provider Information Request – Staffing tab)

Specialist Palliative Care Nurses employed within the community trust

Specialist Palliative Care – Staff currently in post:

Locality Band WTE

North Herts/Royston Band 7 0.8

Band 6 0.8

Band 6 0.8

Stevenage Band 7 1.0

Band 7 1.0

Band 7 0.6

Hertsmere Band 7 1.0

Band 7 1.0

Watford Band 7 1.0

Band 7 1.0

Band 7 0.8

Total: 9.8

(Source: Information provided by operation lead for End of Life Services 20180919)

Vacancies

The trust set a target of 10% for vacancy rates. A breakdown of vacancy rates from April 2017 to

March 2018 by staff group in community services for end of life care is below:

Community end of life care total

Staff group Vacancy rate

Other Qualified Scientific, Therapeutic, Technician Staff 100%

Public Health and Community Health Services 50.6%

NHS Infrastructure Support Staff 42.8%

Qualified nursing & health visiting staff (Qualified nurses) 1.8%

Total 40.3%

(Source: Routine Provider Information Request (RPIR) – Vacancy)

Most of the community based staff we spoke with had some vacancies within their teams.

Recruitment was ongoing, and staff told us when new staff were appointed they felt fully informed

and could arrange their welcome and induction. The community trust was involved in the NHS

Improvement ‘national nurse retention programme’.

Turnover

The trust had set a target of 12% for turnover rates. From April 2017 to March 2018 there were no

leavers in community end of life services so the annual turnover rate was 0%.

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(Source: Routine Provider Information Request (RPIR) – Turnover)

Sickness

The trust set a target of 3.6% for sickness rates. A breakdown of sickness rates from April 2017 to

March 2018 by staff group in community services for end of life care is below:

Community end of life care total

Staff group Available

days

Sickness

days

Sickness

(%)

NHS Infrastructure Support Staff 474 9.8 2.1%

Other Qualified Scientific, Therapeutic, Technician Staff 400 0 0%

Public Health and Community Health Services 730 4 0.5%

Qualified nursing & health visiting staff (Qualified nurses) 341 2 0.6%

Total 1,945 15.8 0.8%

(Source: Routine Provider Information Request (RPIR) – Sickness)

Nursing – Bank and Agency Qualified nurses

From April 2017 to March 2018 the trust reported bank and agency usage for registered nurses in

community end of life care as below:

Shifts available 17

Filled by bank 16

Shifts not filled 1

(Source: Routine Provide Information Request – Bank and agency tab)

(Source: Universal Routine Provider Information Request (RPIR) – P23 Suspensions or

Supervised)

Medical Staffing

A whole time equivalent consultant in palliative medicine was employed by the trust to provide

medical cover within the localities. Additionally, further support was provided by a palliative care

consultant based at one of the local hospices within the community. NHS England specialist level

palliative care April 2016 states there should be a consultant in palliative care medicine providing

clinical leadership across a number of localities, therefore medical staffing was reflected current

guidelines.

Quality of records

Staff generally kept appropriate records of patients’ care and treatment.

The trust aimed to achieve good practice in record keeping across the localities. The trust

regularly completed monthly record keeping audits. To ensure that all records were effectively

communicated to other services, for example ambulance services and nursing care agencies,

relevant and up to date information regarding treatment escalation plans, DNACPR forms patient’s

wishes and preferences were stored in a bottle and placed in the patient’s fridge - ‘the message in

a bottle’ initiative.

The trust’s electronic record system relating to end of life care aims and objectives had recently

been updated. This upgrade ensured that all relevant information was accessible in the same on

the system, providing an easier system for the staff to navigate. The changes made within the

system were altered in agreement with the end of life care champions within each setting. This

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was reviewed by the locality managers, palliative care medical consultant and specialist MacMillan

clinical education manager. All staff within the localities were given training to ensure the new

change was effectively embedded.

Community nurses had access to electronic tablets. They accessed the electronic system and

completed the notes during visits to patients. We visited four patients within the community

services that were receiving end of life care, we observed all the nursing staff completing the

electronic and paper documents to a high standard.

Patient’s individual community care pathways included records of conversations with the patient

and family members about decision making at the end of life, this was documented both on a

paper copy and electronically stored within the advanced care plan.

Medicines

The service prescribed, administered, recorded and stored in accordance with good

practice.

Patients who were deemed to be at the end of their life, were prescribed a range of medicines that

could be administered when required to manage their symptoms, these were referred to as

‘anticipatory medicines’. We saw this worked well and staff were confident in making decisions

about when these medicines should be administered, for example, during a home visit with the

specialist care nurse we saw her discuss with the family how to best control the patients pain, the

anticipatory medication was adjusted, prescribed and given as necessary.

Anticipatory medicines were stored safety in the patient’s home, we saw that medication was kept

in a high-level cupboard out of reach of vulnerable adults and children. During our inspection we

saw the community nurse dispose of out of date medicines by completing a double check with

another health care professional and disposing of them in the correct manner on returning to the

locality base.

The community settings had palliative care ‘just in case ‘guidelines. This included types of

medicines that could be used and doses required. The guidelines contained a list of pharmacies

that could be used if medication was needed immediately but was not readily available. Standard

level agreements with outsourced pharmacies were in place to ensure an effective provision was

maintained for patients within the community.

Controlled drugs for use in end of life care were seen to be stored safely on in the inpatient and

community services. We observed community nurses discussing the safe storage of medicines in

patients’ homes. On community inpatient wards, we saw that controlled drugs were appropriately

monitored and audited.

Community and SPC nurses were non-medical prescribers (NMP). This meant registered nurses

could administer end of life care medications to patients in a timely way. NMPs were trained

appropriately and practiced within their level of competency, within the scope of their professional

bodies.

Safety performance

The safety thermometer is used to record the prevalence of patient harms and to provide

immediate information and analysis for frontline teams to monitor their performance in delivering

harm free care. Measurement at the frontline is intended to focus attention on patient harms and

their elimination.

Each inpatient unit displayed safety information in the public areas using a ‘safety cross’ system.

The information included; the number of falls, the number of pressure ulcers, the number of bed

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days lost to diarrhoea and vomiting, along with cleanliness audit results, the number of complaints

and staff sickness. This data is described in the community inpatients report.

Incident reporting, learning and improvement

The service managed patient safety incidents and generally learned from incidents. Staff

recognised incidents and reported them in a timely manner.

Staff we spoke with understood their responsibilities regarding reporting incidents. The trust used

an electronic reporting system on which all staff had been trained to use. Staff clearly understood

their responsibilities to report incidents, and spoke of a culture where this was actively

encouraged. All staff we spoke with, said they received feedback after reporting an incident

through their locality meetings.

The staff in both the inpatient and community settings, had a clear understanding of the types of

incidents that they felt could be classified as an incident relating to end of life care. For example,

the inability to provide side room facilities during the later stages of a patient’s care. There was a

clear process for communicating, investigating and learning from incidents. However, the trust did

not separate the incidents into specific categories for example, end of life care. Therefore, we

were unable to ascertain how many reported incidents actually related to the end of life services.

The community trust had monthly meetings to discuss Complaints, Litigation, Incidents, concerns

from the Patient advice liaison Service team, and Safeguarding - CLIPSS. In addition, risks were

discussed. We saw from the minutes of the July 2018 meeting specific discussions around the use

of end of life care plans within the inpatient units, because use of these plans had not always been

identified.

Staff working within the inpatient and community settings were aware of their responsibilities with

regards to duty of candour. The duty of candour is a regulatory duty that relates to openness and

transparency. It requires providers of health and social care services to notify patients (or other

relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that

person. Staff could provide examples of situations when an incident had occurred, how they had

informed the patient and their relatives of the incident, made an apology and explained what

investigation and actions had resulted from the incident.

Never events

Never events are serious patient safety incidents that should not happen if healthcare providers

follow national guidance on how to prevent them. Each never event type has the potential to cause

serious patient harm or death but neither need have happened for an incident to be a never event.

From August 2017 to July 2018, the trust reported no never events for community services in end

of life care.

(Source: Strategic Executive Information System (STEIS))

Serious Incidents

Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).

These include ‘never events’ (serious patient safety incidents that are wholly preventable).

In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents

(SIs) in community services for end of life care, which met the reporting criteria, set by NHS

England between August 2017 and July 2018.

(Source: Strategic Executive Information System (STEIS))

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Serious Incidents (SIRI) – Trust data

From April 2017 and March 2018, trust staff within community services for end of life care reported

no serious incidents.

(Source: Routine Provider Information Request (RPIR) – Incidents tab)

Prevention of Future Death Reports (Remove before publication)

There had been no deaths requiring a Coroner's Inquest in relation to community health services

in end of life care in the last 12 months.

(Source: Universal Routine Provider Information Request (RPIR) – P86)

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Is the service effective?

Evidence-based care and treatment

The service provided care and treatment based on national guidance. There was evidence

of its effectiveness.

During our inspection we saw that patients had personalised advanced care plans (ACP). The

care plans included individual’s preferences regarding the type of care they would wish to receive

and where they wanted to be cared for. The ACP is a fundamental part of the NHS End of Life

Care Programme.

Patients’ physical, mental health and social needs were assessed. Their care, treatment and

support was delivered in line with legislation and national evidence-based guidance. For example,

during our inspection we observed nurses controlling anticipatory medicines appropriately in line

with NICE guideline CG140 – strong opioids for pain relief and NG31 - care of the dying adult in

the last days of life. NG31 aims to improve end of life care for people in their last days of life by

communicating respectfully and involving them, and their relatives. We also observed the SPC

nurses following the NHS improving quality, ‘priorities for care of the dying person’. The priorities

of care are to recognise, communicate, involve, support, plan and do. These priorities were

embedded within the inpatient and community settings, we saw laminated advice sheets available

to assist staff in preforming these tasks.

The trust used the gold standards framework (GSF) standards. The GSF provides a clear

standardised set of objectives to provide high quality care for patients in the final months of life.

Nutrition and hydration

Staff gave patients enough food and drink to meet their needs and improve their health.

Staff gave patients enough food and drink to meet their needs within the inpatient setting and,

where relevant in the patient’s home environment. We saw the General Medical Council (GMC)

guidelines were followed for patients who were in the final days and hours of life in relation to

nutrition and hydration. To help those close to patients understand these decisions, we saw

community nurses fully explain their actions and reasons behind them.

We observed community nurses referring patients to dieticians to improve their nutritional intake.

During a visit we witnessed the SPC nurses performing mouth care and prescribing medication to

improve the patient’s oral health.

Pain relief

Patients’ pain was assessed and managed appropriately.

Patients we spoke with told us that their pain was adequately controlled.

We observed SPC nurses and community nurses assessing patients’ pain, as part of their routine

assessments when visiting patients. This included asking patients, who were able to

communicate, about their pain levels. The Abbey pain scale was used for those patients with

communication difficulties. We observed a community nurse visiting a patient who had

deteriorated and was experiencing pain on movement. We observed the nurse providing

increased pain control using the anticipatory medicines regime, all assessments were documented

and communicated to the patients GP.

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Patient outcomes

The service generally monitored the effectiveness of care and treatment and used the

findings to improve them.

Monthly data was collected via audits for end of life record keeping compliance, advanced care

pathway completion and preferred place of death. This data was disseminated using clinical

dashboards and was monitored by the appropriate locality managers. Senior staff told us that a

specific end of life dashboard had recently been implemented. The information on the dashboard

was linked to the trust’s electronic data system.

The clinical dashboard assimilated information such as patients’ preferred place of care, preferred

place of death, advanced care plan and end of life assessment. Due to recent changes within the

electronic record framework we were unable to gather sufficient information to ascertain how

thoroughly the dashboard had been completed, or how up to date the information was. However,

during our inspection, we were informed by senior staff that the end of life dashboard information

had shown an improvement in the compliance regarding patient requested place of care and place

of death.

The service had not been accredited with the GSF quality hallmark in end of life care. However,

the objectives and recognised framework achievements were used within the trust’s localities. We

saw evidence of this at the regular team meetings that were held in conjunction with the local GPs.

The National Audit for ‘care at the end of life’ is open to all organisations who provide inpatient

facilities, including acute trusts, mental health hospitals and community hospitals. HCT had not

participated in this audit, however they were in the process of submitting relevant data prior to

publication in May 2019.

In April 2016, we saw the trust did not have an end of life care policy. Staff we spoke during this

inspection were aware of, and knew where to find, the trust’s end of life policy which had been

implemented in 2017. The end of life policy provided staff with a clear set of guidelines and related

end of life policies.

The trust had participated in five clinical audits in relation to this core service as part of their

clinical audit programme.

Audit name Area covered Key Successes Key actions

Pain Audit (84)

CQC (re-audit)

Specialist

Palliative

Care

Service

• In 92% of cases, the pain

template had been

completed.

• In 79% of cases, the pain

had been scored from

0-10.

• A body map was

completed in 62% of

cases.

• In 64% of cases, there

was evidence that the

pain had been reviewed

following intervention. A

management plan has

been completed in 77%

of cases.

• Report results to the

medicines management

forum (MMF) (July 2017)

and patient safety and

experience group meeting.

(action complete).

• Review national tools and

gain permission to use

these at HCT. (action

complete).

• Collaborative working with

learning disability/children’s

services and adults’

services to standardised

pain templates. (action

complete).

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• 4 pain tools added on system

one (electronic data system

September 2017) and

accessible for all HCT

services abbey pain scale

for cognitive impairment,

entonox pain scale for

learning disabilities, Wong-

Baker faces for children,

pain sites for Adults].

(Action complete).

• Education and training plan

in place to help increase

awareness of the need to

assess all patients to

determine if they are in

pain and to ensure all staff

are aware of the pain tool

and feel confident and

competent to use it. (end of

life care champions are

completing this along with

the clinical nurse specialist

- ongoing)

• End of life care audit group

monitors progress of work

to meet quality

improvement requirements.

• Re-audit to monitor

compliance of the use of

the new pain tools. April

2018 re-audit results much

improved and due to be

shared at the next CEG

meeting on the 14th June

2018.

To audit the use

of opioid

information

leaflet for

adult

palliative

and end of

life care

patients

across HCT

(94)

Specialist

palliative

care

service

• 92% of patients were

asked about the

concern they may have

about starting treatment.

• 80% of patients were told

when and why opioids

were used to treat pain.

• When taking opioids for

background and

breakthrough pain, 80%

of patients were told

• Shared audit results with all

localities and community

hospitals

• Recorded on patient record

when written information is

given to patients about

strong opioids

• More staff awareness of the

2 information leaflets linked

to the medication templates

on System One

183

about how long pain

relief should last for.

• 88% of patients were

given information about

who to contact out of

hours.

• 76% of patients were

advised that

constipation affects

nearly all patients.

The majority of patients

were given appropriate

information about their

treatment and were

well-informed about

their side-effects.

• Reaudit in 3 months

Syringe pump

policy audit

(30)

Specialist

palliative

care

service

• 88% of staff were aware

of the HCT Syringe

Pump policy for adults &

children.

• 88% of staff knew where

to access this policy.

• If the battery was reading

38%, 95.8% of staff

would change it.

• 92% of staff know where

to access help and

support regarding

syringe pumps.

• 71% of staff were

confident to put up a

syringe pump.

Overall, over 80% of staff

were aware of the policy

and acted upon it, had

implemented it in their

practise.

• Training on the revised

syringe pump policy

(including the importance

of why the patient and

family should be provided

with the patient information

leaflet) – ongoing as all

staff have to attend an

annual update.

• Training on the Individualised

care plan for the dying

patient (to ensure that staff

understand why this is

used and when to

implement it). Continual

training now introduced via

several different training

sessions offered to HCT

staff.

• Ensure all new band 5 and 6

staff have palliative care

competencies (within the

competency booklet) and

signed off within 3 months

of starting with HCT. Band

6 and band 7 mentors now

review competency booklet

to provide assurance of

completion. (action

complete).

184

Syringe pump

policy audit

(re-audit)

(97)

Specialist

palliative

care

service

• 97% of staff were aware

of HCT syringe pump

policy for adults and

children.

• 94% of staff knew where

to access it.

• If battery is reading 38%,

98.61% of staff would

change it.

• 96% of staff know where

to access help and

support regarding

syringe pumps.

• 90% of staff were

confident to put up a

syringe pump.

Improvement noticed since

the previous audit,

regarding the

confidence of staff, and

awareness of where to

access the policy.

• Shared all results with

locality and service

managers and request that

all recommendations are

carried out

• Monitored numbers of

incidents involving syringe

pumps with the quality

team

• All staff ensured patients

receive an information

leaflet when commencing a

syringe pump

Internal peer

review for

end of life

issues CQC

(99)

Specialist

palliative

care

service

• In Royston ICT, 100% of

staff were aware of the

end of life care policy

and pain assessment

templates

• In Upper Lea Valley ICT,

100% of staff were

respectful, caring,

informed and discreet.

All audited staff were

respectful, caring and

informed about the

patient's care plan.

• To ensure literature

displayed on communal

boards and walls is up to

date - North Herts ICT.

• To ensure that all staff can

attend end of life education

sessions by the Macmillan

clinical educators.

(Source: Universal Routine Provider Information Request (RPIR) – P35 Audits)

Competent staff

Patients had their needs assessed, preferences and choices met by staff with the right

skills and knowledge.

Staff we met within inpatient areas and community localities felt confident to deliver end of life care

that met the needs of patients.

The trust had previously identified that there had been a gap within the completion of specific end

of life knowledge. The trust had undertaken a joint education project with the Macmillan cancer

support service. The Macmillan clinical education project was a jointly funded partnership to

provide clinical education, training and support to SPC nurses and community nurses across all

the localities.

185

Within each locality end of life champions had been appointed. The champions provided a direct

link between the locality teams and the Macmillan project team. During our inspection we spoke

with end of life champions who felt that they had received enhanced training to be able to pass on

information on to the staff within their teams. We saw evidence of this when visiting one of the

inpatient wards, the end of life champion was to provide an update and teaching session on the

new electronic word template implementation at the team meeting later that day.

Total number of courses run and HCT staff trained in end of life during the reporting period from

April 2018 to September 2018.

(Source; DR51- Additional data information request)

Within the trust there were competency packages specifically for advanced end of life care

practitioners. This package ensured that practitioners, for example the champions, had the

necessary skills and knowledge to provide enhanced care to patients and their relatives in

accordance within the identified end of life pathways.

Appraisal Rates

From April 2017 and March 2018, 67% of all staff within the community services for end of life care

core service had received an appraisal compared to the trust target of 90%.

(Source: Routine Provider Information Request (RPIR) – Appraisals tab)

Updated information received following our inspection showed the SPC nurses to have an

appraisal compliance of 100%

Courses run Frequency Total number of attendees

Advanced Care Planning(ACP) One Stop 3 99

ACP & Dementia Awareness (Induction) 5 97

Dementia & end of life 1 9

ACP workshop 1 7

Symptom Control & Palliative Care Emergencies

1 7

Syringe pump refresher 3 35

Syringe Pump beginners 3 24

Pal Care update & syringe pump refresher 3 99

2 day Intro to Palliative Care & end of life 1 16

Sage and Thyme 2 8

Intermediate Communications 1 7

Advanced Communications 2 3

Champion end of life training/forums 5 67

Total Total

31 478

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Specialist Palliative Care for East & North Hertfordshire is only provided by HCT for North Herts &

Stevenage.

(Source- DR -152)

Multidisciplinary working and coordinated care pathways

Staff, teams and services within the trust across all the localities worked very well together

to deliver effective care and treatment.

The service coordinated with other providers and services, including GPs and hospices to ensure

patients approaching the end of life were identified and supported.

There were weekly multidisciplinary meetings where all patients referred to the palliative care team

were discussed. In addition, this meeting was attended by the hospice medical consultant who

worked closely with the palliative care team to deliver end of life care. The multidisciplinary

meetings provided a platform for a holistic review of patients’ care, where actions were allocated to

the appropriate professional. These regular meetings meant that patients were reviewed it a timely

manner and plans amended when necessary, to reflect their needs.

We spoke with the Macmillan clinical educator who told us about the out of hours prescription

project, which had recruited the help of volunteers within the community. The volunteers assisted

relatives and patients with the collection of medication during the out of hours periods, for

example, weekends and bank holidays. This multi-disciplinary collective working proved to be

effective and had provided good feedback from staff, patients and relatives who had used the

service.

Health promotion

Staff gave examples of patients who had been identified as needing extra support. For example,

patients requiring palliative care who had existing long-term conditions. The nursing staff gave

advice about equipment to aid mobility, dietary advice to help reduce the risk of pressure damage

and opportunities to increase their wellbeing, with information about local activities and support

groups. We observed staff giving health promotion advice about gentle exercise to aid mobility.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

Staff were aware of the Mental Capacity Act 2005. However, during our inspection we found

that consent was not always obtained or recorded in line with relevant guidance and

legislation.

We reviewed 22 DNACPR forms, four within the community setting and 18 within the inpatient

community localities. A DNACPR form is a document issued and signed by a doctor, which tells

the attending medical team not to attempt cardiopulmonary resuscitation (CPR). Within the

community localities we found that all four DNACPR forms had been completed in accordance to

resuscitation guidelines ensuring that all relevant reviews had taken place. However, within the

community inpatient settings we found that, from 18 reviewed DNACPR forms, only eight had

Eligible for

appraisal

Completed appraisal

in past year

Compliance

rateNotes

812 Hertsmere CAHS C145402 2 100%

812 Stevenage Integrated Care Team C133351 1 100%

plus 2 new starters in past 2/12 812 Watford CAHS C14510

2 2 100%plus 1 new starter in past 2/12

812 North Herts Integrated Care Team C133300 n/a

plus 1 new starter in past 6/12

187

been completed correctly according to local policy and guidance. This included the incomplete

documentation of the indefinite decision review and the consultant review.

Within one of the inpatient localities we saw that the DNACPR forms were not reviewed following

transfers from the local acute trust. The trust resuscitation policy stated that all documentation

should be reviewed and communicated to staff. Not all copies of the decisions regarding the

DNACPR status of patients were recorded in the paper and electronic copies. During our

inspection we questioned the staff regarding patient resuscitation status and were told that several

patients were for resuscitation however, their hospital records showed that DNACPR forms had

been completed. This was escalated to the inpatient ward sisters at the time of our inspection.

Where the individual lacked capacity, a Mental Capacity Act (MCA) form should have been

completed and documented within the patient’s paper notes and on the electronic record system.

Mental capacity assessment guidance recommends that where long-term or significant decisions

are to be made in relation to a person who may have lacked capacity, professional staff must keep

a record of how capacity was assessed and any ensuing decisions made. Out of the 22 DNACPR

forms reviewed, nine patients were deemed to be lacking in capacity. Out of the nine patient

records, no MCA forms were documented in either paper or electronic records. This was escalated

at the time of our inspection.

Following our inspection, the trust advised us they had undertaken audits for the completion and

documentation of the DNACPR and MCA forms. Support and clarification was given to ensure

correct documentation and consistent alignment with electronic records were completed. A letter

discussing the correct processes had also been cascaded to staff via ward managers to ensure

both medical and nursing staff complied with the required practices.

The community trust was in the process of implementing a standard DNACPR form throughout all

the localities. We did not see any ReSPECT (Recommended Summary Plan for Emergency Care

and Treatment forms during our inspection.

Mental Capacity Act and Deprivation of Liberty training completion

The trust set a target of 90% for completion of Mental Capacity Act / deprivation of liberty

standards training.

From April 2017 to March 2018 the trust reported that Mental Capacity Act (MCA) training had

been completed by 100% of staff within community health services for end of life care.

The trust supplied updated MCA and DoLS training data as of August 2018. By that date the trust

had a single level of MCA training. As of that date this training module had been completed by

three of the four eligible staff within community health services for end of life care (75%). This was

lower than the trust’s 90% target for completion of MCA training.

As of August 2018, both of the eligible qualified nursing staff had completed MCA training.

However only one of the two eligible medical staff had completed this module.

(Source: DR110, Mandatory training compliance August 2018)

Is the service caring?

Compassionate care

Staff cared for patients with compassion. Feedback from patients confirmed that staff

treated them well and with kindness.

188

Staff interacted with patients and those close to them in a respectful and considerate manner.

Patients and their relatives were positive about experiences of care and kindness offered to them.

During our visits with the community and SPC nurses we saw that staff demonstrated an

understanding of the patients’ emotional needs. Staff made sure that patients’ privacy and dignity

was always respected, during physical or intimate care.

The services regularly received compliment cards and letters of thanks from patients, their friends

and relatives. One recently received card said, ‘Thank you for your kindness during this difficult

period,’ another said the staff were caring and thanked them for their support.

Emotional support Staff provided emotional support to patients to minimise their distress. Staff showed

awareness of the emotional and social impact of patients care and treatment.

Patients and relatives that we spoke with were positive about the support they had received from

the community nurses and SPC team. Patients could access and be given appropriate, timely

support and information to cope emotionally and mentally with their care.

Staff ensured the needs of families and others important to the patient were actively explored,

respected and met as far as possible. People we met told us that they felt welcome to stay with

their loved ones, and that the facilities available to them were highly thought of.

Treatment options were discussed with patients and those close to them. Staff said whilst this was

sometimes difficult and challenging it was important to involve the patient. Staff signposted

patients and those close to them to relevant services that could provide support and advice.

Psychological support and complementary therapies were available to patients in the community

receiving end of life care, through the local hospices.

Understanding and involvement of patients and those close to them

Staff involved patients and those close to them in decisions about their care and treatment.

Staff provided emotional support to patients to minimise their distress. Psychological, religious and

spiritual support were available to patients. Bereavement information was available to assist

relatives to suitable services.

Patients and relatives felt that staff communicated with them in a way which they could

understand, when explaining their care, treatment and condition. Staff communicated with patients

in a way that was appropriate and respectful. We observed staff involving patients and their

relatives during assessments within the patient’s home. We observed community nursing staff

taking time to involve patients during their care giving them time to ask questions.

We observed nurses, doctors and therapists introducing themselves to patients and relatives and

involving patients in decisions about their care.

189

Is the service responsive?

Planning and delivering services which meet people’s needs

The trust planned and provided services in a way that met the needs of patients and their

relatives.

End of life services within the inpatient and community localities provided flexibility, choice and

continuity of care.

Inpatient, community and hospice teams worked together to support the patient’s wishes regarding

their preferred place of care and death. Inpatient staff told us that they had recently facilitated a

difficult transition of care from an inpatient ward to a community care setting. This transfer of care

was problematic due to the lack of social care packages available within the area, however,

through liaising with the community teams this had been managed and the patient’s preferences

had been met.

The community trust had recently redesigned the integrated community team referral hub for East

and North Hertfordshire. The hub created a single point of contact for all the teams within the

community, including referrals to rapid response and Homefirst. The rapid response and Homefirst

services supported those patients with long term or complex conditions to remain at home rather

than going into hospital. The hub was open from 8am till 6pm seven days a week. Out of hours

calls were diverted to specific locality teams.

The community services supported those patients who were uncertain about their future. An end

of life champion with the inpatient community setting, explained a situation where a patient had

been told that they were rehabilitating and they believed their condition would improve, in this

situation the patient did not want to have any conversations relating to the advanced care plan.

The inpatient nurse informed us that she respected the patient’s wishes and documented the

outcome in the electronic record system.

We were told that patients at the end of their life needing a bed within inpatient settings were

prioritised to facilitate their needs and wishes. There were single rooms, some with en-suite

facilities, where friends and family could stay with patients throughout the day and night. There

were facilities for relatives that provided a comfortable environment.

Meeting the needs of people in vulnerable circumstances

The service took account of patients’ individual needs.

End of life services were accessible to all members of the community including people with

conditions such as heart failure, dementia and neurological conditions.

Inpatient areas and community based staff had many resources available to meet the needs of

patients at the end of their life who had other associated conditions. For example, information

leaflets were available in braille, audio format, large print, easy read and a variety of languages.

Patients approaching the end of life were offered spiritual and religious support appropriate to their

needs and preferences in accordance with NICE Quality Statement 13. Some of the inpatient

hospitals had dedicated chaplains, with different religious faiths. During our inspection we saw

relatives within the community arranging spiritual support for patients at the end of life.

Services were delivered and coordinated to ensure that patients who may be approaching the end

of their life were identified and that this information was shared. Nurses described a positive

working relationship with GPs, this enabled them to collectively identify when a patient was

190

entering the end of life phase. We saw that this happened for a patient during our inspection which

prompted the implementation of an advanced end of life care plan.

Staff told us how they had co-ordinated the needs of a patient requiring end of life care, who was

particularly vulnerable due to their social circumstances. The staff liaised with the palliative care

social worker and local government to secure appropriate accommodation for the patient.

Translation and interpretation services, including British Sign Language, services were available

across the community trust, staff knew how to access these services if necessary.

Access to the right care at the right time

Patients could access most services when they needed it. However, the trust did not

provide information on how rapidly patients were discharged from inpatient services,

although information was provided which showed that 28% of patients achieved their

preferred place of death.

Community home visits were never cancelled however, they were sometimes delayed due to the

nature of the service. For example, staff were encouraged to stay with patients for as long as was

required to ensure the patient received suitable care depending on their clinical and psychological

status. If a patient was near to dying at the time of a home visit, staff said they would stay with the

patient and their relatives if requested. Delays were communicated to other patients to reduce any

unnecessary worry and concern. Disruption to the smooth running of the service, for example

delays caused by traffic were also communicated to patients. Patients generally had the choice of

whether they wanted to be visited in the morning or afternoon and if they did not have a

preference, they would be informed in advance of when a member of the team would be arriving.

Community hospitals prioritised admission for patients near to, or at the end of life, if they had

made a choice to be admitted as an inpatient. During our inspection we spoke with staff who said

that the local acute trusts referred patients requiring end of life care to them however, their

condition status was documented for ‘rehabilitation’. This lack of information from the acute trust

had precipitated the implementation of the ‘in-reach’ team. The in-reach team provided robust

clinical decision making for the admission of patients within the community inpatient hospitals,

ensuring that all patients at or near the end of their life, were identified and placed on the correct

care pathway.

Community out of hours calls were triaged and assessed according to patient needs. Patients

requiring end of life care were prioritised. Staff who worked out of hours said they were busy, but

able to work together with colleagues to ensure patients’ needs were met.

In October 2015, the trust stated that staff had recorded the patients’ preferred place of death in

51% of cases. The trust had issues with current data due to an amended template on the

electronic system which had provided inaccurate data. A process of manual data validation had

been completed with a senior clinician for each service to review each set of patient’s records.

A total of 975 patient records had been manually reviewed, which showed that assessment taken

place but not recorded in a place but the electronic data system had not pulled the relevant

information on to the dashboard.

191

Portfolio

Appropriate

assessment taken

place but not

recorded in a place

that pulls through

to the end of life

dashboard

Patient identified

in last year of life

but identified by

the service that

ACP discussions

not appropriate

Planned date in place

for review of end of

life and ACP for

those patients where

no appropriate

assessments are

recorded.

Number of

patients who

had been

discharged

from the

service

Community

Hospitals 129 / 180 (72%) 11 (neuro) 0 40

Herts

Valleys

CAHS

105 / 151 (70%) 0 15 30

East and

North ICTs 296 / 389 (76%) 31 33 31

Specialist

Services

including

SPC

156 / 255 (61%) 22 55 21

TOTAL 686 / 975(70%) 64 / 975 (6%) 103 / 975 (11%) 122/975 (12%)

(Source – manual data validation of the end of life September 2018)

Further information proved by the trust for the period October 2017 to September 2018 had

identified the 1544 patients recognised as at the end of their life had died in the last 12 months of

these 209 had cancer and 1335 non- cancer. Of these 81% had a preferred place of death

recorded and 28% of patients achieved their preferred place of death. No information was

provided on the number of patients achieving a rapid discharge.

Referrals

The trust has identified the below services in the table as measured on ‘referral to initial

assessment’ and ‘assessment to treatment’.

The trust met the referral to assessment target in the target listed.

Name of in-patient ward or unit

Days from referral to initial assessment Comments, clarification

National / Local Target Actual (median)

Specialist Palliative Care

126 1 Onset of treatment occurs at

initial assessment

(Source: CHS Routine Provider Information Request – Referrals)

The data below shows that in the localities in Hertfordshire where HCT provide specialist palliative

care (Watford, Hertsmere, North Herts and Stevenage) on average 45% of patients identified as

being at or near end of their lives were referred to the SPC team in 2017/18.

192

(DR53-Percenatge of patients referred to the Specialist Care Team)

Learning from complaints and concerns

Complaints and concerns were treated seriously. They were investigated, but there was no

system in place to ensure lessons were learnt from the results. Outcomes from complaints

and concerns were generally shared with inpatient and community staff through monthly

reports.

Complaint reports were produced every month and discussed within the CLIPSS monthly meeting.

The reports produced information relating to specific community localities. During our inspection

the operational lead for end of life care stated that any specific complaints relating to end of life

care were not individually disseminated to senior community trust staff. Following our inspection,

the operational lead for end of life reflected on the need for specific reviews to be made in relation

to detailed end of life incidents, rather than being grouped with all the inpatient or community

service complaints.

Information about how to make a complaint or raise a concern was available to patients and staff

within community localities.

The trust received feedback from relatives regarding the length of time some community patients

had waited for their daily care. However, on investigation the outcome of the complaint showed

that the care had been delayed due to emergency care being prioritised.

Complaints

From April 2017 to March 2018 there had been no complaints about community health services for

end of life care.

(Source: Routine Provider Information Request (RPIR) – Complaints)

Compliments

From April 2017 to March 2018, the trust told us that they have received over 12,000 compliments;

however, they did not provide the data by core service so we are unable to identify how many

compliments were received specifically for community health services for end of life care.

(Source: Universal Routine Provider Information Request (RPIR) – P53 Compliments)

End of Life Readcode recorded

2017 Apr

2017 May

2017 Jun

2017 Jul

2017 Aug

2017 Sep

2017 Oct

2017 Nov

2017 Dec

2018 Jan

2018 Feb

2018 Mar

Grand Total

Herts Specialist Palliative Care Referral 115 111 82 90 62 68 71 69 55 80 66 64 933

No Herts Specialist Palliative Care recorded 39 85 72 63 56 54 88 82 85 149 184 178 1135

Grand Total 154 196 154 153 118 122 159 151 140 229 250 242 2068

74.68% 56.63% 53.25% 58.82% 52.54% 55.74% 44.65% 45.70% 39.29% 34.93% 26.40% 26.45% 45.12%

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Is the service well-led?

Leadership

Leaders had the skills, knowledge and experience required to run a service providing

sustainable care.

The service was managed by an operational lead for end of life care and a consultant in palliative

medicine. Senior managers had the knowledge and experience required and understood the

challenges needed to embed a quality and sustainable service. The end of life team spoke

passionately about the care provided by all staff.

SPC nurses were integrated within the locality community nursing teams. They were line managed

by the locality manager with support from the trust palliative care consultant. Where there were no

locality SPC nurses, the locality managers met regularly with hospice teams to sustain, improve

relationships and working practices.

Leaders were visible and approachable. Staff told us their locality managers operated an open-

door policy and they could discuss any concerns with them. Staff were well connected to other

teams across the trust. Community nurses spoke with the SPC staff regularly. We observed that

the specialist nurses were available to answer telephone queries from community nurses and

supported them on visits when necessary.

There was a clinical competency package for end of life care which supported staff to develop

their skills. This had been developed by the Macmillan clinical education managers, to ensure that

clinical development and training was provided within the community trust. Staff within the trust

complimented the Macmillan team on the support and dedication they had provided to promote

end of life care within the localities.

Vision and strategy

The trust had a vision for what it wanted to achieve and workable plans to turn it into

action.

It was clear that there had been some progress with end of life care in the trust since our last

inspection. A strategy that included partnership working between the trust and the local clinical

commissioning group had been developed, staff had received enhanced training to provide a more

robust service and senior leadership had been addressed to provide a standardised approach to

patient care.

The trusts vision for end of life care was to:

“Ensure health and wellbeing is maximised in the last year of life and that patients and carers are

supported to access appropriate services and jointly plan treatment and a preferred place of

death.”

(Source – End of Life Care Strategy July 2017)

The trust realised that the end of life service required an increased visibility with a robust

participation in order to establish their vision and strategy across all the localities. During our

inspection in March 2016 the trust had not embedded the end of life policy. At this inspection an

updated policy dated June 2017 was in evidence within all the inpatient and community settings.

We saw notice boards dedicated to end of life care which included the community trust vision and

strategy.

The end of life care strategy was underpinned by the national ambitions for palliative and end of

life care (2015) the outcomes for the strategy were:

194

• The number of patients identified to be in the last year of life increases.

• All patients at the end of their life receive high quality, personalised care.

• Patients and carers are supported in identifying and living the life they wish at the end of

their life and planning for a good death.

• All end of life and palliative care services are coordinated effectively.

Delivery of the strategy was overseen by the specialist palliative and end of life care strategic

implementation group chaired by the operations manager.

(Source – End of Life Care Strategy July 2017)

Culture

Managers across the trust promoted a positive culture that supported and valued staff,

creating a sense of common purpose based on shared values.

Across all areas staff said they were committed and passionate about the care they provided to

patients. They reported feeling proud to work within their community settings and were positive

about the job they did.

End of life champions were present within each locality, they spoke of a strong desire to improve

the service and how to cascade information to other staff. However, they told us that it was difficult

to encourage all the community staff to complete the essential objectives for example, some staff

found it difficult to discuss preference of death with patients, this frequently did not get completed

on the electronic system. New focus groups had been set up to improve the motivation and

commitment within the service.

There was an emphasis on the safety and wellbeing of staff. There was a lone working policy and

staff knew how to access it. Systems and processes were in place to ensure staff were safe when

lone-working and working in the community. If staff were deemed at risk, staff would be doubled

up during while attending patients in their homes.

There was a culture of group working within the inpatient and community settings. Staff we spoke

with felt that they were listened to by the management locality teams and could openly raise

concerns. Staff of all levels within the community trust felt they could raise concerns without any

reprisal.

Openness and honesty were encouraged at all levels of the trust and staff felt able to report

incidents and raise concerns. Staff we spoke with had not been involved in failings of care that

would have led to responsibilities to implement duty of candour, but had an awareness of the

policy and where to find it.

We saw cooperative, supportive and appreciative relationships among staff groups. They worked

collaboratively which meant staff were enabled work with and to meet the needs of patients

requiring end of life care.

Governance

There was an effective governance structure in place. Processes and systems of

accountability supported the delivery of the end of life care strategy.

All staff at all levels working within the SPC were clear about who they reported to. There were

clear lines of accountability, and the responsibility for cascading information upwards to senior

managers and downwards to staff in the community was understood by all staff we spoke with.

195

There was a non-executive director on the trust board who had a responsibility for end of life care.

The business performance review presented to the executive board every month. This meant

there was representation at board level of the end of life services offered by the trust.

The end of life steering group addressed the need for quality, improvement, engagement and how

to implement this within the service. This was clear from discussions with them and from minutes

of meetings. This group fed information directly into the assurance report which ensured that end

of life was then discussed at the health care governance committee. The health care governance

committee was attended by the executive and non-executive board members. The purpose of the

meetings was to share information related to each end of life team within the localities and trust

wide issues. The trust had recently implemented an end of life care dashboard which highlighted

areas including pain control, preferred place of death and advanced care planning. Due to the

recent implementation of the dashboard the trust could not provide us with current data regarding

the dashboard standards. The meetings were minuted and circulated to attendees.

Each locality held governance and development meetings which were attended by community

senior sisters, SPC leads and the community hospitals’ locality managers. Shared learning,

incidents and deaths were discussed at each meeting.

Staff groups had regular team meetings and there were plenty of opportunities for staff to speak to

their managers. Staff told us they could raise concerns and ideas and these would be listened to

and taken seriously. The staff received relevant and up-to-date information, for example, feedback

from incidents, during staff meetings.

Management of risk, issues and performance

The trust had effective systems for identifying risks, planning to eliminate or reduce them,

and coping with both the expected and unexpected. However, end of life care was not

always included.

A strategic end of life steering group had been organised to ensure risks within the service were

addressed. However, this was a recent initiative and its effectiveness had not been ascertained.

A task and finish operational group chaired by an executive team member had been developed in

line with the steering group to ensure the service improved and that this was sustained.

During our inspection we requested up to date information about the risk register. We were told

that the risks had been recorded in a locality report. However, incidents and risks, pertaining to the

end of life service, had not been individually identified and reported on. The operational manager

commented on this lack of oversight during our inspection and realised this was an area that

needed to be developed.

All community localities had a specific action plan relating to risks, but not specific to end of life

care. We were told at our inspection that an enhanced training plan had been developed and that

further training on the electronic data system, where risks were recorded, had been rolled out.

The trusts board papers dated July 2017, stated that the mode of communication had been

reflected upon and that it had been identified that specific localities required further training in this

area. The Macmillan clinical education manager discussed with us the importance of ensuring

effective communication with patients, relatives and between staff. Training assistance and

support had then been arranged at different localities ensuring the risk had been addressed and

actioned appropriately.

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Information management

The service had collected, analysed, managed and used information to support its

activities, using secure electronic systems with security safeguards.

The trust had an information governance policy which described how information was managed

and controlled through the trust’s policies and protocols. The policy identified measures that

ensured the security of information that was held about patients and staff. In addition, the policy

identified measures to be implemented in the event of an information governance breach. There

had been no breaches in information governance reported within the community hospitals or the

community, within the past year.

The trust had a data protection policy in place, which incorporated the Data Protection Act 1998;

staff received training on information governance as part of their mandatory training. Information

provided by the trust showed that from April 2017 to March 2018 compliance with information

governance training within the end of life team was at 100%.

The electronic data system had been implemented however some information recorded

electronically was additionally recorded on paper. This led to duplication of work. Some

information recorded on paper was different to that recorded electronically, for example DNACPR

forms.

A clinical dashboard assimilated information such as patients’ preferred place of care, preferred

place of death, advanced care plan and end of life assessment. However, due to recent changes

within the electronic record framework we were unable to gather sufficient information to ascertain

how thoroughly the dashboard had been completed, or how up to date the information was. Senior

staff informed us the end of life dashboard information had shown an improvement in the

compliance regarding patient requested place of care and place of death. Further data provided

confirmed this.

Staff had their own trust email account and received regular updates on, for example, available

training courses they could attend. Staff could also see when their mandatory training was due or

had expired. Staff showed us how they accessed policies, practices and guidance using the

intranet while at locality bases and when out in the community. Staff who worked in the community

had their own laptops and had access to the trust’s network and patient records, providing there

was connectivity. Some staff told us there were network connectivity problems within some rural

areas, however, there were recognised areas staff drove to where connectivity was usually much

better.

Engagement

The trust engaged well with patients, staff, the public and local organisations to plan and

manage appropriate services.

The service consistently sought feedback from the relatives and carers of patients who received

end of life care. Feedback was collated and reported to the areas they related to. Both inpatient

and community settings received reports relating to patient experience. Improvements made as a

result of feedback, for example providing a more detailed list of emergency contact numbers within

the community were included in the reports.

Patients and members of the local community had opportunities to get involved in the

improvement of the services and were encouraged to become volunteers or members of

Hertfordshire Community Trust. We saw evidence of this in relation to the volunteer medicine

group service and the implementation to improve access to end of life care for the Gypsy and

Traveller community across the county.

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The trust ran a survey as part of its ongoing engagement with staff. This covered 16 core

questions and additionally, a small number of ‘hot topic’ questions in order to gain more detailed

feedback. We were not provided with individual results for the inpatient and community settings,

however we were told that generally, the trust had seen an overall trend of improvement,

particularly on staff recommending the trust as a place to work, staff health and wellbeing

questions and the quality of appraisals. The trust had actions for areas of the survey where staff

had reported concerns. For example, to improve staff morale within inpatient settings, which had

led to a health and wellbeing programme being introduced, along with resilience training and

improved use of technology.

Learning, continuous improvement and innovation

The trust was committed to improving services by learning from when things went well,

and when they went wrong, promoting training, research and innovation.

The trust had implemented a strategy, a new governance framework and a vision for the

development of end of life care. They had acted upon shortfalls found in the previous inspection

and were dedicated to improving the service through ongoing reviews. The community trust were

in the process of contributing towards the National Care of the Dying audit.

The Macmillan clinical education team within the trust's specialist palliative care team won a

finalist award in the 'Innovation Excellence' category at the national Macmillan professional awards

in November 2017. The team won the award for delivering innovative and tailored training for

individual clinical teams, introducing a network of champions, which had highlighted end of life

care across the whole of Hertfordshire.

The equality and community engagement forum had heard presentations from several groups

throughout the year, including HCT’s end of life and specialist palliative care team and carers in

Hertfordshire, this was to understand the needs of patients, their families and carers at different

stages in their life. In addition, discussions had been held with regards to collaborative working

had a positive impact on the local community.

The service had improved the care and treatment provided to those in the last 12 months of their

lives by being accessible, specialised and knowledgeable. Priorities for improving the quality of the

service were clear. They were also documented in the strategy. Progress made against the

delivery of priorities were monitored within the localities using action plans.

Accreditations

NHS trusts are able to participate in a number of accreditation schemes whereby the services they

provide are reviewed and a decision is made whether or not to award the service with an

accreditation. A service will be accredited if they are able to demonstrate that they meet a certain

standard of best practice in the given area. An accreditation usually carries an end date (or review

date) whereby the service will need to be re-assessed in order to continue to be accredited.

There were no services reported within inpatient and community services that have been awarded

an accreditation.

(Source: Universal Routine Provider Information Request (RPIR) – P66 Accreditations)