Hertfordshire Community NHS Trust Board Meeting in Public. Thursday 12th November pm

Transcription

1 Hertfordshire Community NHS Trust Board Meeting in Public Thursday 12th November pm East Hertfordshire District Council Wallfields Pegs Lane Hertford SG13 8EQ For map and parking information please see attached AGENDA Lead Attachment Allocated Time Approx (0) Patient / Learning Story 30 mins UNICEF Accreditation: The Baby Friendly Initiative Promoting Health and Wellbeing for All Babies Kim Bilsby Locality Manager, East & South Attachment 0 Time (A) Preliminaries 12 mins DO F DO F CH DO F 1. Welcomes, Introductions and Apologies for Absence 2. Chair s Announcements / Notice of Urgent Business (to include confirmation of Board appointments and leavers): 2.1 To note temporary cover arrangements for key functions of the Medical Director 3. Members Declarations of Interest (Members to declare any interests material to items on the agenda) Attachment (A1) 1

2 Board 4. Ratification of items of Chair s and Chief Executive s Action taken since the last meeting under Standing Order 5.2 DO F DO F 4.1 Chair s approval under SO 5.2 to Enteral Feeds Contract 5. To approve the Minutes of the meeting held on 17 th September Matters Arising from the Minutes of the meeting held on 17 th September 2015 Attachment (A2) (Minutes) Attachment (A3) (Tracker) (B) Clinical Services & Healthcare Governance 20 mins CH 1. Director of Quality & Governance / Chief Nurse s Report Attachment (B1) 5 mins 1.1 Safe Staffing Report 1.2 Serious Incident Report 1.3 Complaints Report 1.4 PLACE Report Attachment (B2) Attachment (B3) Attachment (B4) Attachment (B5) 3 mins 3 mins 3 mins 3 mins AM 2. Chair of Healthcare Governance Committee s (verbal) 3 mins Assurance Report (C) Operations & Performance 16 mins JH 1. Director of Operations Report Attachment (C1) 5 mins PB 2. Summary Integrated Board Performance Report Attachment (C2) 3 mins PB 3. Business Unit Assurance Reports Attachment (C3) 3 mins CH 4. High Level Risk Register Attachment (C4) 5 mins (D) Strategy, Resources & Engagement 52 mins DL 1. CEO s Report, Strategy Update and Strategic Framework Attachment (D1) 7 mins "Sign up to Strategic Outline Case for Your Care Your Future." Break at 3.00 approx (10 mins) PB 2. Director of Finance s Report Attachment (D2) 5 mins 2

3 AS 2. Director of HR and OD s Report Attachment (D3) 5 mins LS 3. Strategy & Resources Committee Chair s Assurance Report Attachment (D4) 5 mins DL 6. Foundation Trust Progress Report Attachment (D5) 3 mins AR JP BG 7. Foundation Trust Committee Chair s Assurance Report 8. Audit Committee Chair s Assurance Report 9. Community Engagement Committee Chair s Assurance Report Attachment (D6) Verbal Attachment (D7) 3 mins 3 mins 3 mins DL 10. Communication & Engagement Strategy To approve Attachment (D8) 4 mins DL 11. Influencing the Influencers Strategy To approve Attachment (D9) 4 mins (E) Board Governance & Leadership 7 mins CH 1. The Well Led Framework To Note Attachment (E1) 3 mins AM 2. Note of the Remuneration Committee Meeting held on 27 th October 2015 Attachment (E2) 2 mins All 3. To agree schedule of Board and Committee meeting dates for 2016/17 Attachment (E3) 2 mins (F) Urgent Business 3 mins DO F (As notified under Item (A) 2 above) (G) Risks Arising / Observations 3 mins DO F 1. Summary of Risks Arising (Verbal) 3 mins (H) Supporting Papers / Items for Receipt and Noting Only 1 min (NB: These items are not for discussion but are papers which support Reports or are for receipt and noting only. Clinical Services & Healthcare Governance CH CH AM B1 (i) Safe Staffing and Efficiency National Policy (letter dated 13 th October 2015) B1 (ii) Log of Complaints Received Qtr /16 B2 (i) Minutes of the Healthcare Governance Committee meeting held on 8 th September Attachment (H1) Attachment (H2) Attachment (H3)

4 PB PB PB PB DL AR JP Operations & Performance C2 (i) Integrated Board Performance Report (September 2015) Strategy, Resources & Engagement D2 (i) Month 6 Financial Position Report D2 (ii) Annual Audit Letter 2014/15 D2 (iii) Freedom of Information Annual Report D4 (i) TDA Return (October 2015) D6 (i) Minutes of the Foundation Trust Committee meeting held on 9 th Sept 2015 D8 (i) Minutes of the Audit Committee meeting held on 15th September 2015 Board Governance & Leadership No items Attachment (H4) Attachment (H5) Attachment (H6) Attachment (H7) Attachment (H8) Attachment (H9) Attachment (H10) (I) Date, Time & Venue of Next Meeting(s) 1 min DO F Thursday 28 th January am pm Board meeting in public: The Council Chamber St. Albans City & District Council Civic Centre St Peters Street St Albans Hertfordshire AL1 3JE (J) Questions from the Public 3 mins DO F The Chair will take questions from members of the public. Questions which cannot be addressed at the meeting or in the time allocated will be noted. Replies will be communicated to questioners following the meeting and reported to the next Board meeting in public. (K) Informal Review of Meeting 2 mins DO F An informal review and critique of the meeting. 4

5 Please note that Board papers and Trust papers referenced in Reports are available on the Trust s Website at: Hard copies, or copies in large size font or in translation can be provided on application to: The Company Secretary Hertfordshire Community NHS Trust Unit 1A Howard Court 14 Tewin Road Welwyn Garden City Hertfordshire AL7 1BW 5

6 Parking is FREE after 5pm - MAX stay 5 hrs

7 Abbr'ns In Full Abbr'ns In Full A&E Accident & Emergency FRR Financial Risk Rating acft Aspirant Community Foundation Trust FT Foundation Trust ACS Adult Care Services FYE Full Year Effect ACSC Ambulatory Care Sensitive Conditions GM General Manager AD Assistant Director GP General Practitioner ADD Attention Deficit Disorder GRR Governance Risk Rating Adm Admission GUM Genito Urinary Medicine AfC Agenda for Change H&SCA Health & Social Care Act 2012 AHP Allied Healthcare Professional H&SMAT Hertfordshire & South Midlands Area Team ALOS Average Length of Stay H&WBB Health & Wellbeing Board ALTO Arms-Length Trading Organisation HBL Herts Beds Luton AQP Any Qualified Provider HB&LBU Hertfordshire, Beds & Luton Business Unit (part of CECSU) AT Area Team (of NHS England) HCA's Health Care Assistants BAF Board Assurance Framework HCAI Healthcare Associated Infection BI Business Information HCC Hertfordshire County Council BU Business Unit HCHS Hertfordshire Community Health Services BUPR BU Performance Review HCS Health and Community Services BURR BU Risk Register HCT Hertfordshire Community NHS Trust C.dif Clostridium difficile HDD Historic Due Diligence CAMHS Child & Adolescent Mental Health Service HEE Health Education England CCG Clinical Commissioning Group HEI Higher Education Institution CECSU Central Eastern CSU HGC Healthcare Governance Committee CEO Chief Executive Officer HICSS Herts Integrated CSU CFT Community Foundation Trust HLRR High Level Risk Register CHD Coronary Heart Disease HMP Her Majesty's Prison CIP Cost Improvement Programme HPFT Hertfordshire Partnerships Foundation Trust CLAHRC Collaboration for Leadership in Applied Health Research and Care HPV Human Papilloma Virus COPD Chronic Obstructive Pulmonary HR Human Resources HRD Human Resource Directors CoS Continuity of Service HSAB Hertfordshire Safeguarding Adults Board CPD Continuous Professional Development HSCB Hertfordshire Safeguarding Childrens Board CQC Care Quality Commission HSCIC Health and Social Care Information Centre CQUIN Commissioning for Quality & Innovation HSJ Health Service Journal CRR Contractual Risk Rating HSMC Hertfordshire Supply Management Confederation CSF Children, Schools and Families HUC Herts Urgent Care (Out of hours GP service) CSR Comprehensive Spending Review HVCCG Herts Valleys CCG CSU Commissioning Support Unit I&E Income and expenditure CWLG County Workforce Leadership Group I/P or IP Inpatient DH Department of Health IBP Integrated Business Plan DHR &OD Director of Human Resources and IBPR Integrated Business Performance Review DoF Director of Finance ICS Intermediate Care Strategy DOLS Deprivation of Liberty Safeguards ICT Information and Communication Technology DoN Director of Nursing ICT Integrated Care Team DOps Director of Operations IG Information Governance DQHH Delivering Quality Healthcare for Hertfordshire IM&T Information, Management & Technology DS&BD Director of Strategy & Business Development IPC Infection prevention and control DSSA Delivering Single Sex Accommodation IT Information Technology DTC Delayed Transfers of Care IV Intravenous DVT Deep Vein Thrombosis JNC Joint Negotiating Committee E&N East and North E&NHCCG East & North Herts CCG KPI Key Performance Indicator E&NHHT EBITDA HERTFORDSHIRE COMMUNITY NHS TRUST LIST OF COMMON TRUST AND NHS ABBREVIATIONS East and North Hertfordshire Hospital Trust Earnings Before Interest, Taxes, Depreciation and Amortisation LAC Looked After Children ED Early Discharge LCGs Locality Commissioning Groups ENHT East & North Hertfordshire NHS Trust LETB Local Education & Training Board EoE East of England LIFT Local Improvement Finance Trust EPR Electronic Patient Record LINks Local Involvement networks EWTD European Working Time Directive LMC Local Medical Committee PMO Project Management Office

8 HERTFORDSHIRE COMMUNITY NHS TRUST LIST OF COMMON TRUST AND NHS ABBREVIATIONS Abbr'ns In Full Abbr'ns In Full LTC Long Term Conditions PREP Professional Registration Education LTFM Long Term Financial Model Preparation M&E Midlands & East (Cluster of SHAs) PROMS Patient Related Outcome Measures MD Medical Director PSPP Public Sector Payment Policy MIU Minor Injuries Unit PT Physiotherapy Monitor Independent regulator of FTs PYE Part Year Effect MRSA Methicillin-Resistant Staphylococcus Aureus QIA Quality Impact Assessment MSK Musculoskeletal QIPP Quality Innovation Productivity and NED Non-Executive Director Prevention NHS National Health Service QOF Quality Outcome Framework NHSE NHS England QRP Quality Risk Profile NHSLA NHS England (previously NHS") RAF Risk Assessment Framework NHSP NHS Professionals RAG Red, Amber, Green ( Traffic Light rating) NIB National Information Board RAID NIHR National Institute for Health Research RAS Remote Access Service NMC Nursing & Midwifery Council RCN Royal College of Nursing NMP Non Medical Prescriber RTT Referral to Treatment Time (18 weeks) NPDA Nat Provider Development Agency SHA Strategic Health Authority NPSA National Patient Safety Agency SI Serious Incident NQB National Quality Board SI(RI) Serious Incident (Requiring investigation) NTDA NHS Trust Development Authority SIP Staff In Post O/P or OP Outpatient SIP System Integrated Plan OD Organisational Development SIRO Senior Information Risk Owner OH Occupational Health SLA Service Level Agreement SLR/M Service Line Reporting/Mgt OT Occupational Therapy SLT Speech & Language Therapy PALS Patient Advice and Liaison Service SMART Specific, Measurable, Agreed, Realistic, Timely PASA Purchasing and supply agency SMT Senior Management Team PBC Practice Based Commissioning SOM Single Operating Model PCT Primary Care Trust SWOT Strengths Weaknesses Opportunities Threats PESTEL Political Economic Social Technological Environmental Legal Systm1 HCT s Clinical IT System PHE Public Health England TCS Transforming Community Services PID Project Initiation Documentation TDA Trust Development Authority PLACE Patient Led Assessments of the Care Environment TDAAF TDA Accountability Framework PMO Project / Programme Management Office TFA Tri-partite Formal Agreement PMR Provider Management Regime TUPE Transfer of Undertakings (protection of employment) PQQ Pre-Qualifying Questionnaire WCF Working Capital Facility Wf&OD Workforce & Organisational Development WHHT West Hertfordshire Hospitals NHS Trust WHSR West Hertfordshire Strategic Review WSM Work Stress Management WTE Whole Time Equivalent YCYF Your Care Your Future YTD Year to Date

9 Board: 12 th November 2015 Attachment A1 TRUST BOARD Title: TEMPORARY COVER ARRANGEMENTS FOR THE MEDICAL DIRECTOR Meeting Date: 12 th November 2015 Executive Lead(s): Clare Hawkins, Director of Quality & Governance / Chief Nurse Author(s): Clare Hawkins Director of Quality & Governance / Chief Nurse Clive Appleby Company Secretary For: NOTING AND RATIFICATION 1.0 Purpose & Recommendations 1.1 Caroline Allum, Medical Director, is currently on long term sick leave. Below are the arrangements in place for covering regulatory / Board-lead duties during this period, which the Board is asked to note and ratify. 1.2 Interim cover arrangements have also been made for the Medical Director s full portfolio, over and above the regulatory / board responsibilities. These arrangements have been reported to the Healthcare Governance Committee. 2.0 Medical Director Temporary Cover Arrangements (Regulatory / Board roles) Responsibility / Portfolio Revalidation (Responsible Officer) Appraisal (Responsible Officer) Doctors - concerns / performance (Responsible Officer) Exclusion Caldicott Guardian Operational / Delivery Lead Dr. Carol Scholes Macmillan Consultant in Palliative Medicine Dr. Carol Scholes Macmillan Consultant in Palliative Medicine Dr. Carol Scholes Macmillan Consultant in Palliative Medicine Jackie Hughes Senior HR Business Partner Clare Hawkins Dir. Of Quality & Governance / Chief Nurse (Supported by IG lead) 1 Accountable Executive Director David Law, CEO David Law, CEO David Law, CEO Alison Shelley Dir of HR&OD Clare Hawkins Dir. Of Quality & Governance / Chief Nurse

10 Board: 12 th November 2015 Attachment A1 Responsibility / Portfolio Accountable Officer Controlled Drugs Mortality Review Mortality Review Forum Research Governance Medical Advice Joint Local Negotiating Committee (JLNC) Operational / Delivery Lead Simon Wan Chief Pharmacist Dr. Carol Scholes to review notes as they come in. Dr. Clifford Lisk to chair Dr. Carol Scholes Macmillan Consultant in Palliative Medicine Research & Development Forum = Sally Anne Doyle-Caddick Research Delivery Lead Dr. Carol Scholes Macmillan Consultant in Palliative Medicine JLNC chair (Dr. Carol Scholes) Accountable Executive Director Clare Hawkins Dir. Of Quality & Governance / Chief Nurse Clare Hawkins, Dir. Of Quality & Governance / Chief Nurse Clare Hawkins, Dir. Of Quality & Governance / Chief Nurse Clare Hawkins, Dir. Of Quality & Governance / Chief Nurse Clare Hawkins, Dir. Of Quality & Governance / Chief Nurse / David Law CEO Alison Shelley Dir of HR&OD 3.0 Relevant Strategic Objective(s) / Strategies This report impacts on all strategic objectives and links to all Trust strategies. Author(s) of paper: Clare Hawkins Dir. of Quality & Governance / Chief Nurse & Clive Appleby Company Secretary Date: October

11 Board Board: 12th 12 November th Attachment A2 A2 HERTFORDSHIRE COMMUNITY NHS TRUST Minutes of the Hertfordshire Community NHS Trust Board Meeting Held in Public on Thursday 17 th September 2015 at Rothamsted Conference Centre Harpenden, Hertfordshire Key Points from the Meeting for the Board to note: * The following were approved / ratified: (i) The Case for Change for Your Care, Your Future. (The West Herts Strategic Review). (ii) Risk Management Strategy 4th Edition (Sept 15) (iii) Emergency Planning Core Standards Self-Assessment and Memorandum of Understanding * The Chair reported that: (i) The appointment of Jeff Phillips (JP), NED and Chair of the Audit Committee, has been extended by the TDA to 13 th September * The following were received and considered: (i) Minutes and Action Trackers from the Board meeting held on 9 th July 2015 (ii) CEO s Report and Strategy Update (iii) Standing Reports from Executive Directors (iv) Assurance Reports from NED Committee Chairs (v) Quality Report Qtr /16 (vi) Complaints Report Qtr /16 (vii) Serious Incident Report (June / July 15) (viii) Quality Improvement Plan (As at August 2015) (ix) Safe Staffing Update Report (June 2015) (x) A report on Freedom to Speak Up (xi) Summary Integrated Board Performance Report (Sept 15) (xii) Business Unit Assurance Reports (Sept 2015) (xiii) High Level Risk Register (Aug 15) (xiv) Foundation Trust Progress Report (Sept 15) (xv) Record of Remuneration Committee Meetings held on 23 rd June and 28 th July 2015 * Dr. Carol Scholes, Macmillan Consultant in Palliative Medicine, presented on Dying Without Dignity - The Parliamentary and Health Service Commissioner s Report and a patient story, A Palliative Care Patient s Experience of Coordinated Care was received from Mandy Whiteman, Palliative Care Nurse, and Ruth Bradford, Clinical Quality Manager * Additional supporting papers were received. (See min:173/15 for list) * The meeting concluded with a review of risks arising * Questions and observations were invited from the public, staff and informal observers present. Present: * = Voting Board member Declan O Farrell (DOF) Chair * Anne McPherson (AM) Non-Executive Director * Jeff Phillips (JP) Non-Executive Director * Alan Russell (AR) Non-Executive Director (Vice Chair) * Dr Linda Sheridan (LS) Non-Executive Director * Brenda Griffiths (BG) Non-Executive Director (Designate). David Law (DL) Chief Executive * Caroline Allum (CA) Medical Director * 1

12 Board: 12 th November 2015 Attachment A2 Phil Bradley (PB) Director of Finance* Clare Hawkins (CH) Director of Quality & Governance /Chief Nurse * Alison Shelley (AS) Director of HR & OD In Attendance: Richard Moore (RM) General Manager, Adult Service East & North (For Julie Hoare (JH), Director of Operations) Meg Carter (MC) Healthwatch Observer Clive Appleby (CApp) Company Secretary For item 140/15 Presentation and Patient Story: Dr. Carol Scholes (CS) Macmillan Consultant in Palliative Medicine Mandy Whiteman (MW) Palliative Care Nurse, Ruth Bradford (RB) Clinical Quality Manager Patient Experience (0) Patient Story 140/15 End of Life Care Action Dr. Carol Scholes, Macmillan Consultant in Palliative Medicine, presented on Dying Without Dignity The Parliamentary and Health Service Commissioner s Report. (May 2015). Mandy Whiteman, Palliative Care Nurse, and Ruth Bradford (RB), Clinical Quality Manager, presented A Palliative Care Patient s Experience of Coordinated Care. (P&J s Story) Observations and Questions from the Board: (i) (ii) (iii) Unfortunately P was not well enough to present his story in person, but was happy for his experiences to be shared via RB and MW. The Board expressed their appreciation to P&J for allowing their story to be shared and conveyed their best wishes. The current priority for HCT was to draft a formal end of life strategy and this was in progress. This has also been identified by the CQC as an action required. There were a lot of strategic initiatives in place, but the formal strategy will pull the various strands together. P&J have had the one point of contact (which is MW in this case). There is also access to a 24 hour advice line and the specialist palliative care team are also contactable from 9-5 at weekends (although the contact number varies according to location). The GP 2

13 Board: 12 th November 2015 Attachment A2 has visited regularly. (iv) (v) (vi) (vii) (viii) (ix) (x) To progress the development of a good EoL service, CS stated that requirements include good education and information (for staff, patients and the public generally), clear leadership (system-wide and internally), capacity, supporting technology and listening to the views and needs of patients in a structured way. P&J s experience appeared to be very positive on the whole (and gratefully appreciated), but there were some issues. One of these was an expectation from the district nurse that J chased for the hospital discharge letter. It was noted that communications through the care system could be much better and a lot of patients are transferred home without the paperwork required to support seamless, ongoing care at home. However, carers should not be expected to have to chase for this. Having a key worker for each patient would help with supporting better communications. Lots of EoL strategies are being developed by local healthcare organisations and a joint strategy would be desirable. Experience suggests that delay in supplying discharge notes is a common event and that most hospitals do not process discharge communications very well. EoL is an important issue and with significant annual expenditure ( 180m in Herts in 2014/15), and it involves a number of organisations. However, there is no one organisation with overall responsibility. HCT should offer this to the CCGs and could make a lot of difference, especially if supported by a bold strategy. The Board thanked CS, RB and MW for their presentations also recognised the excellent job being done by all HCT staff involve din end of life care. It was noted that RB was compiling a portfolio of patient stories with the help of volunteers from Healthwatch. It was agreed that over time and subject to patient / carer agreement, the stories could be compiled into a single book. CH / (RB) To note (A) Preliminaries & Board Governance Action 141/15 Welcome, Introductions and Apologies 3

14 Board: 12 th November 2015 Attachment A2 DO F welcomed those present, and advised the public in attendance that there would be an opportunity for questions and observations at the end of the meeting. Apologies were received from Julie Hoare (JH), Director of Operations and it was noted that Richard Moore, General Manager Adult Core Services E&N, was deputising. 142/15 Chair s / CEO s Announcements & Notice of Urgent Business 1. Extension of Appointment of Jeff Phillips (JP), NED and Chair of the Audit Committee DO F reported that the TDA have confirmed an extension to the appointment of Jeff Phillips as Non-Executive Director from 14 September 2015 until 13 September Consideration will be given to extending the appointment at the end of this term, depending on the needs of the Trust at the time. 143/15 Members Declarations of Interest Relating to Business on the Agenda / For the Register of Interests No declarations. 144/15 Ratification of items of Chair s and Chief Executive s Action taken since the last meeting under Standing Order 5.2 No items. 145/15 Minutes of the Meeting held on 9 th July 2015 The minutes of the meeting held on 9 th July 2015 were agreed as a correct record. 146/15 Matters Arising from the Minutes of the Meeting Held on 9 th July 2015 (Board Tracker) DO F thanked the Executive Team for matters actioned, which it was agreed be removed from the Tracker. It was noted that: 113/15: A statement on Sign Up To Safety was incorrectly identified as action completed. This should be an action in progress and a statement will be presented to the November meeting of the Board. 08/14: Patient Information packs have been printed and the Keeping in Touch (KIT) visits will be used as a means of assurance that they are being used 4

15 Board: 12 th November 2015 Attachment A2 consistently. There were no matters arising not otherwise included on the Tracker. (B) Clinical Services & Healthcare Governance 147/15 Medical Director s Report (CA) The Medical Directors Report for September 2015 was received and discussed. Items reported on were: (1) HCT services: Community Hubs (Hemel, Harpenden and Cheshunt) Mortality Review Next meeting of the Review Forum is 15 th September 2015 End of Life Care (EoL) Good progress being made on developing the strategy and policy Clinical Strategy Is out for consultation with commissioners and staff. (1) Community Hospitals The summary sheet about HCT s community hospitals for the acute Trusts has now been developed. Datix incident reports of inappropriate discharges, out of hours transfers and transfers without accompanying medical records are being reviewed, to provide the basis of discussions on this risk issue with the acute trusts. An internal escalation process is also in place. (2) Pharmacy: Community nurse administration charts A proposed solution presented to the LMC on 2 nd September was widely accepted. Dressings Project (HVCCG) First stakeholders meeting held. Shadow budget to be in place for Qtr /16. (3) Research Qtr 1 figures submitted to the NIHR Entry submitted to HSL awards (Clinical Research Impact category). Unfortunately HCT was not shortlisted. Research funding bid of 250k submitted in 5

16 Board: 12 th November 2015 Attachment A2 conjunction with University of Hertfordshire for a randomised controlled trial of the University s innovation humanoid robot (KASPAR) Outcome still awaited (4) High Value Healthcare Services now reporting and progress in reporting outcome measures has been reported to HGC. (5) Single Point of Access Team convened to consider options report to be submitted to the Executive Team in September or October (6) External Stakeholders West Herts Strategic Review Clinical Advisory Group. Case for change updated and going to all Boards at the end of October. HVCCG A GP has started as part of the development programme based in the diabetes service. E&N Herts Access Working Group HCT potentially to lead two work streams CQC have asked HCT to participate in in a thematic review looking at integrated care for older people (7) Revalidation The AOA (Annual Organisational Audit) statement of compliance has been submitted. Dr. Carol Scholes has been appointed as Deputy RO and Associate Medical Director and will take up this role later in September. (8) Key Risks: (a) (b) Inappropriate discharges. Incomplete documentation is transferring with patients. Executive team are addressing. They are ensuring roust governance arrangements. Escalation process for inappropriate discharges will be in place by 1/10/15. Decision will be made about action in the face of original case notes not transferring by 9/9/15. Financial model for Wound Care with HVCCG needs to be agreed by a multidisciplinary group 6

17 Board: 12 th November 2015 Attachment A2 and monitored to ensure adequate resource transferred by the CCG (c) Dedicated funding was not forthcoming from the Trust in 2015/16 for its Research Office. To continue to support delivery of NIHR recruitment investment will be needed for the next financial year. Challenge and Response to Board Questions (a) The single point of access project is a Herts-wide project and is not restricted to a single service, or to just health organisations (ie will also link with the County Council). The intended outcome is a reliable, robust system which works for GPs. A good model has been introduced in Birmingham and arrangements will be made to visit. (b) The escalation process for inappropriate discharges / transfers will be fully in place by 1 st October and is supported by a protocol for reporting via datix. CA receives reports on a regular basis and links to Barnet and PAH Trusts, JH links to E&NH Trust and WHH Trust. The arrangements include transferring patients back to an acute trust if they are inappropriate for HCT care and there is an internal escalation process if ward staff are in doubt. It is also being made clear to the acute trusts that patient transfers will not be accepted after 6pm as this constitutes a risk to patient safety. (c) (d) There is a mechanism for out of hours contact with the acute trusts via the respective on-call systems. The position on inappropriate transfers will be monitored by HGC. Decision(s), Outcome(s) and Actions: (1) The Medical Director s Report for September 2015 was noted. 148/15 Director of Quality & Governance / Chief Nurse s Report (CH) The Director of Quality & Governance / Chief Nurse s Report for September 2015 was received and discussed. Items reported on were: 7

18 Board: 12 th November 2015 Attachment A2 (1) Executive Summary The CQC Quality Improvement Plan was submitted to the CQC on 27 August A response is awaited as is an indication of the nature and timing of reinspection. (See also Min 152/15 below) Governance review for HMP The Mount healthcare service completed. CQC action plan due for submission 21 st September. Action plan in place to address service improvements required at the Herts and Essex Hospital, Oxford ward. Executive team are monitoring monthly. PLACE report shows HCT in bottom 20% of Trusts nationally for privacy, dignity and wellbeing. Good progress noted in preparations for nursing revalidation. LAC GP model is fully operational and making a positive impact, with over 90% of LAC receiving initial assessment within timescales. (100% in August 2015, compared to 35/40% in 2014) Trust annual reports for Safeguarding Children, Safeguarding Adults, Looked After Children, Complaints and Patient Experience have been presented to Healthcare Governance Committee and the Board. Good quality performance reported for Q1. HCT submitted a formal supporting response to TDA consultation document to reduce agency spend (2) Current Performance: Patient safety incident reporting has improved compared to the previous two years. In Qtr /16 there has been a 46% reduction in the number of medication incidents with harm. The Trust has met all Qtr 1 CQUIN targets for HVCCG and is on target to meet Qtr 1 for west Essex. E&NCCG have submitted a partial payment of 12% met against target of 13% (3) Risks and Challenges The CQC Steering Group will identify and mitigate any risks related to capacity to deliver the Quality Improvement Plan. (See also min 152/15 below) A risk relating to limited GP cover at HMP The Mount has been mitigated in the short term through use of a locum GP. 8

19 Board: 12 th November 2015 Attachment A2 An interim ward manager has been appointed to manage risks related to service improvement at Oxford Ward, Herts & Essex Hospital. PLACE Report shows HCT as being in the bottom 20% of trusts nationally for privacy, dignity and wellbeing. A lot of the requirements for this category relate more to eg provision of facilities such as television. However, actions are underway to address the findings and a report will come to the November Board meeting. (4) The following papers relevant to the DQ&G s report are in the supporting papers and thanks are due to all staff involved in compiling them: (i) Complaints Annual report (ii) Safeguarding Adults Annual Report (iii) Safeguarding Children Annual Report (e) Looked After Children Annual Report (f) Patient Experience Annual report Challenge and Response to Board Questions (a) (b) (c) Some of the outcomes from the PLACE report could have been anticipated but not all. As eluded to above, some of the test criteria do not relate to privacy, dignity or wellbeing at all, but to the availability of certain patient facilities. It was also noted that patients are getting more rigorous in what they are looking for. A comms plan is in place in respect of the PLACE Report. Progress is being made on addressing the wide range of issues at the Herts & Essex Hospital, but this is a journey of improvement rather than being able to adopt a lot of quick solutions or impose changes to embedded unacceptable cultures overnight. (Progress is reported to HGC). It is also important to note that there has been no deterioration in patient care. Decision(s), Outcome(s) and Actions: (1) The Director of Quality & Governance / Chief Nurse s Report for September 2015 was noted. 149/15 Quality Report Qtr /16 (Lead Director: CH) The Quality Report for Qtr /16 was received and discussed. 9

20 Board: 12 th November 2015 Attachment A2 It was noted that: (i) (ii) The Report covered progress and performance in the quarter on high value healthcare, patient safety, patient experience, clinical effectiveness and efficiency. There was also a focus on risks and opportunities. Challenge and Response to Board Questions (a) (b) It was good news to see a significant increase in the UNICEF Audit Scores (Quality Priority 2) There are risks around achievement of the diabetes and stroke CQUINs, especially the former. These are being kept under continuous review as not to arise as an issue in Qtr.4. Decision(s), Outcome(s) and Actions: (1) The Quality Report for Qtr /16 was noted. 150/15 Complaints Report (Qtr /16; Apr - June 2015)) (Lead Director: CH) The Complaints Report for Qtr /15 was received and discussed. It was noted that: (i) (ii) (iii) A total of 56 complaints were received in the Quarter. (Compared to 61 in Qtr 1, 2014/15 and 56 in Qtr 4 ). 39 complaints were closed and 17 remain open. The top five categories of complaint were: Standards of Care (14) Staff Attitudes (9) Clinical Treatment (8) Communications (8) Date Appointment/ Attendance (6) (iv) No complaints in the Qtr were identified as Category 3 ( Red Flag ) complaints. (v) Good performance continues in acknowledgement / response times, with 100% compliance in April and June and 93% in May. (Target = 80%). (vi) 1,517 compliments were received in the Quarter. (3.7 per 1,000 contacts). 10

21 Board: 12 th November 2015 Attachment A2 Challenge and Response to Board Questions (a) It was noted and appreciated that there is now more visibility in the report on complaints arising from HMP The Mount. Decision(s), Outcome(s) and Actions: (1) The Complaints Report for Qtr /16 was noted. 151/15 Serious Incident Report (June/July 2015) (Lead Director: CH) The Serious Incident Report for the period 1 st June to 31 st July 2015 was received and discussed. It was noted that: (i) (ii) (iii) For the period 1 st June to 31 st July 2015, ten SIs were reported and one has been requested for deescalation. (April / May = 25, two of which were subsequently de-escalated). Grade 3 and 4 pressure ulcers continued to make up the bulk of reported SIs, with five cases reported. (Out of ten incidents) The balance of incidents was spread across: Slips / trips and falls Sub-optimal care Treatment delay Decision(s), Outcome(s) and Actions: (1) The Serious Incident Report for June -July 2015 was noted. 152/15 Quality Improvement Plan (Lead Director: CH) The Quality Improvement Plan as at August 2015 and as discussed under the DQ&G s report was received and noted. 153/15 Safe Staffing Update Report (June 2015) (Lead Director: CH) A paper advising of the Trust s Safe Staffing position as at June 2015 was received. 11

22 Board: 12 th November 2015 Attachment A2 It was noted that: (i) As at June 2015 none of the 11 units reported safe staffing levels below the HCT threshold of 90% for nursing and care staff. (ii) The July position also shows above 80% (iii) HGC are monitoring staffing hotspots Decision(s), Outcome(s) and Actions: The Safe Staffing Report was noted. 154/15 Freedom to Speak Up Review (Lead Director: CH) A report on Freedom to Speak Up was received. It was noted that: (i) (ii) The Report (i) advises the Board of the key recommendations following the Francis Review of how organisations manage concerns raised by staff and (ii) sets out the action plan for HCT to take to meet the recommendations The report and actions have previously been considered by HGC and HGC will continue to monitor. Decision(s), Outcome(s) and Actions: The Freedom to Speak Up Report and Action Plan was noted. 155/15 Chair of Healthcare Governance Committee s Assurance Report (Sept 2015) (Committee Chair: AM) The Chair of Healthcare Governance Committee s report for September 2015 was received and discussed. Assurance levels reported were as follows: Red (Negative) Assurances: 1. Unable to fully comply with New-born Screening Service action plan as dependent on WHHT to relocate hearing service to a more suitable environment with access to IT. 12

23 Board: 12 th November 2015 Attachment A2 2. New commissioning arrangements will affect viability of the New-born Screening Service. Amber/ Red (Limited) Assurances: 1. Limited assurance on the full delivery of the CQC Quality Improvement Plan. Risk assessment needs to be carried out to quantify the level of risk. 2. Continued concern on the ability of small services to be sustained with ongoing HLRR presence of End of Life Care and the re-escalation of the Community Diabetes Service.: Includes admin staff as well as healthcare professionals. The diabetes service has fluctuated on the HLRR but has been re-escalated. There is no point inviting CQC re-inspection if the gaps have not been addressed 3. HCAI TDA IPC lead report action plan identifies quality of estate is poor and repairs sub-optimal. It is a complication that the estate does not belong to the Trust. 4. Herts & Essex Hospital action plan underway but still has a distance to go to provide reasonable assurance. 5. Slow progress on Community Paediatric Service Transformation project arising from Royal College of Paediatrics and Child Health Review May To be embedded in CQC Quality Improvement Plan 6. HGC recommends that the new high level risk on Quality and Governance arising from the CQC inspection with appropriate mitigation be reflected in the BAF. 7. A new contract, increased numbers and a different prisoner population profile, along with a recent HMIP/ CQC inspection presenting challenges to Prison Health. New prison indicators show a reasonable baseline but there are elements that require further work to give a better degree of assurance. GP cover is the main element of concern. 13

24 Board: 12 th November 2015 Attachment A2 Indicators go through the BUPR process and can see where progress is being made. Amber/Green (Reasonable) Assurances: 1. GP s no longer writing up HCT prescription charts by end of September Safe staffing report achieved 80% fill rate in June and July Further assurance sought via presenting the range as well as the average fill rate. 3. Speak out Safely action plan provides reasonable assurance but requires some minor amendments to principle 13 on transparency around confidentiality clauses in settlement agreements 4. Complaints Report highlighting a trend in problems with appointments to Physiotherapy services despite changes made last year. 5. SI Report identifying a number of gaps in Children s Community Services, including pressure damage prevention and MCA for young people. 6. CQUIN Report on track for quarter 1 except for NHS England LAT because of late agreement of CQUIN 7. All quality priorities on track for quarter 1 Green (Significant) Assurances: 1. Quality Report continues to develop and cover a wide range of quality indicators across all dimensions of High value Healthcare in HCT. 2. Complaints Annual Report 3. Safeguarding Adults from Abuse Annual Report 4. Safeguarding Children Annual Rep 5. Looked after Children s and Care Leavers Annual Report 6. Patient Experience Annual Report Mitigations against the above red and amber/red rated areas and committee governance matters were also noted. Decision(s), Outcome(s) and Action(s): 14

25 Board: 12 th November 2015 Attachment A2 (1) The HGC Chair s Report for September 2015 was noted. (C) Operations & Performance 156/15 Director of Operations Report (Sept 2015) (RM for JH) The Director of Operations Report for September 2015 was received and discussed. Items reported on were: (1) Adult Services ICT have delivered target in month activity levels and achieved 95% Priority one referral target times; a commendable achievement given summer annual leave absences and difficulty recruiting to vacancies. ICT turnover ranges from 7.3% to 30.8% with an average of 17.6% across the County. Recruitment to ICT has been identified as a priority. Recruitment is also a challenge for MSK, palliative care and diabetes As part of the adult delivery model, specialist services are being aligned to localities to work alongside the ICT The respiratory nursing service commissioned by ENCCG is underway in conjunction with ENHT. A new skin health pathway is being rolled out. The lymphoedema service has taken on the West Essex service on an interim basis until March 2016 Bed based services continue to be challenged by the pressures of the local health economy as a whole. (Performance is better in E&N compared to HV) Holywell unit has now moved to the refurbished Langley House and an open day was held. The recently recruited overseas nurses have settled in well. (2) Children s Services The leadership structure in the Children s OT and Physio service has been reorganised to integrate the Herts and West Essex teams. The PALMS service has continued to reduce waiting times for families and has also held successful stakeholder events across the County. An official launch event is to be held in October. Step 2 has faced an increase in demand but has still managed to reduce waiting times. Two contracts have recently been extended: (i) 15

26 Board: 12 th November 2015 Attachment A2 Special Needs Dental Service (To March 2018) and (ii) West Essex Children s Services (To March 2017) Work is in hand to scope implications of changes to SystmOne,which will allow for more automation. Discussions continue with HVCCG on the demand pressures faced by the West Herts Community Paediatric Service. (3) Key Risks Adults and Children s services Workforce levels Specialist palliative care, some bed based units and ICTs, Community paeds, continuing care, school nursing (North Herts and Wel/Hat) SLT, Diabetes and Community Children s nursing. HV funding for safe staffing for DoLS and plus size patients Winter resilience bids roll out 18 weeks performance in community paeds Wheelchair service IT systems, stock HES delivery Inappropriate transfers from acute to HCT bed based units Child health system national data management issue (4) System Resilience Three bids for winter resilience supplementary services have been successful in E&N and five in HV. Resilience will also be enhanced by the development of Home-First style integrated services across E&N Herts A rapid response service has been commissioned for St. Albans and Harpenden The HV healthcare system is one of 27 systems to receive support from the Emergency Care Improvement Programme (ECIP). (5) Partnership Working Priority areas noted as: Partnership working with the RFH on PACE Single assessment framework with partners in HV Work with HPFT on the RAID service to support HCT beds (bid approved) (6) Transformation Improving Clinical Practice and Productivity in the Integrated Community Teams Demand and capacity work (with a robust tool to be in place by March 2016), 16

27 Board: 12 th November 2015 Attachment A2 competency frameworks and development of a dashboard Mobile Working - technological and implementation improvements Estates- working in conjunction with HCT estates lead to support delivery of the estates strategy. It was further noted that: (i) Four beds in HEH will be changed to stroke beds to support the West Essex stroke pathway. (ii) DTCs are going up, with the majority of cases awaiting care packages. LoS is on target. Supporting / linked documents are: IBPR HLRR BUPR assurance reports Challenge and Response to Board Questions (a) (b) (c) (d) (e) The Step 2 service is a cinderella service and demand is higher than capacity. It is recognised as a good service by the commissioners but there is no additional funding to date. HCT is working with HPFT on a review of CAMHS to better align services. This doesn t link specifically to the national directive on improving mental health services but it meets the principle of mental health as being equal to physical health The issue of social care struggling to support provision of packages of care should be escalated to senior / Councillor level in the County Council and different ways of dealing with the problem should be considered. The Board supported this approach. Social Care input needs a collective solution and it has been discussed with the TDA. It is probably not appropriate however to report social care delays through the serious incident route. Given the number of social care delays now, it looks ominous for the winter period. The problem currently facing social care was not being able to attract staff rather than funding, as funding has been made available from the CCG. 17

28 Board: 12 th November 2015 Attachment A2 (f) It needs to be noted that not all DToCs are down to social care delays and need to keep an eye on the data. Decision(s), Outcome(s) and Actions: (1) The Director of Operation s Report (September 2015) was noted. 157/15 Summary Integrated Board Performance Report (Sept 2015) (Lead Director: PB) The Trust s Summary Integrated Board Performance Report (Data for July 2015) was received and discussed. It was noted that: (i) (ii) (iii) The report had been considered in some detail by SRC and the full report, including detailed analysis, is in the supporting papers. The July scorecard demonstrates continued strong performance across a number of metrics and HCT continues to comply with key national targets. Areas for attention in the full set of indicators were: Children s Safeguarding Levels 1, 2 3 below new target of 95%. HCT were achieving previous target of 90% Smoking Cessation indicators all below target DTOC rate above the 5% threshold for second consecutive month with 7.6% recorded in July Patients discharged on or before Estimated date of discharged is 66% in July against 90% target Staff turnover at 13% and over the 12% threshold. (iv) Performance highlights were: No MRSA cases reported in July Achieving all National indicators, Inc. School health programme and 18 week waiting times Achieving Priority 1 urgent referrals in ENCCG (100%) HVCCG P1 and P2 and P3 referral priorities targeting to follow Clinical and medical staff adult safeguarding training Level 2 below now achieving the 90% target Stroke and Non-Stroke ALOS below thresholds in July. 18

29 Board: 12 th November 2015 Attachment A2 (v) (vi) There has also been an improvement on mandatory training uptake; DToCs have been discussed under the DOps Report and staff turnover is addressed in more detail in the DHR&OD s Report. Since the report was compiled it has now been confirmed that there have been three CDiff cases in YTD. Decision(s), Outcome(s) and Action(s): (1) The Board noted the performance, areas of progress and areas where performance is not meeting target levels. 158/15 Business Unit Performance Assurance Reports (Sept 2015) (Lead Director: PB) Business Unit Performance Reports for the three Operations Business Units were received, covering the Business Unit Performance Reviews held in August It was noted that: (i). (ii) The reports are completed at the end of each Business Unit Performance Review and are considered as a matter of routine by the Executive Team. Areas rated as Red were as follows: Children s and Young People s Services: Community Paeds: West Herts WaitingTimes Step 2 waiting times and need for commissioner investment East and North Adults: Skin Health Pathway Pressures on MIU MSK physio Holywell / Wheelchair service overspend ICT referral priorities Resilience of smaller services Herts Valley Adults Funding requirement to meet DoLs and bariatric 19

30 Board: 12 th November 2015 Attachment A2 patients High Turnover and vacancies in ICT Push to get 90% for smoking status Diabetes turnaround plan Palliative care Prison KPIs (iii) General Manager comments and actions being taken associated with the assurances were noted. Challenge and Response to Board Questions (a) (b) It was extremely helpful for the Board to have sight of these reports, but they still need more, but brief context, rather than just a general description which gives no guide to the issues. The BUPR reports are presented to the Board for assurance and information as to risks and trends. The Board needs to be conscious that management of the issues is the function of the executive. Decision(s), Outcome(s) and Actions: (1) BUPR Assurance Reports to set out more clearly the context around issues, risks and what is being done to manage the risks. PB (Nov 2015) (2) The Business Unit Performance Assurance Reports for September 2015 were noted. 159/15 High Level Risk Register (August 2015) (Lead Director: CH) The High Level Risk Register (HLRR) and summary as at August 2015 were received and discussed. It was noted that: (i) Since the previous HLRR report there are now 15 risks on the register of which: 1 = new risk 11 = risks unchanged in score 3 = risks escalated from BU risk registers (ii) (iii) 1 risk has been de-escalated from the HLRR as the score has reduced below 15. The new risk relates to: 20

31 Board: 12 th November 2015 Attachment A2 Outcome requirement s from the CQC inspection and summit (iv) The three risks escalated from BU risk registers which have increased in score to above 12 relate to: Community Diabetes service - high caseloads Community Diabetes service - staffing levels on account of vacancies and sickness absence Health Visiting and School Nursing: Risk of staff shortage on account of high level of staff pregnancies and loss of staff due to increased workload. (v) The risk de-escalated to BU register relates to: Capacity to meet increased demand for changes to SystmOne (vi) The HLRR is reviewed and challenged by the Executive Team and Healthcare Governance Committee. Challenge and Response to Board Questions (a) Risks are being identified through discussion and other assurance sources to the Board but are not necessarily being reflected in the HLRR. Decision(s), Outcome(s) and Action(s): (1) Risk reporting and the HLRR needs to be reviewed to ensure it is capturing all risks appropriately, as risks are being identified through other assurance sources to the Board but are not being reflected in the HLRR. CH (Nov 15) (2) The Board noted the HLRR and actions being taken to mitigate risks as at August (D) Strategy, Resources and Engagement 160/15 CEO s Report & Strategy Update (Sept 2015) (DL) The CEO s Report as at September 2015 was received and discussed. Items reported on were as follows: (1) Summary Headlines: 21

32 Board: 12 th November 2015 Attachment A2 The Board was requested to agree the Case for Change for the West Herts Strategic Review, which was attached in full as a supporting paper. Addressing delayed transfers of care (DToC) with Herts CC. Contractual issues with HVCCG are being pursued to close the financial gap in respect of the bed base, wheelchair services and community paediatrics Discussions with the Senior Management Team on (i) a framework and change model for strategic delivery (ii) consolidation of current projects (iii) adoption of a Plan, Do, Study, Act approach (iv) communicating the strategy to staff. (Framework attached to CEO s Report and a formal proposal to come to the November Board meeting). (2) Current Main Areas of Work and Risks and mitigating actions in respect of the Trust s five strategic objectives: Objective 1 (Supporting self-care) Objective 2 (Clinical outcomes and safety) Objective 3 (Expansion of community services) Objective 4 (Efficient use of resources) Objective 5 (Organisational capacity) (3) The External Environment Emergency Care Remains below 95% standard in West Herts and West Essex West Herts Strategic Review Event for all stakeholder boards to sign up to the outline case to be held on 23 rd October. Integration Programmes: East & North focus is (i) extending models of enhanced community provision (ii) creation of a single referral route and (iii) Managing transitions of care. West focus is (i) taking forward an agreed model of care and identifying key functions of primary and community care and (ii) Your Care, Your Future (YCYF). Challenge and Response to Board Questions (a) The Case for Change for YCYF was justifiable but the real issue will become delivery and commitment to 22

33 Board: 12 th November 2015 Attachment A2 defined outcomes. In this context, wording of HCT signing up to each stage of the process will need to be carefully drafted to ensure reservation of the Trust s position where appropriate and not signing up to a carte blanche. Decision(s), Outcomes and Actions: (1) The Board agreed the Case for Change for Your Care, Your Future. (The West Herts Strategic Review). (2) The CEO s Report for September 2015 was noted. 161/15 Director of Finance s Report (Sept 2015) (PB) The Director of Finance s report for September 2015 and the Month 4 Financial Position Report were received and discussed. Items reported on were: (1) Detailed summaries of developments, performance and work in progress relating to: (i) (a) (b) (c) (d) (ii) (a) (b) (iii) Finance Recruitment continues with successful appointments of a Deputy Director of Finance and a Finance Manager. A directorate away day was held on July which included identifying project leads for key pieces of work. The LTFM has been updated to include 2014/15 outturn and 2015/16 quarter 1 position At the end of month 4 the Trust has delivered a surplus of 299k, 11k ahead of plan. (See also (2) below). Strategic Estates Community Hubs (Cheshunt, Hemel, St. Albans, Stevenage, Watford) Capital Developments and Estate Rationalisation: Developments, Operational Management and the Total Facilities Management Contract Information Governance 23

34 Board: 12 th November 2015 Attachment A2 (a) (b) (c) (d) (iv) (v) IG toolkit Incidents (Including one serious incident reported to the ICO whereby patient audit data had been stolen from a staff member s car). Freedom of Information Act requests Subject Access Requests under the Data Protection Act Performance and Information: (a) Business Intelligence (b) Performance (c) IT (d) Staffing Contracts and Commercial Opportunities (2) Finance Report: Month 4 (July 2015) (Supporting Paper H8) (3) Risks At the end of month 4, the Trust had a year to date surplus of 299k which was 11k better than plan. The forecast indicates an end of year pay cost overspend of 1.02m. This position would be offset by income over performance. Clinical income was currently 181k adverse to the YTD plan. The clinical business units had a YTD favourable variance of 4k against plan, an adverse movement of 28k in July Month 4 CIP delivery was 54k less than plan and YTD CIP performance was 172k behind plan, although the programme is still forecast to fully deliver the 4.125m 2015/16 planned target. The key points of focus for the directorate will be the delivery of the 2015/16 financial plans, agreement of the 2016/17 and 2017/18 CIP plans, contribution to the IBP and preparation for the Historical Due Diligence review (HDD). Key risks included: (i) (ii) Wheelchair service costs Enhanced bed base staff costs for patients under DoLs and bariatrics. 24

35 Board: 12 th November 2015 Attachment A2 (iii) Impacts of funding shortfalls Challenge and Response to Board Questions (a) (b) A meeting is being held with the two CCGs on Monday 21 st September to consider funding shortfalls and possible impacts on services. The TDA is aware of the position and their support is being solicited. In respect of the serious IG breach, all parents have been notified and calls from concerned parents have been taken. The breach has been reported to the ICO but there has been no communication back to date. There have been IG breaches in children s services in the past, but these have been different in that they have related to misaddressed communications, and measures were put in place to prevent re-occurrence. Decision(s), Outcome(s) and Action(s): (1) The Board were aware of the risk of a year-end overspend and the requirement to ensure that budget and funding remained on track. In this context, the Board supported the Executive Team in respect of whatever measures were necessary vis- a - vis commissioners in order to achieve this. (2) The Director of Finance s Report (September 15) and Month 4 (July 15) financial information were noted. 162/15 Director of HR and OD s Report (Sept 2015) (AS) The Director of HR and OD s Report (Sept 2015) was received and discussed. Items reported on were: (1) Headlines: Sickness absence remains below target. Mandatory training performance has improved further; now at 89% against 90% target. Staff turnover has increased and is under close review. Appraisal rates have deteriorated but trajectories are in place for completion. Significant focus on resourcing continues, with implementation of our 15/16 Resourcing Framework & Plan and enhanced reporting. Our first overseas nurses have joined. The Trust held a very successful staff celebration 25

36 Board: 12 th November 2015 Attachment A2 and Leading Lights Awards event, including the recognition of the long service of over 200 of its staff. The Trust continues to actively engage in Workforce Planning at local and regional levels. The Trust has engaged further with the national work regarding Agency usage and is responding to newly received targets. (2) Detailed summaries of developments, performance and work in progress relating to: (i) Workforce Performance Indicators: Sickness, Turnover and Vacancy rates Mandatory Training Appraisal (ii) Staff Engagement (WF&OD Strat.Objective 1): A successful Celebrating High Value Healthcare and Leading Lights awards event was held on 7 th July. (iii) Workforce Planning and Resourcing( WF&OD Strat.Objective 2): Resourcing Plan Recruitment Pipeline Overseas Recruitment Temporary Staffing Nursing Agency Spend Workforce Planning (iv) Learning & Development (WF&OD Strat.Objective 3): Alignment with the mandatory Skills for Health Core Skills Training Framework (v) Employment Practices (WF&OD Strat. Objective 4: Equality & Diversity): Equality & Diversity and implementation of EDS 2 Pensions Scheme Implementation HCT commended on data quality. Challenge and Response to Board Questions: (i) An update on the Resourcing Plan will be going to September SRC. This will include more granularity on vacancies and identify hotspots. 26

37 Board: 12 th November 2015 Attachment A2 (ii) (iii) (iv) HR is now in a position to record the start to end times for recruitment ie from when a vacancy arises to when a post is filled.. The Resourcing team is being re-organised. This will include having a Head of Resourcing and the supporting skill mix is currently out to consultation. All 13 of the nurses recruited from overseas have now started. Decision(s), Outcome(s) and Action(s): (1) The Board noted the Report from the Director of HR and OD for September /15 Risk Management Strategy 4 th Edition (Lead Director: CH) Edition 4 of the Trust s Risk Management Strategy (Sept 2015) was received. It was noted that updates to Edition 3 relate to: Adjustment to the HCT strategy template Revised SWOT analysis Revised risk appetite Additional KPI to support assurance of milestone achievement Decision(s), Outcome(s) and Action(s): (1) The Board approved Edition 4 of the Risk Management Strategy 2014/ /20 164/15 Emergency Planning Core Standards Self-Assessment and Memorandum of Understanding (Lead Director: JH) The following were received: (i) The HCT Emergency Planning Core Standards Self-Assessment as submitted to NHSE in August 2015 and (ii) Hertfordshire Local Health Resilience Partnership Memorandum of Understanding on EPRR It was noted that: (i) Hertfordshire Community NHS Trust considers its overall level of compliance with the core standards to be substantially compliant. 27

38 Board: 12 th November 2015 Attachment A2 (ii) There are no categories where HCT is not compliant, all categories were rates as partially compliant or above (iii) (iv) A rectification plan has been put in place and progress will be monitored by the Emergency planning Strategic Group The EPRR Memorandum of Understanding sets out the agreed contribution to emergency preparedness, resilience and response within Hertfordshire between the key health agencies involved in resilience. Decision(s), Outcome(s) and Action(s): (1) The HCT Emergency Planning Core Standards Self- Assessment as submitted to NHSE in August 2015 was ratified and subscription to the Memorandum of Understanding was agreed. 165/15 Engagement Report: Feedback from Partner Organisations AGMs. (Verbal Reports) Verbal summaries on partner organisation AGMs were reported on as follows: AM = HVCCG (Held: 3/9/15) BG = E&NHHT (Held: 14/7/15) AR = WHHT (Held: 3/9/15) It was noted that E&NH CCG s AGM and West Essex CCG s AGM are both due to be held on 24 th September. 166/15 Strategy & Resources Committee Chair s Report (September 2015) (Committee Chair: LS) The Chair of the Strategy and Resources Committee s verbal report on the meeting held on 23 rd June was received and discussed. Assurance levels reported were as follows: Red (Negative) Assurances: 1. West Hertfordshire Strategic review 2. Cleaning contract performance and escalation report 3. Wheelchair service assurance report 4. Urgent Care Performance Report 28

39 Board: 12 th November 2015 Attachment A2 Amber/ Red (Limited) Assurances: 1. Integration Programme Board reports 2. Finance Report for Month 4 (July) 3. PMO update report Amber/Green (Reasonable) Assurances: 1. Benchmarking Update 2. IM &T Strategy and action plan 3. TDA Self Certification Monthly Submission 4. Good Corporate Citizen progress update 5. SystmOne procurement 6. Contracting progress update Mitigations against the above red and amber/red rated areas were also noted. Decision(s), Outcome(s) and Action(s): (1) The SRC Chair s Report was noted. (2) The TDA submission for August 2015 (July data) as approved by SRC was ratified. (See Supporting Paper H9). 167/15 Foundation Trust Progress Report (Sept 2015) (Lead Director: DL) The Foundation Trust Progress Report (Sept 2015) was received and discussed. It was noted that: (i) (ii) (iii) (iv) (v) The report addressed Background, Timeline, Progress and Risks & Issues. The Trust s application was on hold pending reinspection following the CQCs inspection report finding published in July of Requires Improvement CQC confirmed at the summit meeting in July that HCT was very close to achieving a good rating. The timeline and methodology for re-inspection were not yet known, but re-inspection is likely to be before the end of the financial year. It is anticipated that that referral to Monitor will be later in 2016/17. Although the formal timeline has been suspended, 29

40 Board: 12 th November 2015 Attachment A2 work continues on all elements of the FT delivery plan. (vi) Significant risks to delivery were: The timescale for CQC re-inspection and the requirement for a rating of at least Good The timescale for the Historic Due Diligence Review which is outside of the Trust s control The on-going challenge of developing, and delivering, detailed CIPs in the current economic climate Decision(s), Outcome(s) and Action(s): (1) The Board noted the FT Progress Report as at September /15 Foundation Trust Committee Chair s Assurance Report (Sept 2015) (Committee Chair: AR) The Chair of the Foundation Trust Committee s report was received and discussed. Assurance levels reported were as follows: Red (Negative) Assurances: 1. Uncertainties around the West Herts Review make planning difficult. 2. Uncertainty of CQC re-inspection makes planning difficult. 3. FT Risk Register identifies significant capacity pressures. Amber/ Red (Limited) Assurances: 1. FT timetable not finalised 2. Membership strategy needs strengthening 3. Development of Integrated Business Plan and substrategies continuing. Amber/Green (Reasonable) Assurances: 1. Well-led Framework now published Green (Significant Assurances): 1. FT communications plan is taking shape 30

41 Board: 12 th November 2015 Attachment A2 2. Further FT authorisation of Community Trusts emphasises the validity of this strategy for HCT. 3. HCT now has the maturity to address the process challenge to achieve FT status. Actions required or underway by the Executive Team to address the areas identified and/or to mitigate associated risks within the control of HCT were noted. Decision(s), Outcome(s) and Action(s): (1) The FTC Chair s Report was noted. 169/15 Audit Committee Chair s Assurance Report (Sept 2015) (Committee Chair: JP) The Chair of the Audit Committee s verbal report from the meeting held on 15 th September 2015 was received. It was noted that: (i) (ii) (iii) (iv) A full assurance report will come to the November Board meeting. Matters considered included wheelchair services audit. No new risks had been identified. The Annual Audit Letter was received and considered and this will come to the November board meeting. (E) Decision(s), Outcome(s) and Action(s): (1) The Audit Committee Chair s Report was noted. Board Governance & Leadership 170/15 Note of the Remuneration Committee meetings held on 23 rd June and 28 th July 2015 (Committee Chair: Anne McPherson) A record of the Remuneration Committee meetings held on 23 rd June and 28 th July 2015 were received. It was noted that the items discussed on 23 rd June were: End of year Appraisals Very Senior Manager (VSM) Pay 15/16 Letter from the TDA to the Trust Chair Re: Exec Board Pay Restraint Letter from Secretary of State to Trust Chairs regarding VSM Pay Agency National Directive 31

42 Board: 12 th November 2015 Attachment A2 It was noted that the items discussed on 28 th July were: The Committee reviewed the remuneration of the Executive Directors with reference to the VSM Framework Spot rate for the role, and latest anonymised TDA and FTN Community Benchmark Data. The Committee discussed and agreed actions. It was suggested DL review the remit, interaction and alignment of Executive Director roles. The main item of note was that the Committee agreed that there would be no increase in basic pay for executive directors in 2015/16. Decision(s), Outcome(s) and Action(s): (1) The notes of the Remuneration Committee meetings held on 23 rd June and 28 th July 2015 were noted. (F) Urgent Business 171/15 No items (G) Risks Arising and Post-Agenda Item Reflections 172/15 It was noted that key risks emerging from the Board s deliberations and reflections post-agenda item discussion were: (1) Resolution of financial issues with HVCCG (2) Meeting strategic objectives and the volume of work / initiatives currently in progress (3) The possible impact on HCT of WHHT being placed in special measures. (H) 173/15 Supporting Papers / Items for Receipt and Noting Only The following supporting papers were received and noted for information: Clinical Services & Healthcare Governance B2 (i) Complaints Annual report (ii) Safeguarding Adults Annual Report (iii) Safeguarding Children Annual Report (iv) Looked After Children Annual Report (v) Patient Experience Annual report Operations & Performance 32

43 Board: 12 th November 2015 Attachment A2 C2 (i) Integrated Board Performance Report (August 2015) Strategy, Resources & Engagement D1 (i) Your Care, Your Future: The Case for Change D3 (i) Month 4 Financial Position Report D4 (i) TDA Returns (August 2015) D6 (i) Minutes of the Foundation Trust Committee meetings held on 1 st July and 5 th August 2015 (I) 174/15 Date, Time & Venue of Next Meeting(s) Board meeting in public: Thursday 12 th November pm East Hertfordshire District Council Wallfields Pegs Lane Hertford SG13 8EQ (J) 175/15 Questions / Observations from the Public Q: In the light of the risk identified in the Medical Director s report that dedicated funding has not been forthcoming for the research office in 2015/16, would the Trust plan to reconsider and invest further in research? A: The Trust takes research seriously and there has been significant growth in investment in this area over recent years. There are some bids for investment funding in progress, although community services does not attract the same degree of investment as acute hospitals. It is recognised that investment in research can represent spend to save, if supported by a business case. However, funding for research also has to be balanced with the financial constraints within which the Trust and the NHS as a whole are currently operating. Q: CApp reported that some questions / observations have been raised by Mrs. AM, who with her husband, Dr.GM, presented their experiences relating to the care of their son as the patient Story to the Board in January A full reply will be compiled and sent to Mrs.M, but in summary the questions/ observations related to: 33

44 Board: 12 th November 2015 Attachment A2 1. A welcome change in continuing care with increased staff levels, low sickness levels, and mostly being able to fulfil the package approved by the multi-agency panel, but where is information presented on how well continuing care is delivering it's care packages? 2. Inconsistency in the level of service provided by the wheelchair service 3. Issues and impact on parents of a change in medication policy. Receipt of the Questions / Observations from Mrs. M was noted. (K) Informal Review of Meeting 176/15 No specific observations. Common Abbreviations AC = Audit Committee BAF = Board Assurance Framework BU = Business Unit BUPR = Business Unit Performance Review BURRs = Business Unit Risk Registers CCG = Clinical Commissioning Group (HV = Herts Valleys; E&N = East & North Hertfordshire) CEO = Chief Executive Officer CQC = Care Quality Commission Dir = Director of. DD = Deputy Director DoH = Department of Health ENHT = East & North Herts NHS Trust FT(C) = Foundation Trust (Committee) GM = General Manager HCC = Hertfordshire County Council HCT = Hertfordshire Community NHS Trust HGC = Healthcare Governance Committee HLRR = High Level Risk Register HPFT = Hertfordshire Partnership University NHS Foundation Trust HVHC = High Value Health Care IBP = Integrated Business Plan IBPR = Integrated Business Performance Report KPI = Key Performance Indicator LTFM = Long Term Financial Model NED = Non Executive Director NHSE = NHS England (formerly known as the NHS Commissioning Board) PLACE = Patient Lead Assessments of the Care Environment RAG = Red/ Amber / Green ratings RemCom = Remuneration Committee SRC = Strategy & Resources Committee TDA = (NHS) Trust Development Authority ToR = Terms of Reference WHHT = West Hertfordshire Hospitals NHS Trust WTE = Whole Time Equivalent (staffing) YCYF = Your Care, Your Future (West Herts Strategic Review) YTD = Year to Date 34

45 Board: 12 th November 2015 Attachment A3 RAG Traffic Light Key: ` HERTFORDSHIRE COMMUNITY NHS TRUST BOARD TRACKER (September 2015) To be considered at current meeting (ie action deadline reached) No Action Required Action Deferred Action not yet initiated but within target Action not yet initiated and likely to miss target Action In Progress but not on target or target has expired Action in progress and on target Action Completed Minute Meeting Item / Action Required Ref No. Date 140/15 17/09/15 Patient Stories (x) It was noted that RB was compiling a portfolio of patient stories with the help of volunteers from Healthwatch. It was agreed that over time and subject to patient / carer agreement, the stories could be compiled into a single book. Board Lead Target / Finish Date CH Jan 16 Progress Patient stories to be published on new look website (Jan 16) R/A/G 158/15 17/09/15 BUPR Assurance Reports PB Nov 15 (1) BUPR Assurance Reports to set out more clearly the context around issues, risks and what is being done to manage the risks. 159/15 17/09/15 High Level Risk Register CH Dec 15 On track 1

46 Board: 12 th November 2015 Attachment A3 Minute Ref No. Meeting Date Item / Action Required (1) Risk reporting and the HLRR needs to be reviewed to ensure it is capturing all risks appropriately, as risks are being identified through other assurance sources to the Board but are not being reflected in the HLRR. Board Lead Target / Finish Date Progress R/A/G 113/15 9/07/15 Sign Up To Safety: (1) A Board statement be devised to demonstrate leadership and support for the campaign. AMc Jan 16 Board Statement (and full progress report) to Board in jan /15 13/05/15 Safe Staffing: Non bed-based units (1) Safe staffing levels for teams other than inpatients be developed, and that this be wider than just for nurses, in order to recognise overall team capacity and patient safety issues. 81/15 13/05/15 Serious Incident Report: Pressure Ulcers (1) HGC will explore possible wider impacts as possible contributory factors to the number of pressure ulcer cases, such as the possible impacts of CIPs, staffing numbers and capacity, etc. CH Dec 15 Capacity, Demand and Acuity workstream review scheduled for November 2015 AM/CH Sept 15 This action is part of routine review by the Serious Incident Review Panel 2

47 Board 12 th November 2015 Attachment B1 1.0 Introduction HERTFORDSHIRE COMMUNITY NHS TRUST Report from the Director of Quality and Governance/Chief Nurse November 2015 This paper provides an update from the Director of Quality and Governance/Chief Nurse to highlight items of interest or information arising since the last Board report. It is supplementary to the quality data contained within the IBPR. This report now includes updates that would usually be included in the Medical Director s report. 2.0 Executive Summary Limited assurance on delivery of the CQC quality improvement plan with progress update due for completion by November 20 th. Internal quality assurance visit planned for The Mount on November 11 th. Following this assessment of progress against delivery of the CQC action plan will be made. HCT continues to work to the Board agreed staffing ratios in its inpatient units Implementation of nurse revalidation on track. Improvements noted at Herts and Essex hospital inpatient unit. PLACE action plan underway and planning for the next assessment is in hand. Risk remains in relation to the impact of the LMC recommendation that GPs do not authorise HCT medicines administration charts. Friends and family test results are at 97% against a target of 90%. All school health programme measures were achieved in the 2014/15 school year. As of November children s safeguarding training (levels 1, 2 and 3) are achieving the revised target of 95%. 3.0 Recommendations The Board is asked to note the content of this report. 4.0 CQC Inspection A formal programme of actions to support service improvement which ensure safe, effective care in line with the regulatory requirements is underway. This is coordinated through the CQC Quality Improvement Plan (QIP), now approved by the Board and submitted to the CQC. Assurance of actions taken is under review with reports from the business units due by Nov 20 th. Following this an updated QIP will be circulated to the Board. Future reporting dates have been set out and will be rigorously monitored to avoid any delay in assurance being received. 1

48 Board 12 th November 2015 Attachment B1 5.0 HMP The Mount Following the joint CQC & HMP inspection in April 2015, the Trust was notified on 25 th August that an outcome of requires improvement was achieved. The three areas requiring improvement were: administration of medication, complaints and audit of clinical services. Progress is underway and the Quality team will complete an internal assurance visit on November 11 th. 6.0 Safe Staffing NHS Improvement, the CQC, NICE and the Chief Nursing Officer for England have issued an update in relation to the current national safe staffing guidance. This reiterates the requirement for providers to demonstrate that safe and quality care is provided for patients and that they are making the best use of resources. This confirms that the 1:8 ratio is a guide not a requirement. HCT will continue to work to its currently agreed staffing ratios in the community hospitals and will implement further national safe staffing guidance in due course. For the fifth consecutive month all community hospitals reported an average fill rate for registered nurses of more than 80%, demonstrating an increasing improvement in staffing levels. There is a continuing trend of using above HCT threshold of HCAs on both day and night shifts to care for increasing numbers of complex patients and those with DOLS in place and at high risk of falls. The safe staffing report is presented at this Board meeting. 7.0 Nurse Revalidation The Nursing and Midwifery Council governing council voted to approve the model and the first registrants will be due to revalidate from April Our plan to implement nurse revalidation in the Trust is on track. 8.0 The Shape of Caring review The Trust has contributed to the consultation document Raising the Bar Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants (Health Education England). 8.0 Herts & Essex Hospital Oxford and Cambridge wards In September I reported concerns in relation to the inpatient unit at Herts and Essex hospital. Improvements have been noted and the Executive team has reduced its monitoring of risks to monthly as a result. 9.0 PLACE The PLACE report for 2015 was published by the Health and Social Care information Centre on 11 th August HCT scores for privacy, dignity and wellbeing are in the bottom 20% of Trust s nationally. The low scores arise as a result of new areas of inspection such as patient access to the internet, snacks for relatives during the day and night, facilities for relatives to stay overnight and access to shared TV in communal areas. The report and action plan are presented to this meeting. 2

49 Board 12 th November 2015 Attachment B Medicines Management Good progress is being made with the development of increased numbers of Independent Prescribers in the Trust. The Chief Pharmacist is working jointly with the Learning and Development team to plan education sessions starting from January This work includes development of competencies within the Allied Health Professionals. North Herts physiotherapists are piloting administration of medicines to patients seen jointly with the community nursing team, which will prevent duplicate visits. The evaluation of the Homefirst pharmacist in Lower Lea valley has been positive and a business case is being developed to make this a substantive post. Increased pharmacy support into Potter s Bar inpatient unit has been possible due to the temporary closure of Gossoms End inpatient unit. This allows us to replicate the work already started across other inpatient units to improve the clinical aspects of medicines management. Issues related to the LMC recommendations to GPs to stop completion of the HCT medicines administration work are being addressed. Risk remains in relation to administration charts for people requiring insulin. HCT has taken guidance from the Royal College of Nursing and continues to work with the LMC to find a safe resolution Current Performance Quality performance remains strong. Friends and family test results are at 97% against a target of 90%. All school health programme measures were achieved in the 2014/15 school year. As of November children s safeguarding training (levels 1, 2 and 3) are achieving the revised target of 95%. One C Difficile case was reported in September. The patient was at Queen Victoria Memorial Hospital. Root cause analysis is underway. A slight deterioration in harm free care relates to nine patients affected by catheter associated urinary tract infection. Actions continue to promote effective catheter care by our staff, patients and carers Risks and Challenges Limited assurance on delivery of the CQC quality improvement plan with progress update due for completion by November 20 th. Internal quality assurance visit planned for The Mount on November 11 th. Following this assessment of progress against delivery of the CQC action plan will be made. A long term solution for GP service into The Mount has not yet been found. This is escalated to the Associate Director of Operations. Risk remains in relation to the impact of the LMC recommendation that GPs do not authorise HCT medicines administration charts. Clare Hawkins Director of Quality & Governance/Chief Nurse November

50 Board: 12 th November 2015 Attachment B2 TRUST BOARD Title: SAFE STAFFING BOARD REPORT Meeting Date: 10th November 2015 Executive Lead: Author(s): For: Clare Hawkins Director of Quality and Governance/Chief Nurse Jackie Sibson Clinical Projects Manager NOTING 1.0 Purpose & Recommendations 1.1 To advise the Board regarding safe staffing levels for September To ask the Board to note the following: 2.0 Executive Summary 2.1 September continued with the positive trend in safe staffing levels, being the sixth consecutive month when RN levels have been above 80% threshold for all units. 2.2 The requirement for additional HCA hours continued throughout the month to cover complex needs as detailed below: - 13 patients with Deprivation of Liberty Safeguards in place - 15 patients at high risk of falls 8 of these patients were at Herts & Essex Hospital - 41 patients requiring escorts to appointments off site compared to 24 in August and - 6 in July. 2.3 Day time HCA levels at Nascot Lawn fell below the 90% threshold for the third consecutive month. When necessary an additional RN worked on the unit to cover any gap in hours and to help care for children with more complex needs, thus ensuring that safe staffing levels were maintained.

51 Board: 12 th November 2015 Attachment B2 3.0 Relevant Strategic Objective(s) / Strategies 3.1 Trust Strategic Objectives 1 We will improve clinical outcomes and enhance patient safety 4 We will use resources efficiently to enhance our ability to improve services 5 We will develop the organisational capacity to deliver our vision and objectives 4.0 References, Appendices & Attachments Appendices & Attachments (1) Safe Staffing Report September 2015 Author(s) of paper: NAME Jackie Sibson, Clinical Project Manager Date: 28 th October 2015

52 Board: 12 th November 2015 Attachment B2 Sign Off: To be completed as part of papers to Executive Team, Board Committees and Board Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year): Healthcare Governance Committee November 2015 Issues arising from committee consideration Data Quality Statement By way of assurance to the Board, and in order to inform discussion / decision, the accountable executive director confirms that to the best of their knowledge, and subject to any exceptions identified, data contained in this report is: Data Quality Domain Complete Accurate Relevant Up To Date Valid Clearly Defined Description Comments / Exceptions / x Information is as comprehensive as possible to inform the board and no significant known facts or statistics which may influence a decision are omitted. As far as can be reasonable ascertained or validated, information in the report is accurate. Information contained in the report is relevant to the matters considered in the report. Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written Information is presented in a format which complies with internal or national models or standards The meaning of any data in the report is clearly explained Executive Director Sign-Off This paper has been approved by the accountable executive director who is satisfied that (i) the implications for risks, (ii) quality/service/regulatory impacts and (iii) resource implications, have been considered. Clare Hawkins Director of quality and Governance/Chief Nurse Company Secretary Sign-Off (Board papers only) This paper has been quality control checked and approved by the Company Secretary

53 Board: 12 th November 2015 Attachment B2 Safe Staffing Update Report September Introduction This report is to provide the Board with an overview of the safe staffing levels within HCT inpatient units for the month of September There is no nationally agreed RAG rating to determine safe staffing thresholds for nursing; however NHS England has applied a threshold where organisations declaring less than 80% fill rates for registered nurses (RN) will be subject to additional scrutiny as this level of nursing staff would be determined as unsafe. HCT has agreed that further internal validation will be undertaken for inpatient units where staffing falls below 90% or is above 110% of planned staffing levels. Where this applies, units will be expected to provide assurance as part of the monthly Business Unit Performance Review meeting that patient care was not compromised. A brief overview only is included in this update report. 2.0 Executive Summary September continued with the positive trend in safe staffing levels, being the sixth consecutive month when RN levels have been above 80% threshold for all units. The requirement for additional HCA hours continued throughout the month to cover complex needs as detailed below: - 13 patients with Deprivation of Liberty Safeguards in place - 15 patients at high risk of falls 8 of these patients were at Herts & Essex Hospital - 41 patients requiring escorts to appointments off site compared to 24 in August and 6 in July. 3.0 September data analysis Data from the e-roster and fill rate reports from NHS Professionals (NHSP) are used to complete staffing information. Staffing levels for all units, day and night shifts, Registered Nurses and Health Care Assistants (HCA), is included in appendix 1. Units falling below 90% of planned staffing levels: In September all adult units reported staffing levels above the HCT 90% threshold. 1

54 Board: 12 th November 2015 Attachment B2 For the third consecutive month Nascot Lawn, children s respite unit, reported day time HCA levels below the 90% threshold. The September level of 88.6% was higher than both the August level of 70% and the July level of 67.4%. The previously low figures were due to recruitment of additional HCAs, both of whom are now in post and have completed their induction and training for their new role. When necessary an additional RN worked on the unit to cover any gap in hours and to help care for children with more complex needs, thus ensuring that safe staffing levels were maintained. Units recording above 110% of planned staffing levels: In September all 11 units reported using staffing hours above the HCT threshold of 110% (compared to six in April, nine in May, six in June, seven in July and eight in August). o Nascot Lawn used higher levels of RNs to provide appropriate care for the complexity of the children on the unit. o Gossoms End Rehabilitation Unit used higher levels of RNs on several night shifts to provide one to one care when additional HCAs were not available o Eight of the 11 units used additional HCAs across both day and night shifts. These were St. Peters Ward, Hemel Hempstead General Hospital, Herts & Essex Hospital, Queen Victoria Memorial Hospital, Gossoms End Rehabilitation Unit, Langley House Rehabilitation Unit, Danesbury and Holywell Neurological Units and Sopwell Ward, St Albans City Hospital. o Potters Bar Community Hospital and Langton Ward, St. Albans City Hospital both used additional HCAs on day shifts. Additional HCAs were required to meet the needs of patients with complex needs and to ensure delivery of safe care as identified below: During September,13 patients with Deprivation of Liberty safeguards (DOLs) in place required additional care, some of whom needed individual care for all or part of the month. The13 patients were on Holywell neurological rehabilitation unit, St Peters Ward, Hemel Hempstead General Hospital, Herts & Essex Hospital, Queen Victoria Memorial Hospital, Sopwell Ward, St. Albans City Hospital, Gossoms End Rehabilitation Unit and Langley House Intermediate Care Unit. This is an increase from the 10 patients with these needs cared for on our units in both July and August. Queen Victoria Memorial Hospital needed additional hours to care for one plus size patient with high dependency needs requiring additional HCA staff during both the day and night shifts. Our units cared for a total of 15 patients at high risk of falls during September, compared to 19 in July. These patients were cared for at Potters Bar Community Hospital; St Peters Ward, Hemel Hempstead General Hospital; Sopwell Ward, St. Albans City Hospital; Holywell Neurological Unit, Gossoms End Rehabilitation Unit and Herts & Essex Hospital, which cared for 8 of the 15 patients during the month. 2

55 Board: 12 th November 2015 Attachment B2 Additional hours were needed at Sopwell and Langton Wards, St Albans City Hospital, Herts & Essex Hospital and Potters Bar Community Hospital, Gossoms End Rehabilitation Unit and Langley House Intermediate Care Unit to escort 41patients to outpatient appointments off site compared to 24 patients in August and six in July. Danesbury and Holywell Neurological Unit also needed additional hours to provide one to one care for two patients one with complex needs and another with high levels of anxiety. Units with below 80% RN fill rate During September all units reported an average fill rate for RNs of more than 80%. This is now the sixth consecutive month when staffing has been above 80% RN fill rate for all units. 4.0 Monitoring There is a robust system in place which monitors staffing levels of RN and Care staff on all units each day. This is supported by the Safe Staffing Reporting and Escalation Standard Operating Procedure, which was updated this month, confirming minimum staffing levels and escalation procedures. Ward staff are required to report daily on their agreed staffing levels and actual level of staff on duty. Any unresolved risks are escalated to the Director of Operations Monday to Friday and the Tier 1 Director/General Manager at weekends. In addition to this, episodes of low staffing levels requiring mitigating action are reported via a DATIX incident report to ensure accurate monitoring. 5.0 Quality Indicators The patient safety and patient experience indicators for all inpatient units are monitored monthly through the community hospital metrics alongside the percentage of Harm Free Care each unit is reporting. Staffing indicators are provided as part of the monthly Business Unit Performance Reviews and to HCT board in the monthly Integrated Board Performance Report. Through the review processes that are in place, data relating to areas such as reported incidents, complaints received and patient feedback received via the Friends and Family test are scrutinised. Specific concerns are identified and if necessary units are requested to provide further information and assurance that patient safety is maintained. 3

56 Board: 12 th November 2015 Attachment B2 6.0 Conclusion The monthly reporting of staffing levels for nurses and care staff will continue for all inpatient units in line with national guidance and requirements. In addition staffing levels will continue to be monitored on a daily basis and ward managers will escalate concerns to senior managers and Directors to ensure HCT board members are aware. Whilst monthly safe staffing data is released externally for inclusion on the NHS Choices website, monthly reporting and further review of safe staffing levels also takes place internally through the Business Unit Performance Reviews alongside the individual quality metrics. The internal reviews support the Business Units to identify trends and themes that may affect patient safety, patient experience and patient outcomes. Jackie Sibson Clinical Projects Manager November

57 Board: 12 th November 2015 Attachment B2 Appendix 1 - Average fill rates for September 2015 for Registered Nurses and Care staff for all bed based units Bed based unit DAYS Average fill rate Registered Nurses DAYS Average fill rate Care Staff NIGHTS Average fill rate Registered Nurses NIGHTS Average fill rate Care Staff Nascot Lawn 115.1% 88.6% 100% 103.8% St Peter s ward 95.8% 166.7% 98.3% 202.1% Danesbury 100.5% 115.5% 106.6% 112.6% Potters Bar Comm. Hosp % 112.5% 100.8% 99.9% Langton ward 105.3% 117.8% 98.3% 100% Gossoms End 94.4% 112.7% 111.3% 118.3% Herts & Essex Hosp % 162.2% 97.6% 217% Holywell ward 109.1% 208.7% 105% 231.1% QVM Hosp % 114.7% 100% 122.2% Sopwell ward 97.5% 164.2% 100% 166.7% Langley House 105.2% 118.7% 106% 125.6% 5

58 Board 12 th November 2015 Attachment B3 SERIOUS INCIDENT REPORT 30 th September Introduction This Serious Incident report provides information and analysis of the serious incidents (SIs) that have been notified to our commissioners: Herts Valleys CCG, East and North Hertfordshire CCG, Hertfordshire, South Midlands Local Area Team, East Anglia Area Team, West Essex CCG and the Local Authority, for the two month period, 01 st August 2015 to 30 th September Summary analysis of Serious Incidents During the period 1 st August to 30 th September 2015 a total of 11 serious incidents were reported. A request was made for one serious incident to be de-escalated. The number of serious incidents declared is similar to the previous two month period, 1 st June and 31 st July 2015, when a total of ten serious incidents were reported. Overview of new Serious Incidents (01/08/15 30/09/15) During this two month period, 11 serious incidents were reported, one of which was later de-escalated. The breakdown on SIs reported is identified below: Reported SIs 01/08/15-30/09/15 Number reported Number down graded Total confirmed incidents Information governance Slips/trips/falls Abuse/alleged abuse of adult patient by staff Deaths in custody Total Serious Incident report 30/09/2015 Page 1

59 Board 12 th November 2015 Attachment B3 3. Analysis and impact Information governance (1) A member of the Quality team left a work bag in her car parked outside her home overnight. The car was broken into and the bag stolen. The bag contained a Trust laptop and papers with names and some clinical information relating to approximately 100 children. All families have been informed. The incident was reported to the Information Commissioner s Office and investigation has commenced. Slips/trips/falls meeting serious incident criteria (4) During August and September four patients fell and sustained fractures. One fall concerned a child living at home who fell from a tilting toilet chair recommended by the OT team and supplied by Hertfordshire Equipment Services. The child sustained a fracture just above the knee and has a leg plaster in place. Three falls concerned adults, two of whom sustained a fracture of the hip (Langton ward and QVM) and one of whom sustained a fracture of the wrist (Potters Bar Community Hospital). The patient who sustained a fracture of the wrist has returned to the ward. The patients who sustained hip fractures were transferred to the acute trust for surgery. Investigation of all four incidents is currently underway. Abuse/alleged abuse of adult patient by staff (3) Three incidents concerned allegations of abuse by staff. One allegation was raised by a care home who expressed concern that a therapist had treated a patient behind a locked bedroom door. Investigation of this incident has concluded and there is no evidence of inappropriate behaviour. The therapist was new to working in the community and made poor decisions concerning the need for a chaperone which will be addressed through supervision. A patient at Gossoms End developed a pressure ulcer following the application of a full leg plaster which was rubbing on the patient s heel. It is suggested that the HCT member of staff who escorted the patient to the plaster clinic failed to effectively pass on advice which contributed to omissions in care. Investigation has not yet concluded. The E&NCCG passed on concerns from a GP following a conversation between the GP and a patient s family. The family were concerned about elements of the care their relative had received while at Herts and Essex hospital; the relative died from a cardiac arrest two days after being transferred from Herts and Essex hospital. Management of this incident is on-going. Deaths in custody (2) In August one prisoner was found hanging in his cell and was pronounced dead. In September another prisoner was found hanging in his cell, he was resuscitated but later died in hospital. Investigations have commenced. Serious Incident report 30/09/2015 Page 2

60 Board 12 th November 2015 Attachment B3 4. Learning from Serious Incidents 2015/2016 Inpatient falls In May a patient fell and sustained a fracture. The incident was reported as a serious incident and was later downgraded after information gathered demonstrated that reasonable preventative care was in place at the time of the fall. In response to this incident, a checklist has been developed (Appendix 1). The checklist is designed to capture a fuller analysis of the care and prevention of falls expected to be in place across HCT Community Hospitals. It is intended to assist the investigator in gathering and presenting information during investigation and will support sound and consistent decision making regarding whether a fall could reasonably have been prevented. More importantly the checklist will help identify when there has been an omission in care and therefore help focus on what changes need to be made and where the learning can be identified. During August-September two falls investigation reports were completed (ref 2015/19266 and 2015/20744). The outcomes and learning have been considered. Both patients who fell and sustained fractures whilst in our care had histories of frequent falls. One patient had advanced dementia and poor awareness; the other had been admitted into our care from an acute hospital where she had undergone surgery following a fall at home. Investigation identified that all reasonable preventative care was in place at the time of the fall and it is unlikely that the falls could have been prevented. However, at the time of the fall the Morse falls risk assessment had not been repeated weekly for one patient, although she was already on the falls pathway so this oversight would not have affected the care received. The learning is being taken forward by the falls champion and ward manager. Fluctuating mental capacity and DoLS An investigation earlier in the year identified that although a patient had a mental capacity assessment completed, the assessment had been completed during the day and the patient demonstrated fluctuating capacity and was often more confused at night. In response to this the Adult Safeguarding team has developed a Sharing Lessons in Practice to provide clarity regarding fluctuating capacity which was disseminated to all staff via the October Clinical Matters. In addition training has been adjusted and the Adult Safeguarding team has increased their presence in the community hospitals to support staff and patients when dealing with the complexities of mental capacity and DoLS. Deaths in custody Within this two month period two prisoners at The Mount died from strangulation. Both men were found in their prison cells with ligatures around their necks. Serious Incident report 30/09/2015 Page 3

61 Board 12 th November 2015 Attachment B3 Deaths in custody reported as serious incidents over recent years are as follows: Year Number of deaths reported as serious incidents (including natural and non-natural causes) Number of deaths from non-natural causes (all deaths were from strangulation) 2012/ / / /2016 (to30/09/2015) 2 2 It is unusual for two deaths to have occurred in one year and so close together. Whilst both deaths are currently being investigated as serious incidents, the Prison Healthcare team is reviewing recent deaths from hanging to ensure systems are in place to support healthcare delivery is as robust as is reasonably possible. Serious Incident Panel The SI Panel continues to meet monthly. With fewer serious incidents being reported it is intended that all serious incident reports will be presented at the meeting, with the Chief Nurse or Deputy, who chair the meeting, ensuring that learning from SI investigations is identified and taken forward to improve care. Examples of learning include: Recent investigation reports have identified that some patients have experienced missed or late visits where tasks communicated via SystmOne (electronic patient record system) have not been acted on and patient visits have not been recorded (nurse entered details of a patient visit but this was not recorded). The Quality Lead for Mobile Working has attended the SI panel and will be taking forward learning and actions following investigations associated with SystmOne/mobile working. The Team Leads within the Watford Integrated Community team continue to undertake a monthly dip test where they review the care of six patients, with or at risk of developing pressure ulcers, to provide assurance that all appropriate preventative care was provided. Discussion at the Serious Incident Panel identified that embedding this process in other teams would be beneficial. To support engagement in this initiative the Patient Safety team will promote the initiative with all teams via their Locality Managers using the positive experience reported by the Watford ICT. Pressure Ulcer prevention Although fewer pressure ulcer serious incidents are now reported the drive to ensure that patients receive appropriate pressure ulcer preventative care remains high. The Pressure Ulcer Prevention Working group has used information from previous serious incident investigations and Serious Incident report 30/09/2015 Page 4

62 Board 12 th November 2015 Attachment B3 developed a Sharing Lessons in Practice that was disseminated to all staff in October via Clinical Matters. Lessons shared include prevention, categorisation of pressure ulcers, equipment and case management. The Patient Safety Team continues to review all grade 3 and 4 pressure ulcers reported via Datix to ensure any indication of serious harm is identified and reported as an SI. All grade 3 and 4 pressure ulcers are reviewed and logged on a tracker to provide evidence that appropriate actions are taken when lapses of care have been identified. 5. Number of Serious Incidents reported by commissioner The number of serious incidents reported by commissioner is provided along with the number of contacts to provide contextual information. NB. The majority of SIs reported relate to falls in Community Hospitals. HVCCG has the highest number of Community Hospitals which is reflected in the SI s reported. Position for August &September 2015 Herts Valleys East & North CCG Herts CCG No. of new SIs declared during Aug & Sept No. of patient contacts during Aug & Sept No. of SIs per 1000 contacts West Essex CCG Local Authority Herts South, Midlands Area Team NHS England East Anglia area team , ,847 5,218 12,332 68,160 TOTAL 305, Cumulative position from 01/04/2015 to 30/09/2015 Herts Valleys East & North CCG Herts CCG Cumulative total of SIs declared West Essex CCG Local Authority Herts South, Midlands Area Team NHS England East Anglia area team TOTAL Cumulative no. of patient contacts 301, ,209 13,521 42,635 NHS England 166, ,918 Serious Incident report 30/09/2015 Page 5

63 Board 12 th November 2015 Attachment B3 No. of SIs per 1000 contacts Analysis of Serious Incidents reported The type and number of SIs reported from 01/04/2015 to 30/09/2015 is provided as a total against the new categories as defined on STEIS*. Cumulative information provides a clear overview concerning how frequently specific types of serious incidents occur and this in turn will help inform actions that may need to be taken. * STEIS = Strategic Executive Information System. STEIS is the national data base for reporting/declaring SIs. It is used and accessed by commissioners, DOH, CQC. STEIS categories changed 19/05/2015 in response to the NHS England SI Framework that became operational 01/04/2015. Category of Serious Incident as defined on STEIS* Number reported 2015/16 (as of 30/09/2015) Pressure ulcers meeting SI criteria 18** Slips/trips/falls meeting SI criteria 8 Sub-optimal care of the deteriorating patient meeting SI criteria 1 Abuse/alleged abuse of adult patient by staff 7 Treatment delay meeting SI criteria 1 HCAI/infection control incident meeting SI criteria 1 Death in custody 2 Information governance breach meeting SI criteria 1 TOTAL 39 Serious Incident report 30/09/2015 Page 6

64 Board 12 th November 2015 Attachment B3 ** 14 PU SIs were declared in April and May, before the new SI Framework criteria was applied. Whilst the new criteria would not necessarily support all 14 incidents being reported as serious incidents, retrospective changes have not been made and data for all incidents declared and logged on STEIS since 01/04/2015 will be included in this report. 7. Monitoring Monitoring of progress against expected standards continues through a bi-weekly report which is made available to the General Managers and locality managers. It is expected that information for individual serious incidents will be updated within an Internal Incident Review (72 hour) report followed by the Investigation (60 day) report and the bi-weekly progress report reflects these expectations. The report provides details of open SIs and identifies those on track, those where deadlines are pending (amber) and those where deadlines have been breached (red). The expectation is that General Managers and their senior manager teams use the reports to ensure management of serious incidents remains in line with expected timeframes. The progress report has been developed to reflect the importance of the action planning stage, where recommendations are developed into actions that ensure full implementation. This is in addition to providing information for senior managers to ensure that deadlines for the completion and submission of reports are met. In addition to the bi-weekly progress report, the timeliness of the completion of serious incident reports is monitored via the monthly Integrated Board Performance Report and monthly Business Unit Performance Reports. During August and September 2015 two Internal Incident Reviews (72hr reports) were returned two days late, seven were returned on time. Both delays were due to human error (oversight). Delay has not affected the investigations which commenced on time. Seven investigation reports were submitted during this two month period. One was submitted three days late due to an error in calculating the submission date. Information relating to open serious incidents has been reviewed to ensure calculations are correct. The organisation has a statutory duty to be open and honest with patients and their families following a notifiable patient safety incident (Duty of Candour). HCT expects that duty of candour requirements are met for all incidents reported as a serious incident. The service is expected to use a checklist (Appendix 2) to maintain a record of who has spoken with the patient/family and what their wishes are. The checklist is returned to the Serious Incident team as confirmation that they have met the statutory duty of candour requirements. Information is included within the bi-weekly progress report for review by the General Managers. 8. Serious incidents referred for closure or confirmed closed by the CCG During 2014/2015, HCT aimed to have 40 or less open SIs at any one time. With the introduction of the new criteria significantly fewer incidents now meet the serious incident threshold and as such fewer serious incidents are expected to be open at any one time Serious Incident report 30/09/2015 Page 7

65 Board 12 th November 2015 Attachment B3 At the time of writing this report (30/09/2015) 21 serious incidents remain open of which a clock stop has been applied to five and 12 are open pending completion of the investigation. One report has been submitted to the commissioner within the last few weeks and feedback is awaited. The remaining three serious incidents are those where the serious incident team need to review and work with the commissioners to ensure that either closure is agreed or actions are completed for closure to be supported. Number of SIs reported by Commissioner and those that remain open Number of confirmed SIs declared 2013/2014 Number of confirmed SIs declared 2014/2015 Number of confirmed SIs declared 2015/2016 (to30/09/2015) Number remaining open at 30/09/2015 East & North Herts CCG Herts Valley CCG Hertfordshire & South Midlands Area Team Local Authority West Essex CCG East Anglia Area Team Total Tricia Wren Deputy Director, Quality & Governance, Deputy Chief Nurse October 2015 Christine Stock Clinical Quality Manager Serious Incident report 30/09/2015 Page 8

66 Board 12 th November 2015 Attachment B3 Appendix 1 FALLS CARE CHECKLIST Date of Admission Was Morse completed within 2 hours of patient s admission? Y/N Score Was Morse score reviewed weekly in line with Trust Policy? Y/N Dates Score Was there a Falls Care Plan in place at the time of the fall? Y / N dd/mm/yy Is there evidence that the interventions identified in the falls care plan were implemented? Did the patient require increased supervision? Was additional supervision in place at the time of the fall? Y/N Y / N Y/N Details of Supervision dd/mm/yy If the patient required additional supervision which was not provided at the time of the fall, provide details below: List interventions in place to reduce falls risk, i.e. High/ low bed, sensor mats etc. Intervention: Y/N Date and Details Observable bed Equipment- High/low bed, sensor mat etc. Equipment had been checked as working Therapy Sessions for patients at high risk of falls Observation or Care Rounding Was patient on medication that increased risk of falls? e.g. benzodiazipines, night sedation, antipsychotics? If patient required the following, were they being used appropriately & close to hand at the time of fall Spectacles? Hearing Aids? Walking Aids? At time of fall, was the patient wearing footwear? Y/N Y/N Y/N Details Details Details Was footwear appropriate and well-fitting Y/N Details Was the ward fully and appropriately staffed at the time of the fall? (info from Ward M ger) Please state below, those staff rostered for the shift and those actually on the shift. Y / N Staff Rostered Staff actually on Shift Any other relevant information: Serious Incident report 30/09/2015

67 Board 12 th November 2015 Attachment B3 Assessment of this Fall Could this fall have been prevented? The Chief Nurse or delegated authority has reviewed this report and assessed the fall to be Preventable/Not Preventable Serious Incident report 30/09/2015

68 Board 12 th November 2015 Attachment B3 Appendix 2 Serious Incident Reference: Discussion undertaken by (name & title): Duty of Candour Prompt DUTY OF CANDOUR Y/N DATE Details & assurance (who discussed with patient, what was agreed & outcome of discussion, where is the information documented ) Was the patient/relevant person notified of the SI as soon as practicable? For most SIs this will be within 5 working days (a max of 10days in exceptional circumstances) Was an offer made to provide an explanation of the events which resulted in the incident and any other pertinent information? Record if the person declined the offer Has or will a written apology be sent the patient/relevant person? If requested, has or will updated information be provided as the investigation proceeded Has or will a copy of the investigation report be provided within 10 working days of the report being signed off? Has equity of access, equality and non-discrimination been considered when determining how to share information. Have full written records of meetings or other contact with the relevant person been maintained? DUTY OF CANDOUR AND SERIOUS INCIDENTS Serious Incident report 30/09/2015

69 Trust Board 12 th November 2015 Attachment B4 HERTFORDSHIRE COMMUNITY NHS TRUST Quarterly Complaints Report 1st July th September Introduction This complaints report provides the following: Information and analysis on complaints received by Hertfordshire Community NHS Trust between the period 1 st July th September Information on the performance of the service to meet the 80% agreed complaint response timescales. Actions taken by services in response to complaints received. 2. Summary analysis of Complaints received A total of 65 complaints were received during this quarter; 23 in July, 20 in August and 22 in September. The Trust made contact with 451,068 patients during this period, which equals 0.14 complaints per thousand contacts and is below the average for Aspirant Community Foundation Trusts (0.18). 47complaints have been closed and 18 remain open awaiting completion of investigation and subsequent response. 3 of the complaints received in this reporting period were graded as a category 3 using the identified risk matrix (Appendix 1) compliments were received in July, August and September. This equates to 5.11 compliments per thousand contacts. 1

70 Trust Board 12 th November Total number of complaints received: Attachment B4 Quarter 1 April-June Quarter 2 July-Sept Quarter 3 Oct-Dec Quarter 4 Jan -March 2015/ / / / / / Total 4. Overview Summary of complaints by theme and service: The number of complaints received has increased slightly this quarter with 65 received to date. A breakdown of complaints received by Business Unit in Q2 can be found in the supporting papers (H2). Overall review of complaint breakdown for this quarter demonstrates that Herts Valley Business Unit received 26% of all complaints, which demonstrates a decrease on Q1 (36%), while East & North Herts Business Unit received 55%, an increase on Q1 (30%). Children s Services have seen a decrease in the number of complaints received, from 34% in Q1 to 18% in Q2. Concern regarding the standard of care provided remains a constituent theme in this and previous reporting periods. There has been a slight decrease in the number of complaints regarding staff attitude, from 16% in Q1 to 12% in Q2. One of the themes emerging this year is the rise in complaints regarding Health Visiting Services. The Patient Experience Team has met with the Head of Children s Services to review the complaints and agreed that they will now be shared at the Children s SMT and learning points will be discussed. The Health Visiting Team recognise that they have a high volume of new Health Visitors in the service who may be less experienced in dealing with some of the complex and sensitive safeguarding concerns that arise. Actions are being taken to support new HVs such as communication training, safeguarding supervision and discussions with the University to ensure this is built into the current HV training. The Health Visiting Team is also undertaking further analysis to identify any further themes and learning. An increase in the number of complaints across the physiotherapy services has been noted this quarter. The Clinical Quality Manager in the Patient Experience team has met with the Therapy Service Lead and analysed the complaints in each of the four areas of the service 2

71 Trust Board 12 th November 2015 Attachment B4 to establish whether there are similar themes in each service area, identifiable root causes and measures that can be taken to prevent reoccurrence of similar complaints. Themes emerging following analysis include: Staff attitude/quality of care, patient communication with the service, patient information and expectation of service and waiting times. An action plan has been developed by the service manager which is being monitored via SMT. Immediate actions taken include addressing staff attitude with individuals, escalating the telecommunication problems at QE11, developing an electronic administrative process and requesting further resource from the CCGs to address the waiting times. A longer term project to improve the discharge pathways from acute to community services also commenced in October 15. Table1 Business Unit July 2015 August2015 September 2015 Q2 Total Complaints Herts Valley East and North Children s Specialist Children s Therapies Children s Universal Q2 Total Complaints Table2 Themes Number Received % of complaints Standards of Care 13 20% Children s Herts Valley Community 2 (HV and SN) 4 (ICT) 1 (HMP The Mount) Herts Valley Bed-based 1 (Langley) 1 (Potters Bar) East & North Community 1 (Adult SLT) 2 (ICT) East & North Bed-based 1 (QVM) Clinical Treatment 12 18% Communication 10 15% 1 (Paeds West Essex) 1 (Paeds) 1 (Nutrition and Dietetics) 1 (Langley) 1 (Acute Therapies) 2 (ICT) 1(MSK Wat & Dac) 3 (MSK Physio OT & West) 1 (MSK Physio E&N) 1 (HV and SN) 2 (Diabetes) 2 (Acute Therapies) 2 (MSK Physio E&N) 1 (MUSKAT) 2 (Herts and Essex Hospital) 3

72 Trust Board 12 th November 2015 Attachment B4 Themes Number Received % of complaints Attitude of Staff 8 12% Children s 1 (OT) 1 (WE Paeds) 2 (HV and SN) Herts Valley Community Herts Valley Bed-based East & North Community 1 (Langley) 1 (ICT) 1 (MSK CROPS) 1 (MSK Physio E&N) East & North Bed-based Date Appointment/Attendance 7 11% Admissions/Discharge Arrangements 5 8% Aids/Appliances/Equipment 4 6% Diagnosis/Misdiagnosis 2 3% Personal Records 2 3% Premises 1 2% 1 (Herts Paeds) 1 (HomeFirst) 2 (Acute Therapies) 1 (MSK CROPS) 1 (Neuro) 1 (Podiatry) 1 (Sopwell) 2 (Acute Therapies) 1 (HomeFirst) 1 (OT) 1 (ICT) 2 (Wheelchair) 1 (HMP The Mount) 1 (MIU) 1 (HV and SN) 1 (ICT) 1 (Langley) 1 (Herts and Essex Hospital) Failure to Follow agreed procedures 1 2% 1 (ICT) 4

73 Trust Board 12 th November 2015 Attachment B4 Table 3 Service Number of Complaints Number of contacts Complaints per thousand contacts Acute Therapies 7 24, Community Nursing & Integrated Teams East & North 7 130, Health Visiting & School Nursing 6 116, Community Hospital West 6 11, Community Nursing & Integrated Teams West 5 118, Children s Community Medical Services 4 2, Community Hospitals East and North 4 3, MSK Physio& OT West 4 13, MSK CROPS (Watford & Dacorum) 3 2, MSK Physio E& N /MSK Triage 3 17, Children s Occupational Therapy Services 2 3, HMP The Mount 2 N/A N/A Adult Diabetes Community Service 2 7, Wheelchair Service 2 N/A N/A HomeFirst Service East and North 1 10, HomeFirst Service West 1 2, MUSKAT St Albans & Hemel Neurological Rehabilitation 1 21, Minor Injuries Unit 1 2, Podiatry Service 1 18, Nutrition and Dietetics 1 9, Adult Speech & Language Therapy 1 5, N/A Not available on SystmOne 5

74 Trust Board 12 th November Red Flag Complaints Attachment B4 There was 3 red flag complaints received in Q2: HVCCG 1019: Family raised concerns regarding care provided to their father by the Watford Community Nursing Team, family feel that the care provided was sub-optimal and continued to their father s death. The incident was declared a Serious Incident (SI) and an the investigation identified that the possibility that the patient had sepsis was recognised by the nurses and discussed with the GP, however the patient declined admission to hospital preferring to stay at home. Throughout this time the community nurses were visiting for leg dressings and review has identified that at times care fell below expected standards. Three nurse visits were missed, there was poor communication with the patient about his care and when visits were changed the patient was not informed. In addition there appears to have been poor communication between the ICT and the Rapid Response Teams. These failings affected Mr RI s confidence in the nursing service and they must be addressed. A copy of the SI Report has been shared with the family and an action plan is in place. HVCCG 1026: Niece raised concerns regarding pressure ulcer care provided to her aunt and that she had not been updated in relation to the outcome of the SI. Apology provided that the SI Report had not been shared with her. The pressure ulcer has been declared as avoidable due to delayed provision of pressure relieving equipment. Poor documentation of wound and failure to ensure good communication between visiting professionals may have contributed to the break down in pressure areas. An action plan is in place and monitored via the SI panel. HVCCG 1066: Family raised concerns that their father fell whilst at Potters Bar Community Hospital sustaining a fractured wrist. The family contacted the Patient Experience Team as they were concerned that appropriate measures were not in place to prevent a similar incident happening again. Assurance has been provided of measures put in place to prevent any further incidents. The incident was declared a Serious Incident and the investigation is on-going. A copy of the SI Report will be shared with family once finalised. 6. HMP The Mount Complaints In Q2, 19 complaints were received directly by the Prison Healthcare Team and managed in Stage 1. 2 complaints were escalated to stage 2. Quarter 1 April-June Quarter 2 July-Sept Prison Healthcare Complaints Stage 1 Quarter 3 Oct-Dec Quarter 4 Jan -March 2015/ Total 6

75 Trust Board 12 th November Complaint Response Timescales Attachment B4 HCT works to an agreed response rate of 80% to ensure that all complainants receive a response within timescale. 100% of complaints were responded to within timescale in July, August and September as indicated below in Charts 1and 2. Charts 1 and 2 100% % complaints responded within timescale 2015/ % % of Red Flagged complaints against total number of complaints 2015/ % 96% 94% 8% 6% 92% 4% 90% 2% 88% July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Aug Sep 0% July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Aug Sep 8. Being Open 100% of all complaints were acknowledged either verbally or in writing within 3 workings days, and 100% of all complainants were offered the opportunity to meet with staff to discuss their concerns in more detail. HCT have held 5 Local Resolution Meetings to facilitate resolution of the complaint. 7

76 Trust Board 12 th November 2015 Attachment B4 9. Learning from Complaints. Key outcomes and actions taken to improve practice are captured for this period in the log of complaints (pages 10-25). Outlined below are some of the changes that HCT has undertaken to improve the patient experience as a result of patient complaints: The Women s Health Physiotherapy Service has reviewed its processes to ensure all patients are given relevant information regarding their condition, clear details of how to book a follow up individual appointment with a Women's Health physiotherapist if needed and a robust system to ensure information about the physiotherapy treatment is relayed back to the referring consultant team. The MSK Physio E & N Service are ensuring that all clinicians now record all hospital referrals on patient electronic records and patients are only taken off the list when they have been referred on to a consultant. The team is also looking at creating specific 'tasks' that cannot be removed until they have been dealt with and implementing a system to contact patients who have not responded to an onward referral to avoid patients falling through the systems. Herts & Essex Hospital has addressed the issue of inadequate communication with Princess Alexandra Hospital and transfer paperwork. They have also reviewed the process for flexed criteria admissions to ensure that patients receive therapy if clinically appropriate. The Diabetes Service has reviewed their appointment letters for Garston Clinic and now includes a map and directions for patients. The Welwyn & Hatfield Community Nursing Team has reviewed the allocation of urgent visits to ensure those most in need are seen promptly. The Children s OT Service in West Essex is reviewing their processes for ordering equipment and implementing a staff training programme 10. PHSO There were no complaints referred to the Parliamentary and Health Service Ombudsman (PHSO). However, in this quarter, HCT received notification of the investigation results of a complaint referred to the PHSO in Q4.The complainant s main concern surrounded the level of therapy input received at Danesbury and perceived lack of support and progress as a result of therapy. The PHSO did not uphold the complaint and supported the Trust response that appropriate care was provided. 8

77 Trust Board 12 th November Monitoring Attachment B4 The Patient Experience Team continues to have weekly complaints management meetings to ensure complaints are on target to meet agreed timescales and weekly update reports are shared with Business Units. A process is in place to monitor repeated complainers i.e. re-opened complaints and habitual complainants. These are identified and logged on Datix to ensure that the Trust maintains a record of all previous correspondence and actions agreed with the complainant. This element will be reported in future complaint reports to ensure Board members are kept informed. No repeat complainers have been identified this quarter. Protected Characteristics: The Patient Experience Team started capturing evidence to demonstrate that the Trust offers equal access to all groups of people who wish to make a complaint in line with the national directives to ensure people in the 9 protected characteristics groups are not discriminated against. In order to capture the elements of protected characteristics, each complainant is offered the opportunity to provide additional information. The charts below outline the responses received for Q2. Responses to all nine characteristics have been poor and the team are working on ways to improve uptake. No complainants identified themselves as disabled in this quarter. Complainants Gender Q2 2015/2016 Complainants Age Q2 2015/2016 2% Complainants Ethnicity Q2 2015/2016 White British Not Stated 3% Not stated 46% Male 25% Female 29% 98% Not stated 97% 9

78 Trust Board 12 th November 2015 Attachment B4 Complainants Status Q2 2015/2016 Patient 40% Relative 23% Friend 3% MP 2% Carer 32% 10

79 Trust Board 12 th November 2015 Attachment B4 Appendix 1 - Risk Assessment guidance sheet Consequence Scoring Matrix: Insignificant Minor Moderate Major Catastrophic Patient Experience / Complaints / Claims Compliance Confidentiality Injury/Harm (also see doc NPSA terms for grading patient safety incidents) Financial (insured/uninsured loss) Objectives and projects Patient Care Reputation Service Staffing Stress Informal complaint resolved within ward/department Any assessment, inspection or audit that highlights minor non compliances Minor breach of confidentiality. Only a single individual involved. Minor injury not requiring first aid or treatment Complaint peripheral clinical care to Any assessment, inspection or audit recommendation that indicates partial compliance or insufficient assurance with an element of a CQC registration standard Potentially serious breach. Less than 20 people affected or risk assessed as low, e.g. files were encrypted. Minor injury or illness. First aid or short-term medical treatment needed. Complaint involving lack of appropriate care. Claim 10,000-99,999 Any assessment, inspection or audit that indicates reduced rating. Report with challenging recommendations. Partial compliance or insufficient assurance for more than one element of CQC registration standard Serious breach of confidentiality & risk assessed as high, e.g. unencrypted clinical records. Up to 100 people affected. Injuries reportable to external agencies / statutory bodies (e.g. RIDDOR (3 day injury), MHRA etc.) Multiple complaints. Claim 100,000 to 999,999 Any assessment, inspection or audit that indicates enforcement action. Critical report with multiple challenging recommendations. Partial compliance or insufficient assurance for more than one CQC registration standard Serious breach with either particular sensitivity, e.g. sexual health details or up to 1000 people affected. Major injuries or long term incapacity / disability (fracture or dislocation of major limb e.g. leg / arm, amputation) Less than 1,000 1,000 to 9,999 10,000-99, ,000 to 999,999 1M+ Barely noticeable reduction in scope or quality. Less than 1,000 cost increase / schedule slippage. Unsatisfactory patient experience - readily resolvable No significant reflection on any individual or body. Media interest very unlikely Loss/interruption of service or business of less than 1 hour Short term low staffing level temporarily reduces service quality (less than 1 day) Stress symptoms (work related) are mild or temporary. Staff quickly recover Minor reduction in quality/scope. 1,000 to 9,999 budget / schedule slippage. Unsatisfactory patient experience not readily resolvable Damage to individual reputation. Possible local media interest. Loss/interruption of service or business greater than 1 hour and less than 8 hours Ongoing low staffing level minimal impact on service quality Stress symptoms can be selfmanaged and are one off response to unexpected stressful situation. 11 Reduction in scope or quality requiring client approval. 10,000-99,999 budget / schedule slippage. Mismanagement of patient care / minor breach of working practices Minor effect on staff morale. Damage to team/service reputation. Local media interest likely to go public. Loss/interruption of service or business greater than 8 hours and less than 24 hours Late delivery of key objective/service due to lack of staff (recruitment, retention or sickness). Minor error due to insufficient training. Ongoing unsafe staffing level(s) Stress symptoms are more frequent and show a pattern. Can be dealt with by workplace adjustments Does not meet secondary objective(s). 100,000 to 999,999 budget / schedule slippage. Serious mismanagement of patient care / significant breach of working practices Significant effect on staff morale Damage to organisation reputation. Adverse local media coverage lasting up to 3 days. Local MP concern. Loss/interruption of service or business greater than 24 hours and less than 1 week Uncertain delivery of key objective/service due to lack of staff (recruitment, retention or sickness). Serious error due to insufficient staff training Stress symptoms are frequently apparent and in danger of becoming chronic. Increasing staff sickness Multiple claims or single major claim - 1M+ Any assessment with a Zero rating. Significant lapse or noncompliance with statutory requirements (e.g. Major noncompliance with CQC registration standard). Severely critical reports. Risk of prosecution Serious breach with potential for ID theft or over 1000 people affected Death or major permanent incapacity. Never event Does not meet primary objectives. 1M+ budget / schedule slippage. Totally unsatisfactory patient care / serious breach of working practices Damage to NHS reputation. Adverse National Media coverage lasting more than 3 days. MP concern. DOH concern. Loss/interruption of service or business greater than 1 week Non delivery of key objective/service due to lack of staff. Very high turnover. Critical error due to insufficient staff training. Staff on long term sick leave with stress (work related) or physical illness associated with chronic stress. Suicide risk

80 Trust Board 12 th November 2015 Attachment B4 Table 2 Likelihood score matrix (L) What is the likelihood of the consequence occurring? The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used whenever it is possible to identify a frequency. Likelihood score Descriptor Rare Unlikely Possible Likely Almost certain Frequency How often might it/does it happen This will probably never happen/recur Do not expect it to happen/recur but it is possible it may do so Might happen or recur occasionally Will probably happen/recur but it is not a persisting issue Will undoubtedly happen/recur, possibly frequently Table 3 Overall Risk scoring = consequence x likelihood (C x L) Likelihood Likelihood score Rare Unlikely Possible Likely Almost certain 5 Catastrophic Major Moderate Minor Negligible Overall risk score is C x L = Risk score For grading risk, the scores obtained from the risk matrix are assigned grades as follows 1-3 Negligible 4-6 Low Risk 8-12 Moderate(Medium) Risk High Risk 12

81 Board: 12th November 2015 Attachment B5 TRUST BOARD Title: PLACE Programme 2015 Meeting Date: 10 th November 2015 Executive Lead: Author(s): For: Clare Hawkins, Director Quality & Governance, Chief Nurse Tricia Wren, Deputy Director Quality & Governance, Deputy Chief Nurse Ruth Bradford, Clinical Quality Lead, Patient Experience APPROVAL 1.0 Purpose & Recommendations 1.1 To inform the Board of the PLACE results achieved for HCT in 2015 and areas for improvement 1.2 To ask the Board to approve the report and note the actions taken to achieve improved scoring for the next assessment in Executive Summary 2.1 Patient Lead Assessment of the Care Environment (PLACE) are undertaken nationally in all NHS in-patient care provider units. This is the third year of the National PLACE programme. 2.2 The assessments focus on the environment in which care is provided, which includes non-clinical services such as cleanliness, condition and maintenance, food, hydration, and the extent to which the provision of care with privacy and dignity is supported. A new dementia assessment was added this year. 2.3 The results of the 2015 programme highlights that HCT has improved in 19 areas of assessment but 12 areas achieved a reduced score since 2014 and one area has remained the same. 2.4 Low scores were achieved in the assessment of privacy and dignity and the new Dementia element that was added this year. A working group and action plan is in place to address the concerns identified and improve the patient experience.

82 Board: 12th November 2015 Attachment B5 3.0 Relevant Strategic Objective(s) / Strategies 3.1 Trust Strategic Objectives 2 We will improve clinical outcomes and enhance patient safety 6 Impacts on all Strategic Objectives 3.2 Links to: Quality Strategy 4.0 References, Appendices & Attachments References: Attachments: The 2015 PLACE Programme Author(s) of paper: Tricia Wren, Deputy Director Quality & Governance/Deputy Chief Nurse Ruth Bradford, Clinical Quality Manager, Patient Experience October 15

83 Board: 12th November 2015 Attachment B5 Sign Off: To be completed as part of papers to Executive Team, Board Committees and Board Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year): SMT/Exec October 2015 Healthcare Governance Committee November 2015 Issues arising from committee consideration First draft discussed Comments and amendments added Data Quality Statement By way of assurance to the Board, and in order to inform discussion / decision, the accountable executive director confirms that to the best of their knowledge, and subject to any exceptions identified, data contained in this report is: Data Quality Domain Complete Accurate Relevant Up To Date Valid Clearly Defined Description Comments / Exceptions / x Information is as comprehensive as possible to inform the board and no significant known facts or statistics which may influence a decision are omitted. As far as can be reasonable ascertained or validated, information in the report is accurate. Information contained in the report is relevant to the matters considered in the report. Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written Information is presented in a format which complies with internal or national models or standards The meaning of any data in the report is clearly explained Executive Director Sign-Off This paper has been approved by the accountable executive director who is satisfied that (i) the implications for risks, (ii) quality/service/regulatory impacts and (iii) resource implications, have been considered. Clare Hawkins Director of Quality & Governance/Chief Nurse Company Secretary Sign-Off (Board papers only) This paper has been quality control checked and approved by the Company Secretary / x

84 Board: 12th November 2015 Attachment B5 The 2015 PLACE Programme Introduction The Patient-Led Assessments of the Care Environment (PLACE) are undertaken nationally in all NHS inpatient care provider units. This is the third year of the National PLACE programme. The assessments focus on the environment in which care is provided, which includes non-clinical services such as cleanliness, condition and maintenance, food, hydration, and the extent to which the provision of care with privacy and dignity is supported. A new dementia assessment was added this year. In Hertfordshire Community NHS Trust (HCT), 8 sites with bed-based and outpatient facilities were assessed as part of this programme, with visits undertaken between March and June The assessment teams were made up of at least 50% of volunteers (Patient Assessors) drawn from Hertfordshire Healthwatch. This report will provide information about the assessment team, provide tables to compare results from the 2 previous years assessments and analyse HCT performance in the 4 key areas highlighting reasons for reduced scores. Examples are provided of actions to be taken to address the areas of reduced scoring and improve patients overall experience of care. The Assessment Team Volunteers from Healthwatch Hertfordshire, who had participated in last year s PLACE programme, were involved again this year. There were 8 volunteers in total from Healthwatch. One non-executive director and a member of staff from the Department of Health attended one PLACE assessment each as observers. The Clinical Quality Manager for Patient Experience and two Clinical Quality Leads from HCT were the staff members of the assessment team and one member of staff from NHS Property Services participated and took a coordinating role in each assessment. A training session was undertaken at Healthwatch and clarification of the expectations and commitment needed by Patient Assessors was discussed at this session. Results of the 2015 programme The PLACE assessment covers 4 key areas which are scored out of 100%. The information in Table 1 below sets out the results for each of the sites and compares 2015 results with 2014/2013 results. 1

85 Board: 12th November 2015 Table 1 Attachment B5 KEY Improved from 2013 & 2014 Decreased from 2014 Improved from 2014 after decreasing from 2013 Cleanliness Food and Hydration Potters Bar Community Hospital (ward and outpatients) Gossom s End (ward and outpatients) The Runcie Unit (Sopwell,Langton,RAU) St Peter s Ward Queen Victoria Memorial Hospital Langley House Herts & Essex Hospital (ward, children s outpatients and MIU) Danesbury Unit Privacy, Dignity and Well-being Condition, Appearance and Maintenance Table 2 compares HCT scores against the national averages for community hospitals No overall score for all organisations undertaking PLACE in 2015 has been released to enable further analysis. Table 2 Com hospital National QVM Herts and Essex Potters Bar St Peters Langley Gossoms End Runcie Unit Danesbury Com hospital National Langley Herts and Essex Potters Bar QVM Danesbury Gossoms End Runcie Unit St Peters Cleanliness 94% 96% 98% 100% Privacy, dignity and wellbeing 0% 20% 40% 60% 80% 100% Com hospital National Herts and Essex Potters Bar St Peters Danesbury QVM Gossoms End Runcie Unit Langley Com hospital National QVM Danesbury Langley Herts and Essex Potters Bar Gossoms End Runcie Unit St Peters Food 0% 20% 40% 60% 80% 100% Condition, maintenance and appearance 70% 75% 80% 85% 90% 95% Com hospital National St Peters Herts and Essex Potters Bar QVM Danesbury Runcie Unit Gossoms End Langley Dementia 2 0% 20% 40% 60% 80%

86 Board: 12th November 2015 Attachment B5 HCT 2015 performance - Summary and Actions The results of the 2015 programme highlights that although 12 scores have reduced since 2014, 19 scores have improved and one has remained the same (Table 1). The final scores are presented as an overall mark for all areas on each site and therefore include the outpatient clinics where applicable. Cleanliness: When HCT is compared against other community hospitals, 7 out of the 8 wards scored higher than the national average for community hospitals, with Runcie Unit scoring lower by only 0.63%. Examples of the concerns which impacted on the scores included stained seating pads in the reception area, dirt under cushions on bedside chairs and dust on high surfaces and fire extinguishers. Food: Scores were lower than the national average across all bed-bases this year. However QVM score had improved slightly since 2014 Herts & Essex scores were significantly improved by 19.67% in comparison to last year s scores. Langley House was below the national average by 17.36%. Langley produces its meals on site. Catering services are contracted out at the other hospitals and meals are delivered, with the exception of Gossoms End who cook-serve on site. The inpatient survey completed by 19 patients in Langley in March indicated that 89.47% of patients rated the food as very good, 5.26% as good, and only 5.26 % as poor. This is more reflective of the scores from PLACE in 2013 and The 5 PLACE assessors were only able to report on the food they tasted on the day of the assessment. The food scores were reduced across all wards for a variety of reasons: Finger food only being available as wraps and sandwiches Patients needs are met within 24 hours of admission (cannot be guaranteed immediately) Patients choose 2 meals ahead Patients do not always have option of soup, sandwiches and salad as part of their main meal Patients requiring special meals only have option of one hot food choice Mealtimes in some wards commenced before 7.30am for breakfast and before 5.30pm for evening meal Menus were not available in different languages or easy read formats The Trust needs to provide evidence of auditing meals using the dysphagia diet food descriptors or similar tool Patients were not always offered hand wipes and if they were on the tray, they sometimes had difficulty in opening the packet. The organisation needs to evidence that they are fully compliant with assessing its food procurement and catering practices against the government buying standards for food and catering services. More food choice needs to be available 24 hours More choices of drinks need to be available More choice for patients on special diets More choice of breakfast Different formats of menu need to be available such as easy read, large print Chilled water needs to be constantly available do patients who can access it independently can do so. (water was available at all times in jugs at bedside) 3

87 Board: 12th November 2015 Attachment B5 There needs to be clear information at ward level advising patients how to obtain advice on food allergens. Actions The information has been shared with the Nutrition and Dietetic Leads to review and produce an action plan for all the bed bases to address the issues. Privacy, dignity and wellbeing: The reasons for reduced scores in the area of privacy, dignity and wellbeing are consistent across the 8 wards. The concerns relate to lack of internet access for patients, no access to snacks for relatives during the day and night, facilities at the bedside only for relatives to stay overnight, access to shared TV in communal areas rather than at the bedside, and the Trust s current position with Equality duty. The overall scores were also affected by wards not having treatment rooms for minor procedures and dressings. These are carried out at the bedside with the privacy of curtains around the bed. In outpatient clinics scores are reduced because patients would need to leave the consulting room and walk back past the waiting area. Specific to Danesbury is the lack of an available multi-faith prayer room or quiet room and a room designated exclusively to accommodate family visiting. Specific to Potters bar is the external social area for patients to access outside facilities. This was not well kept and had cigarette butts and litter visible in the garden. At Gossoms End there are trip hazards in the external social spaces and ramp does not have non-slip surface. There is also no hearing loop. At St Peters no social space is available externally and in the day room a large area is used for storage making it an unwelcoming environment for patients. At Runcie the external social space is not well maintained and the access door is locked. The ward social space is not furnished to provide a relaxing environment. Condition, appearance and maintenance: Scores were higher in 6 out of 8 wards since last year. Potters Bar score was reduced by only 2.08% and Gossoms End by 2.4%.There were some issues which were applicable to more than one site and affected the scores: Organisation needs evidence that it has assessed the travel needs of patients and visitors to and from the site and made appropriate arrangements to provide for these Some sites charge for parking - St Albans Hospital, Hemel Hempstead and Herts & Essex Parking machines, not pay on exit, parking machines not in covered area, coins only and no change available Information regarding concessionary parking not prominently publicised Visitor and patient parking not located closer to main entrance than staff parking Spaces not wide enough or clearly marked - Potters Bar, St Peters, Runcie 4

88 Board: 12th November 2015 Attachment B5 Internal and external stairs do not have high visibility nosing - Gossoms End, Potters Bar, Herts and Essex Some of the concerns identified have already been addressed by the Trust (Appendix 3). Dementia: The dementia assessment was an additional requirement for PLACE in 2015 and sets out a new framework for dementia friendly environments (Appendix 4). HCT scored lower than the national average for community hospitals across all the wards. The reasons for reduced scores were consistent across all sites with a few exceptions: The flooring was not a matt finish apart from at Danesbury and Potters Bar. The flooring was not noise reducing /noise absorbent apart from Danesbury, Potters Bar and Gossoms End. Prior to next year s PLACE there needs to be clarity about how this is measured. It was a subjective measure by the assessors this year The flooring was not a consistent colour and without speckles, stripes, swirl or pebble effect apart from QVM, Langley and Herts & Essex The lighting from the windows could make the floor appear wet or slippery with exception of Potters Bar and Gossoms End At Gossoms End the floor did not contrast with the walls and furniture Signs to toilets could not be seen from all areas of the ward apart from at Potters Bar The toilet signage at Danesbury, Langley House and Herts & Essex was not consistent, clear and did not use both pictures and text Toilet doors were not painted in a single distinctive colour to differentiate from other doors and doors to staff areas were not disguised Toilet seats, flush handles and rails did not contrast with walls and floor at Gossoms End, QVM, Langley House and Herts & Essex. Taps were not clearly marked as hot and cold at Gossoms End, QVM, Langley House and Herts & Essex Danesbury and Langley House do not have easy to read signs on doors - text is vertical and at Langley House the signs were not hung at an easy to read height The ward name was not prominently displayed apart from Danesbury and Potters Bar Large clock faces and day and date were not clearly visible in all areas Strong wall patterning had not been avoided at Potters Bar, Danesbury and Langley House which all had murals It was not possible to cover mirrors Actions Ward Managers have action plans to address some of the issues. For example, clear clocks need to be easily visible in all areas, as well as day and date, and a means of covering mirrors as required. At Potters Bar the Ward Manager already has a folder for use with dementia patients, which includes day and date information. 5

89 Board: 12th November 2015 Attachment B5 The Estates Team has an action plan to address the issues such as replacing toilet seats so that they contrast with the walls and floor and reviewing and replacing signage. There are other concerns which need to be analysed and considered carefully in terms of cost and potential benefits. For example, removal of the murals to meet the PLACE dementia criteria of avoidance of strong patterns, replacement of flooring to meet the criteria, disguising staff only areas by painting doors in the same colour as the walls, repainting /replacing toilet doors in order that they contrast with other doors and replacing taps so that they are all of a consistent design with clear hot and cold markings. The PLACE action plans were shared with the Locality Managers, the Ward Managers, the Clinical Quality Leads and the Estates Team immediately after each assessment. The action plans will be monitored through the quarterly quality reports and the bi-monthly Patient Safety and Experience Committee Assessment of the process In September a follow-up meeting with Healthwatch was undertaken by the HCT PLACE lead so that both Healthwatch and HCT could feedback on any concerns and successes of the 2015 programme. The feedback was positive in relation to how the assessments had been led and organised and the relationships between volunteers and the staff members of the assessment team. Suggestions for next year include: Deliver the PLACE training jointly with the other provider services in Hertfordshire as the Healthwatch volunteers also assist with PLACE for East & North Herts NHS Trust, West Herts Hospitals Trust and Hertfordshire Partnership Foundation Trust. Ward Managers attend the training in order to have a more in depth understanding of the purpose and process of the assessment. Representation from Trust Board at the training session All HCT staff are given information about PLACE through HCT Communications Pre-place quality assurance visits to be completed by HCT Quality and Estates staff Conclusion There were no concerns across the inpatient sites regarding cleanliness, and half of the sites scored above the national average for community hospitals. The food scores fell below the national average in 6 out of 8 sites. The reasons have been identified and are addressed in the action plan. The condition, appearance and maintenance scores have in the main improved since last year in 6 out of 8 sites. However more actions are required to improve the scores to meet the national average for community hospitals. 3of the inpatient units are on sites not owned by HCT. All repair and maintenance issues are reported to the host sites contractor as soon as possible. 6

90 Board: 12th November 2015 Attachment B5 The scores in relation to privacy, dignity and wellbeing were disappointing and, following analysis of the issues affecting the scores, a detailed action plan is in place. The dementia part of the assessment was more detailed this year. The national dementia score for community hospitals is 78.2%, which is significantly lower than all other areas scored in the PLACE assessment. HCT scores have provided us with a baseline to work from and with a Trust focus on dementia, there is plenty of scope for improvement. Looking ahead to PLACE in 2016, there will be changes to the delivery of PLACE training as requested by Healthwatch. This will include an increased number of staff assessors and clarity for all ward based staff about the purpose and process of the assessment. A PLACE 2016 planning event will be arranged for all HCT staff participating in the process prior to the start to ensure consistency in the assessment and marking process, and to identify where further clarity is required from Health and Social care Information Centre in relation to any part of the assessment criteria.. Tricia Wren Deputy Director Quality & Governance / Deputy Chief Nurse Ruth Bradford Clinical Quality Manager, Patient Experience September

91 Board: 12th November 2015 Appendix 1 Attachment B5 Table 3 - Actions to improve cleanliness Ward Issue Actions Potters Bar Reception area stained seat Reported to the cleaning pads, outpatient area damage contract manager and to fabric on examination couch, service lead for dusty high surfaces physiotherapy. Included Gossoms End Runcie St Peters Physio Outpatient Gym, mud on floor and dirty sink, 2 stained roller blinds on ward Bedside seating- dirt under cushions, ceiling tiles dirty, dusty door frames, dusty radiators in corridors, dead flies in lights Gym curtains need changing, high level window ledge dusty QVM 100% score Nil Langley Low surfaces and fire extinguisher dusty in reception and main corridor Herts and Essex 100% score Nil Danesbury Dusty low surfaces in therapy and dusty fire extinguisher on action plan Reported at time to staff and issues immediately resolved Reported to cleaning contract manager and ward manager requested ceiling tiles and light cleaning via estates help desk. Reported to cleaning services manager and immediate action taken Reported to cleaning supervisor and immediate action taken Reported to cleaning supervisor and immediate action taken 8

92 Board: 12th November 2015 Appendix 2 Attachment B5 Table 4 - Actions to improve dignity, privacy and wellbeing Issue Action Lead/person responsible Television access Review TV options for patients at each unit All communal areas to have TV available Ward Managers/ Estates Manager Dec 2015 Radio access Headphones for radios Seating not available in variety to meet all needs. Internet access Facilities for family to stay overnight Equality Duty e.g. hearing loops Room designated exclusively for family visiting Multi faith prayer room Access to snacks for relatives day and night Service leads to apply for charity funds to purchase radios to be made available on request to patients Disposable headphones to be ordered for all wards Bariatric chairs can be hired as required Audit of seating in all areas to be carried out Scope availability of Wi-Fi in all areas and ability to make available for patients Provision of available local accommodation to be included in patient information packs on each ward HCT is in process of training key staff to undertake access audits and ensure all reasonable adjustments have been made Managers to review ability to make a room available for family visiting if required Manager to identify room to be made available for prayer when required Instruct catering contractors to ensure that Long shelf life food is always available for patients and relatives Ward Managers Dec 2015 Ward Managers October 2015 Ward Managers/Estates Manager October 2015 Head of IMT Nov 2015 Ward Managers Dec 2015 Estates Team Dec 2015 Ward managers Nov 2015 Ward Managers Dec 2015 Ward Manager/Estates Manager Dec

93 Board: 12th November 2015 Appendix 3 Attachment B5 Table 5- Actions to improve condition, appearance and maintenance Ward Issue Action Lead Completion Potters Bar Rubbish under stairwell in car park Reported to estates team and rubbish removed Estates Manager Completed Sept 15 No crossing marked from disabled car parking to main building Cars parked on double yellow lines Cigarette butts and litter and a raised paving slab in garden. Gossoms End Internal décor toilet on ground floor has black tape around inspection panel St Peters Crossings not clearly marked QVM Langley Herts and Essex Hand rail placed too close to wall so that anyone suing it would graze back of hand Internal décorwalls and door frames badly scuffed and plaster damage Internal signagesigns are placed vertically making it a challenge for some patients to read Ward internal plaster damaged Uncovered linen cage at entrance to a 6 bedded As above To provide information to patients and visitors about alternative parking options off site through Trust website Reported to estates team Panel has been replaced Raised with WHHT estates team Raised with WHHT estates team Reported to estates team and quote requested for works Estates team have included in bid for capital funds. Quote to be requested Reported to Manager of PFI Ward manager informed and linen cage 10 Estates Manager HCT Communications Team Estates Manager Estates Manager Estates Manager Estates Manager Estates Manager Estates Manager NHS PS/Semperian Action added to capital bid (40k) Dec 2015 Completed August 2015 Completed August 2015 Responsibility of WHHT Responsibility of WHHT Dec 2015 Dec 2015 Dec 2015 Completed

94 Board: 12th November 2015 Attachment B5 Ward Issue Action Lead Completion Danesbury bay Markings of hot and cold on taps have worn off Signage not clear from reception to ward relocated Ward manager asked to report through estates helpdesk Site reviewed and a large sign is already available in reception NHS PS/Semperian No further action required Dec 2015 Completed 11

95 Board: 12th November 2015 Appendix 4 Attachment B5 PLACE Assessment Framework for Dementia 12

96 Board: 12th November 2015 Attachment B5 13

97 Board 12 th November 2015 Attachment C1 HERTFORDSHIRE COMMUNITY NHS TRUST Report from the Director of Operation s Report November Introduction This paper provides an update from the Director of Operations to highlight key issues of interest / information to the Board. 2.0 Link to Trust Strategic Objectives This paper relates to Strategic Objectives: 1. We will support the people we serve to manage their own health and wellbeing 2. We will improve clinical outcomes and enhance patient safety 3. We will support the substantial expansion of community services through the delivery of excellent core services for adults and children and the development of ambulatory services 3.0 Recommendations The Board is asked to note the content of this Report. 4.0 Service Delivery and Performance 4.1 Children s Services Children s services have continued to work hard in the on-going delivery of services. The integrated management and clinical leadership structure for occupational therapy and physiotherapy is implemented; significant vacancies exist within the structure but the recent appointment of an interim service manager will strengthen the service and support recruitment into the remaining posts. The new PALM service was formally launched on 20 th October; the event which enabled attendees to see many practical examples of work with CYP with Autism or learning disabilities was very positive and well attended by children and young people, their families and commissioners You're Welcome accreditation was achieved by the school nursing service which is a National quality standard for services for young people. As the new school year starts, the service has commenced delivery of the new nasal flu vaccination programme, immunising 500 children per day. In addition the service is now providing a core offer to all Hertfordshire schools including termly liaison and the use of a health needs profile to determine the service offer for each school, National Child Measurement Programme, Year 6 PSHE, Oral Health and screening and vaccination programme. The community paediatric service in West Hertfordshire continues to experience demand which exceeds capacity and achieving the 18 week RTT in this service remains a challenge, despite running additional clinics. In September the service saw 81.3% of patients within 18 weeks (target 95%). Additional funding to address the on-going pressure of demand and the investment required to sustain service delivery in the West Herts Community Paediatric Service has not been agreed by HVCCG and discussions continue as to how this is to be managed going forward. I attended the AGM for West Essex CCG, which was also a celebration event where a range of awards were given. I was pleased to see Jenny Priest and the Children s Community 1

98 Board 12 th November 2015 Attachment C1 Nursing service won a Best of West award for their implementation of paediatric high impact pathways, a fabulous achievement. On the 1 st of October a wide range of staff from children s services came together to plan the future delivery of services. It was an excellent day where all teams demonstrated how they could improve services for the families they serve through creative use of skill mixed teams, simplifying processes, removing things that don t add value to the service users and by using technology. 4.2 Adult Services Adult services continue to work hard in the on going delivery of services. HCT continues to work with ENH CCG developing plans to re-align HSAU (Hyper Acute Stroke Unit) pathway from PAH and repatriate all E&N Hertfordshire patients to E&N Herts services for their on-going rehabilitation. It is expected the formal pathway change date will be April 2016 although all providers have already started mobilisation of project with associated recruitment drive to achieve necessary uplift in resource ICT turnover ranges from 11.6% (12.8%- Sept board report) in Dacorum to 30.6% (30.8%) in the small Royston team - with an average of 15.2% (17.6 %) across the county. Absence levels range from 0.17% (0.14%) in Lower Lea Valley to 6.79% (7.4%) in North Herts with an average of 3.7% (3.86%) across the county. All localities that reported at the BUPR had a friends and family result of over 90%, demonstrating how well the community regard this service. Within the BUPR format we are now able to monitor working establishment which represents the percentage of budgeted WTE actively working, accounting for vacancies, sickness and maternity leave. This metrics allows for the most accurate picture of working resource and was c80% of budgeted staff available for active duty in September 15. Hertsmere (69%), Royston (69%) and North Herts (75%) ICT s have the lowest working establishment ratios and are working with HR, NHSP and local teams to ensure the resource gap is mitigated through use of temporary staff and permanent recruitment. Alongside some community nursing service recruitment challenges, the MSK, palliative care and diabetes nursing service have also faced difficulties in recruiting specialist staff with the right experience. Services have plans in place to manage the staffing challenges. The diabetes services has appointed an interim service manager to provide the extra capacity to drive forward continuous improvement in the performance of this service and recruit to vacancies- three temporary staff have joined the service. This week saw the retirement of diabetes nurse consultant Liz Gregory after 43 years working in the NHS. The service has risen to the challenge to revise the structure of the service going forward to best meet the needs of clients with two clinical lead posts. The wheelchair service is in the process of being transferred to Millbrooks, they took on the collection and delivery component on the 1 st of November. The assessment and procurement functions also move to them on the 1 st of April. This service remains under pressure to meet the demands placed upon it in the interim period within the allocated budget, commissioners are fully informed of this. 5.0 System Resilience Community Hospital services continue to be challenged by the pressures within the wider health and social care system. There has been an increase in attendance at MIU at Herts and Essex hospital; the team are working with E&N CCG and HUC to explore how the service could be extended to 7 days with better integration to the enhanced primary care walk in service. 2

99 Board 12 th November 2015 Attachment C1 Variation in the length of stay and the number of patients delayed being discharged persists with East and North performing far better with better availability of home care. Availability has improved in Herts Valley with a cut in the number of patients delayed by approximately 20% over the last month. Work continues to address outstanding recurrent delays. We are attending an Emergency Care Improvement Programme on the 5 th of November to explore what further improvements can be achieved. ALOS - Stroke ALOS - Non Stroke ALOS Total DToC - NHS DToC - Social DToC Total East and North September % 4.1% 12.2% October % 7.3% 13.9% Herts Valley September % 16.9% 28.0% October % 13.6% 25.4% Please note The DToC is provisional as needs validating by Social. Staffing vacancies have for some time been a particular risk being managed in the bed bases, leading to high levels of temporary staff to achieve safe staffing levels. This has been made more challenging by the increased complexity of patient s needs, for example a patient needing close supervision as they are confused, plus size patients require several staff to safely move/ mobilise them and by the long lengths of stay of some of the more complex patients because of the discharge delays. A review of the risks was undertaken and a recommendation made to temporarily close Gossoms End hospital, re deploying the staff to other units. This was approved by The Trust Board and with the excellent planning of the clinical services manager successfully completed on the 28 th of October. The majority of patients were discharged with a few transferring to alternative bed bases to complete their rehabilitation. Commissioners supported this action and have planned to provide additional enablement beds within residential care settings. I visited St Albans City hospital last week to thank the staff for how professionally they had undertaken the moves and maintained high standards of care. This will result in significantly lower levels of temporary staff being required which is better for the patients care, their experience and the working environment for teams. We continue to have four extra neuro beds based at Langley house to assist in meeting the needs of particularly stroke patients in the area. The Rapid Response service for St Albans and Harpenden, has had a soft launch this month with a full launch in the next month. This will assist in preventing admissions to hospital and rapid discharge from hospital. There is now a rapid response service in three of the four localities in Herts Valley delivering integrated service provision that has been demonstrated to make a difference through the integrated approach and working in partnership with primary care. I have already received a staff story of how rewarding it is to be part of such a high quality and responsive service. We attended a panel review of our emergency planning and resilience arrangements and plans and received very positive feedback. 6.0 Partnership Working The work of the adults Integrated Care Programme boards continue, in Herts Valley the programme is being reviewed to take on the learning from the multi specialist team (MST) approach and care coordination in the light of the changes set out in Your Care Your Future. 3

100 Board 12 th November 2015 Attachment C1 In East and North Herts key initiatives are underway: Shared standards for access to services across providers The Midos service data base has a soft launch in November enabling referrers to see all services available The rapid response integrated team is being recruited to with a planned launch in December to help preventing unnecessary admissions for patients with the priority conditions; dementia, respiratory, urinary tract infections, dehydration, requiring IV s. This service will join up with other similar services e.g. frailty care, overnight nursing service, complex care premium care homes, respiratory nursing service to optimise what can be achieved. All of these changes have been developed with primary care. We have also attended primary care TARGET events in Stort valley and villages, Upper Lea Valley and Welhat to further develop an ongoing working relationship in the planning and delivery of services. Children s services are working very closely with CAMHS to improve access to services and deliver a more integrated approach which will improve the child and family experience as well as being more cost effective. 7.0 Transformation Examples of areas of focus for the transformation and business management team: A dedicated transformation manager will be supporting the implementation of the End of Life, strategy as this is a priority area for HCT. A successful away day was held with the clinicians. Actions from the day include working on reaping the full benefits of integration with the ICTs and considering how HCT can develop the clinical nurse specialists of the future. The Child Health information service is exploring ways to increase the automation of its processes and assess the benefits of the approach. Potential sources of funding have been identified and business case currently is being drafted to develop an electronic red book for families to hold information about their children. A review of customer services is underway to scope opportunities for enhancing provision, an improved customer experience and deliver better value for money. Support in the mobilisation of the health service contract in The Mount Prison including performance reporting, governance arrangements and service improvement and development. Current priorities include: o The implementation of SystmOne across all services o Reducing the performance reporting burden on the service through more effective systems and processes Mobile working connect disconnect approach enhancing access to records even when connectivity to the network is limited. Rolling out of the capacity and demand tool for ICT s to test how is informs and enables more effective service delivery. 8.0 Operational Risks and challenges Adults and Children s Services: Workforce levels (on-going) - Specialist Palliative Care service, ICT s, Community Paediatrics, Continuing Care, prison medical staffing, School Nursing (North Herts and Wel/Hat), Children s Speech and Language Therapy, Children s OT and physiotherapy, Diabetes and Community Children s Nursing. HV BU funding of safe staffing for DoLS and plus size patients and escorts. Winter resilience bids roll out. 18 weeks performance in Community Paediatrics. Wheelchair Service transfer to a new provider, and to meet levels of demand within service funding. Poor transfers to HCT bed based services. 4

101 Board 12 th November 2015 Attachment C1 Arrangements for GP cover at HMP The Mount Where there are small services e.g. eye service 4 staff, minimum staffing levels have been set and the continuity plans reviewed to ensure that services are well managed at times of staffing absence/ vacant posts. There are some areas; particularly very small specialities which we will review with commissioners in the coming months to agree how they are best supported going forward, The organisation achieved its target of reaching mandatory training levels by the end of September; all services are working to maintain these levels. Following the recent CQC inspections actions plans were developed to respond to the areas that needed to be strengthened. Services are leading on the areas relevant to them and driving them forward with reporting through to the Chief Nurse. 9.0 Linked Documents IBPR HLRR BUPR assurance All Directors board reports Julie Hoare Director of Operations November

102 Board 12 th November 2015 Attachement C2 TRUST BOARD Title: SUMMARY OF INTEGRATED BOARD PERFORMANCE REPORT (SEPT2015) Meeting Date: 27 TH SEPTEMBER 2015 Executive Lead(s): Author(s): For: PHIL BRADLEY, DIRECTOR OF FINANCE ROSHAN JHOREE HEAD OF BUSINESS UNIT INFORMATION NOTING 1.0 Purpose & Recommendations 1.1 This paper provides the Trust scorecard and headlines from the Integrated Board Performance Report for September The full report is included under section (H) Supporting Papers. 1.2 The Board is requested to note the Trust scorecard and headlines of the Integrated Business Performance Report. 2.0 Performance Highlights & Areas for Board Review The September scorecard demonstrates continued strong performance by the Trust across a number of metrics. HCT continues to comply with key national level targets such as Minor Injuries Unit waiting times and 18 weeks. More detailed analysis and actions taken are provided in the exception reporting sections of the HVHC domains. Performance highlights No MRSA cases reported in September. All School health programme measures achieved for 14/15 school year. Mandatory training levels increased to 93% in September and above the 90% target HCT committed to achieving. Stroke ALOS on target and below thresholds. Areas for board review One C.diff case reported in September at QVM Community Hospital and above the threshold for the year to date. Children s Safeguarding Levels 1, 2 3 below new target of 95%. HCT were achieving previous target of 90%. 18 week Pledge 2 at 96.6% and below 98% target Smoking Cessation indicators all below target.

103 Board 12th November 2015 Attachement C2 DTOC rate above the 5% threshold for third consecutive month with 10.2% recorded in September. Non-Stroke ALOS above thresholds in September. Patients discharged on or before Estimated date of discharged is 57% in September against 90% target. Staff turnover at 13% and over the 12% threshold. DTOC rate above the 5% threshold for second consecutive month with 7.6% recorded in July Patients discharged on or before Estimated date of discharged is 66% in July against 90% target Staff turnover at 13% and over the 12% threshold. 3.0 Relevant Strategic Objective(s) / Strategies This report impacts on all strategic objectives and links to all Trust strategies. 4.0 Appendices and Attachments Appendix 1 Summary Trust Scorecard (September 2015) Author(s) of paper: Roshan Jhoree Head of Business Unit Information September 2015

104 Board 12th November 2015 Attachement C2 Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year): Stratgey & Resource Committee October 2015 Issues arising from committee consideration Data Quality Statement By way of assurance to the Board, and in order to inform discussion / decision, the accountable executive director confirms that to the best of their knowledge, and subject to any exceptions identified, data contained in this report is: Data Quality Domain Complete Accurate Relevant Up To Date Valid Clearly Defined Description Comments / Exceptions / x Information is as comprehensive as possible to inform the board and no significant known facts or statistics which may influence a decision are omitted. As far as can be reasonable ascertained or validated, information in the report is accurate. Information contained in the report is relevant to the matters considered in the report. Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written Information is presented in a format which complies with internal or national models or standards The meaning of any data in the report is clearly explained Executive Director Sign-Off This paper has been approved by the accountable executive director who is satisfied that (i) the implications for risks, (ii) quality/service/regulatory impacts and (iii) resource implications, have been considered. Phil Bradley Director of Finance Company Secretary Sign-Off (Board papers only) This paper has been quality control checked and approved by the Company Secretary

105 SRC37 12 Summary of Integrated Board Performance Report Sept 2015 Indicator Integrated Business Performance Report Scorecard (July 2015) 2014/15 year end Performance 2015/16 Target Current period performance YTD Performance Current Period RAG YTD RAG Forecast RAG Trend from previous month Trend over time All patients to have smoking status recorded on system one 89% 90% 89% 89% A A G MRSA bacteraemia G G G C.diff cases > 72hrs 5 Full Year 6 Monthly trajectory 0 -July 0 2 G G G 24 hr. Notification to GP 96% 95% 100% 98% G G G % of VTE Assessments 99.6% 100% 100% 100% G G G Patient-related incidents G G G Av. mandatory training 86% 90% 87% 87% A A A Harm free care Compliant Compliant 93.0% 92.8% G G G CAUTI % infections 0.2% <0.4% 0.66% 0.47% A A G No of avoidable category 2 pressure ulcers acquired in HCT care 46 YTD 0 Tolerance 0 1 G G G safeguarding children training level 1 safeguarding adults training at Induction 90% 95% 91% 91% A A G 95% 95% 96% 96% G G G Health Visiting - average caseload size 420 < G G G % 18 Weeks - Consultant led 98.0% 95% 98.9% 98.8% G G G % 18 Weeks - Non-Consultant led 99.5% 98% 98.4% 98.3% G G G Friends & Family Test 97% 90% 97% 97% G G G ALOS - Stroke (Rehab Pathway) 29 days 35 days G G G ALOS - Non stroke (Rehab Pathway) Community Hospitals - average occupancy Community Hospitals - % of NHS bed days lost due to delayed transfers of care 21 days 19 days G G G 91% 82%-88% 91% 88% A G G Total 8.6% (Health 4.8% HCS 2.3% Both 1.5%) 5% for health delays 4% by Mar 16 Total 18.2% (Health 7.6% HCS 10.4% Both 0.2%) Total 14.9% (Health 5.9% HCS 8.7% Both 0.3%) R A G COSR (Risk Rating) G G G Appraisal % 86% 90% 81% 81% A A G No of vacancies (budgeted WTE - Staff inpost WTE) -199 For information Absence Rate 3.50% 3.90% 3.61% 3.61% G G G Underlying Staff turnover 11.70% 12% 13.66% 13.66% A A G

106 Exception Reports for July 15 IBPR (Scorecard) Performance Issue Action By when Responsible Director All Patients smoking status recorded on Systm One Performance remained at 89% of patient s smoking status recorded in July, which is just 1% below the target for the year. 50 referrals to HSSS were made in July and is on the trajectory set for monthly referrals. This is an increase from last month and last year s average of 30. All staff have been written to individually to stress zero tolerance policy for failure to complete mandatory training by October. There was a slight increase in Infection rate this month to 0.66%. Further analysis reveals that nine infections were recorded in July. Six were recorded in the patient s own home. The majority of daily catheters care is provided by non HCT carers, the teams are working closely to increase knowledge and promote good catheter care. The other three incidents were found in Holywell and Sopwell. The Infection control lead will be targeting catheter care practice in these units. It is to be noted that all Children s services are complaint with the training. The uptake for Adult Services training remains on the Risk Register. A trust-wide expectation of staff completing mandatory training should continue to affect this favourably over the next quarter. Children s Services Level 3 Training has decreased this is likely to be seasonal, though CUS uptake is lower than expected, due to training being delayed in order to undertake 2 compulsory courses which have only just commenced. Managers of therapist groups with low uptake have been alerted August 2015 Julie Hoare Mandatory Training Oct 2015 August 2015 Clare Hawkins Clare Hawkins % of patients with a urinary catheter and a new urinary tract infection % of eligible staff trained at appropriated level of safeguarding children in accordance with IC document Level 1, Level 2, Level 3 End of Q2 Clare Hawkins 5

107 Performance Issue Action By when Responsible Director DTOC HCT are over the 5% Health delay threshold for DTOC with 7.6% recorded in July. Sopwell (14.3%) and St Peters (13.7%) reported 165 bed days lost due health related reasons. Overall length of stay increased due to complex discharges and increasing acuity / medical nature of patients on the units. Social care delays remain the highest cause of delayed transfers of care in our bed based units % in July. HCT are working with the CCG and social care to enable the system to flow more efficiently. Appraisal rates are expected to increase from Q3 when the roll out of appraisal process has cascaded from managers to staff. This is currently in process. The Trust s underlying turnover figure for June is above target at 13.66%. The highest rate is Herts Valleys Business Unit where underlying turnover has risen to 16.83%. Children s and Young People s Services were the only Business Unit to stay below target. August 2015 Julie Hoare Staff Appraisal October 2015 Alison Shelley Underlying Staff turnover (Voluntary resignations excluding retirements, redundancy and the end of FTCs) The Trust s exit interview questionnaire is being re-designed to encourage more leavers to complete it. Children s and Young People s Services HR team are beginning a trial in areas where turnover is above 14%, they will call staff who ve handed their notice in (identified by leavers forms received into HR), and will be looking for patterns and trends that could be addressed to reduce turnover. August 2015 Alison Shelley 6

108 Integrated Business Performance Report Scorecard (September 2015) Indicator 2014/15 year end Performance 2015/16 Target Current period performance YTD Performance Current Period RAG YTD RAG Forecast RAG Trend from previous month Trend over time All patients to have smoking status recorded on system one 89% 90% 89% 89% A A G MRSA bacteraemia G G G C.diff cases > 72hrs 5 Full Year 6 Monthly trajectory 1 -Sep 1 4 G R G 24 hr. Notification to GP 96% 95% 99.5% 99.8% G G G % of VTE Assessments 99.6% 100% 100% 100% G G G Patient-related incidents G G G Av. mandatory training 86% 90% 93% 93% G G G Harm free care Compliant Compliant 94.4% 94.4% G G G CAUTI % infections 0.2% <0.4% 0.23% 0.42% G A G No of avoidable category 2 pressure ulcers acquired in HCT care 46 YTD 0 Tolerance 0 1 G G G safeguarding children training level 1 safeguarding adults training at Induction 90% 95% 92% 92% A A G 95% 95% 96% 96% G G G Health Visiting - average caseload size 420 < G G G % 18 Weeks - Consultant led 98.0% 95% 98.7% 98.8% G G G % 18 Weeks - Non-Consultant led 99.5% 98% 96.6% 98.2% R G G Friends & Family Test 97% 90% 97% 97% G G G ALOS - Stroke (Rehab Pathway 29 days days G G G ALOS - Non stroke (Rehab Pathway) Community Hospitals - average occupancy Community Hospitals - % of NHS bed days lost due to delayed transfers of care 21 days 19 days G G G 91% 82%-88% 91% 89% A G G Total 8.6% (Health 4.8% HCS 2.3% Both 1.5%) 5% for health delays 4% by Mar 16 Total 23.4% (Health 10.2% HCS 13.1% Both 0.1%) Total 17.4% (Health 7.0% HCS 10.2% Both 0.2%) R A G COSR (Risk Rating) G G G Appraisal % 86% 90% 81% 81% A A G Absence Rate 3.50% 3.90% 3.82% 3.82% G G G Underlying Staff turnover 11.70% 12% 13.24% 13.24% A A G

109 Exception Reports for September 15 IBPR (Scorecard) Performance Issue Action By when Responsible Director All Patients smoking status recorded on Systm One Performance remained at 89% of patient s smoking status recorded in September, which is just 1% below the target for the year 35 referrals to HSSS were made in September and this is below the trajectory set for monthly referrals. The average for this year is 38, compared to last year s average of 30. The business units will be tasked with managing the services through this with specific trajectories created to achieve target. The Trust was notified of a positive CDI case dating to 2nd Sept The patient had been at QVM but was transferred back to the local acute trust on 4th September A joint RCA meeting is to be held and the Pathology Partnership will be invited to join the review to identify and share learning related to the significant time delay in reporting a positive result. The patient was known to be colonised with Clostridium difficile in August Initial investigations have confirmed that QVM had isolated the patient, sent a stool sample and terminally cleaned the bed space when the patient was discharged preventing risk to other patients. The case in September brings the total number of cases to four since April Performance is above the monthly trajectory set against the ceiling of six cases for 2015/2016. The four cases have occurred in different units/wards with no obvious link to transmission identified. It is to be noted that all Children s services are complaint with the training. The uptake for Adult Services training remains on the Risk Register. A trust-wide expectation of staff completing mandatory training had been expected to affect this favourably over this quarter. However, compliance has been slow to improve, but is now over 90% in all staff directorates. Multiple additional training sessions have been arranged for the next quarter and managers alerted of the names of all non-compliant staff. Compliance is now expected to reach 95% by the end of Q3. Oct 2015 Julie Hoare C.difficile (CDI) cases occurring post 3 days following admission into HCT bed based facilities (i.e. acquired in our facility) Oct 2015 Clare Hawkins % of eligible staff trained at appropriated level of safeguarding children in accordance with IC document Level 1, Level 2, Level 3 End of Q3 Clare Hawkins

110 Performance Issue Action By when Responsible Director 18 Weeks - nonadmitted patients - % of patients being treated within 18 weeks for HCT non consultant led services HCT not achieving the 18 weeks pledge two with 96.6%. MSK Physio and OT WEST have reported 157 breaches. The service has reduced capacity due to staff vacancies. Recruitment is on-going with interviews taking place in November. This issue is on the Risk register. Jan 2016 Julie Hoare DTOC HCT are over the 5% Health delay threshold for DTOC with 10.2% recorded in September. West Herts units recorded 11.2% delays and East and North 8%. St Peters had 20.9% delays and Herts and Essex 15.6% delays. St Peters had 122 days lost to delay and Herts and Essex 123 days. The main delay reasons for St Peters were Patient choice (92 days) and Herts & Essex - Residential placement (44), Funding CHC (39) and Homecare POC (26) HCT are working with the CCGs and social care to enable the system to flow more efficiently. Appraisal rates are expected to increase from Q3 when the roll out of appraisal process has cascaded from managers to staff. This is currently in process. Oct 2015 Julie Hoare Staff Appraisal October 2015 Alison Shelley Underlying Staff turnover (Voluntary resignations excluding retirements, redundancy and the end of FTCs) The Trust s underlying turnover figure for September increased slightly to 13.24%. The Trust has continued with the renewed focus on exit information as part of its Resourcing Plan and a new Trust-wide electronic exit questionnaire has been developed and is about to be launched. This will gather information from staff who would rather give their feedback completely anonymously (identifying only their Business Unit for analysis purposes). October 2015 Alison Shelley

111 Board: 12th November 2015 Attachment C3 TRUST BOARD Title: BUSINESS UNIT PERFOMANCE ASSURANCE REPORTS (October 2015) Meeting Date: 12 th November 2015 Executive Lead(s): Author(s): Phil Bradley, Director of Finance Business Unit General Managers: Marion Dunstone - Children s and Young People s Services Richard Moore - East and North Herts Adults Core Denis Enright - Herts Valley For: ASSURANCE 1.0 Purpose & Recommendations 1.1 Business Unit Performance Reviews are held monthly for each of the Trust s three operational services Business Units, and they cover the whole spectrum of performance. 1.2 General Managers complete an assurance report for the attention of Executive Team. This serves to provide assurance and to highlight any areas of risk. The reports are also submitted to the Healthcare Governance Committee (HGC). 1.4 The Board is requested to note the Business Unit Assurance Reports for October Relevant Strategic Objective(s) / Strategies The reports impact on all strategic objectives and link to all Trust strategies. Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year): Executive Team October / November 2015 HGC November 2015 Issues arising from committee consideration 1

112 Board: 12th November 2015 Attachment C3 Data Quality Statement By way of assurance to the Board, and in order to inform discussion / decision, the accountable executive director confirms that to the best of their knowledge, and subject to any exceptions identified, data contained in this report is: Data Quality Domain Complete Accurate Relevant Up To Date Valid Clearly Defined Description Comments / Exceptions / x Information is as comprehensive as possible to inform the board and no significant known facts or statistics which may influence a decision are omitted. As far as can be reasonable ascertained or validated, information in the report is accurate. Information contained in the report is relevant to the matters considered in the report. Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written Information is presented in a format which complies with internal or national models or standards The meaning of any data in the report is clearly explained Executive Director Sign-Off This paper has been approved by the accountable executive director who is satisfied that (i) the implications for risks, (ii) quality/service/regulatory impacts and (iii) resource implications, have been considered. Phil Bradley Dir. of Finance Company Secretary Sign-Off (Board papers only) This paper has been quality control checked and approved by the Company Secretary 2

113 Board 12 th November 2015 Attachment C3 (To be submitted to the next Executive Team meeting as part of BUPR action tracker) Business Unit: Children's & Young People's Services Date of BUPR Meeting: 22 October 2015 Date of Report: Name and Designation of Person Completing Report: Su Johnston & Ken Warren Date of Next BUPR meeting: 26 November 2015 Issue(s): School Nursing vacancies Paediatric audiology overspend. Not funded for hyperacussis and auditory processing disorder Flu: number of staff immunised must go up, issue with clinics running out of vaccine raised with exec. Staff Survey: Important to encourage staff to complete General Manager s Comments On HLRR - close monitoring and actions in place GM and Head of Specialist services and Therapies to discuss with commissioners. Unable to continue seeing this group of children without additional funding Managers actively encouraging staff to attend and using flu champions where possible. Reduction in number of flu champions in CYP services due to school nurses carrying out flu vaccination programme Managers encouraging and supporting staff to complete surveys and using time in team meetings for staff to do this Exec Team Use Only Assurance RAG Rating & General Manager s Comments Escalation to: (eg HGC, SRC, back to ET, back to BUPR,etc.) Red (Negative Assurances): The Business Unit considers that there are significant gaps / weaknesses in controls or assurance in respect of the following issues and which are of sufficient concern to require escalation to the Executive Team for consideration and agreement on actions required Amber / Red (Limited assurances): The Business Unit considers that there are some gaps / weaknesses in controls or assurance in respect of the following matters and which are of sufficient concern to require escalation to the Executive Team for information at this stage: Issue(s): General Manager s Comments HVCCG have not agreed further investment in Comm Paeds. GM Community paediatrics: staffing, activity, and Head of Specialist services and Therapies to discuss with overspend, debts commissioners the criteria for this service. Director of Finance to follow up on outstanding debts Smoking cessation and ethnicity, get the precentage up above 90% OT/Physio management: Following management & clinical leadership restructure, vacancy in service manager and one area manager post Managers to use BI platform to identify staff who are not recording this on S1 and address this as a priority. Prompt used in HV service to be applied to other CYP S1 units. Unsuccessful recruitment x2, back out to advert with broader person spec for the manager's post. Part time interim service manager starting 2/11/15 Amber / Green (Reasonable Assurances): The Business Unit affirms reasonable assurance to the Executive Team as to controls and assurances in respect of the following matters: Issue(s): General Manager s Comments Green (Significant Assurances): The Business Unit affirms significant assurance to the Executive Team as to controls and assurances in respect of the following matters: Issue(s): General Manager s Comments Summary of any other points for the Executive Team s Attention

114 Board 12th November 2015 BUSINESS UNIT ASSURANCE REPORT (To be submitted to the next Executive Team meeting as part of BUPR action tracker) BUSINESS UNIT East & North Herts Adult Core DATE OF BUPR MEETING DATE OF REPORT NAME OF DESIGNATION Richard Moore OF PERSON COMPLETING DATE OF NEXT BUPR Assurance RAG Rating & General Manager s Comments Exec Team Use Only Escalation to: Red (Negative Assurances): (eg HGC, SRC, back to ET, back to BUPR,etc.) The Business Unit considers that there are significant gaps / weaknesses in controls or assurance in respect of the following issues and which are of sufficient concern to require escalation to the Executive Team for consideration and agreement on actions required ISSUES: GENERAL MANAGERS COMMENTS: LEAD: DATE DUE: MSK position paper presented to E&N CRM in Sep, HV CCG in Oct. MSK West breaching 18 weeks mainly due to MSK Physio demand > capacity (69% working establishment, due to GP Dec-15 M/L + vacancy). Service look to source agency to fill Gap and agreed BU re-align CIP Holywell / Wheelchair Service- Overspend Holywell overspend - DoLs related. Wheelchair service HCT served notice from 31st March Will draft up demobilisation plan and financial turnaround strategy MG Nov-15 Amber / Red (Limited Assurances): The Business Unit considers that there are some gaps / weaknesses in controls or assurance in respect of the following matters and which are of sufficient concern to require escalation to the Executive Team for information at this stage: ISSUES: GENERAL MANAGERS COMMENTS: LEAD: DATE DUE: Transport Issues- responsibilities and staff time RM investigating and set up monthly contract clarification. performance / operations meet. RM / DH Oct-15 MIU- Service facing Pressure with Timescales/ Peak demand days demand > capacity resulting in staff Demand pressures and longer waits. Met with CCG + HUC, RM / DH Dec-15 Appraisal Rates - Agreeing to a Trajectory Appraisals will be in-line with trust timeline to fit appraisal in first 6 months to align with trust objectives. JT / BM Oct-15 ICT Referral Priority P1 achieving 100%, P2 95% and P3 being ratified in Oct MS Nov-15 Staff Survey Managers continue to support staff to cmplete All Nov-15 Mandatory Training- Reporting Issues Jane T/ Jill P working together on a local Pilot. JT Nov-15 Amber / Green (Reasonable Assurances): The Business Unit affirms reasonable assurance to the Executive Team as to controls and assurances in respect of the following matters: Quantum community bed model, CCG continue to query costs Clinical quality therapy lead working with CCG on model refinement, in-accordance with finance JC / RM Nov-15 ISSUES: GENERAL MANAGERS COMMENTS: LEAD: DATE DUE: Green (Significant Assurances): The Business Unit affirms significant assurance to the Executive Team as to controls and assurances in respect of the following matters: ISSUES: GENERAL MANAGERS COMMENTS: LEAD: DATE DUE: Summary of any other points for the Executive Team s Attention MSK activity remains challenging due to low working establishment. Both CCG's aware fo risk to 18 week

115 Board: 12th November 2015 Attachment C3 BUSINESS UNIT ASSURANCE REPORT (To be submitted to the next Executive Team meeting as part of BUPR action tracker) BUSINESS UNIT Herts Valley Adults DATE OF BUPR MEETING 22nd October 2015 DATE OF REPORT 23rd October 2015 NAME OF DESIGNATION OF PERSON COMPLETING REPORT Charlie Cadogan & Ken Warren DATE OF NEXT BUPR 26th November 2015 Assurance RAG Rating & General Manager s Comments Exec Team Use Only Escalation to: (eg HGC, SRC, back to ET, back to BUPR,etc.) ISSUES: GENERAL MANAGERS COMMENTS: Owner Beds overspend options: need to recover 1.1million in rest of year from the bed base. Proposal to be agreed internally and ready to go to CCG. If contract changes are needed, i.e. to the CQUIN around more than 1 move, aready to go to commissioner. Options paper on minimising the overspend to go to exec. Marion D to overseee across both Adult directorates. Red (Negative Assurances): The Business Unit considers that there are significant gaps / weaknesses in controls or assurance in respect of the following issues and which are of sufficient concern to require escalation to the Executive Team for consideration and agreement on actions required Gossoms End has now got no patients in situ Options paper going to executive WC 2nd Nov to put forward options for managing budget for specials Options paper already gone to executive describing options to bring spend back into budget for full year DE Flu/staff survey, staff are to be encouraged in both of these, important to get the numbers up. Diabetes: Service & CQUIN. Issues with ICE pathology system, IT issues causing problem meeting the 8 core processes. All ICE failures to be Datixed and evidenced to CCG who are perfromance managing. Education target is wrong, target is 900 but the service will reach 600 even when putting significant extra resources in. Both have been cascaded and pushed by all managers and continuous communications Weekly service reports show ongoing improvement of the service and this is acknowledged by the CCGs New dedicated service manager in place Working group started to work on service turn around All DH Amber / Red (Limited Assurances): The Business Unit considers that there are some gaps / weaknesses in controls or assurance in respect of the following matters and which are of sufficient concern to require escalation to the Executive Team for information at this stage: ISSUES: GENERAL MANAGERS COMMENTS: Hertsmere ICT: Finances still an issue, plan needed to bring back in to balance. Also need to consider the implications of the introduction of the agency cap on service, perform a risk assessment. Locality are forecast to underspend every month, and are prioritising workload. Further financial monitoring is being put in place. DC/LC Reduce staff turnover from 20%: Include in workforce development plan, what would it take to reduce atrition rate? Skill mix? As acutes reduce bed numbers, how can we recruit acute staff as numbers reduce? P1,2,3: Must get to a position where what is being reported is the actual position. Prison: GP, haven't placed a contract, have a locum GP covering, not sustainable in the longer term, need a permanent solution Prison: Dental equipment is owned by the prison, regularly breaks down but not within the Trust's power at the moment to resolve. Causing issues of appointments being cancelled at short notice and patients not having a good service. Individual team engagment plans being developed Specific BU workforce development plan being reviewed Team Managers are checking the P-lists for accuracy every week/month and new processes have been put in place New recruiting round started. Issue to be picked up at partnership board JH/LM/SM LM CMc CMc/DE Amber / Green (Reasonable Assurances): The Business Unit affirms reasonable assurance to the Executive Team as to controls and assurances in respect of the following matters: ISSUES: GENERAL MANAGERS COMMENTS: Green (Significant Assurances): The Business Unit affirms significant assurance to the Executive Team as to controls and assurances in respect of the following matters: ISSUES: GENERAL MANAGERS COMMENTS: Recruitment & retention premium being considered for Hertsmere ICT Summary of any other points for the Executive Team s Attention

116 Board 12 th November 2015 Attachment C4 TRUST BOARD Title: High Level Risk Register Meeting Date: 12th November 2015 Executive Lead: Clare Hawkins Director of Quality and Governance Author(s): Gerry Phee Risk & Assurance Manager For: Noting 1.0 Purpose and Recommendations To inform the Board of current status of Risk associated with activity and business across all HCT Business Units. 2.0 Executive Summary 2.1 Hertfordshire Community NHS Trust (HCT) High Level Risk Register (HLRR) is compiled from the risk registers of all Business Units and Corporate Directorates, and contains the risks which have a current risk score of 15 and over. The number of High Level risks has decreased by three from the previous submission to Executive Committee in October, and is currently sitting at fifteen. 2.2 The HLRR attached is that reflecting the position as at 2nd November The summary paper outlines changes to the HLRR from 2 nd October 2015 and progress with management of the risks. Following the monthly review with Executive Team the high level risks status and management attached have been agreed. 2.3 There are no emergent risks identified risks are currently held on the HLRR risk register, 15 risks have not changed since last submission and continue to be managed at their current scores of 15 and over. 2.5 No risks have been escalated to the HLRR risk register risks have been de-escalated from the HLRR: Ref Finance & Commercial Business (FT Programme) Challenge of developing 2yrs detailed CIPs in current economic climate leading to LTFM not meeting Monitor requirements Ref 23 - Specialist Palliative Care Service Low staffing levels due to vacancies, sickness and special leave leading to the inability to deliver high quality care to patients 1

117 Board 12 th November 2015 Attachment C4 Ref Health Visiting & School Nursing Numerous confirmed pregnancies across the county within health visiting coupled with the expectation to deliver full Healthy Child Programme by March 2015 and on-going to transition to Local Authority, leading to negative impact on service delivery. Low morale amongst staff and risk of further staff losses due to increased workloads and pressure. Higher level of Safeguarding for remaining staff, including newly qualified health visitors. Experienced staff on Maternity Leave will have an impact on availability of support for newly qualified staff. 3.0 Relevant Strategic Objective(s) / Strategies The Statement impacts on all strategic objectives and links to all Trust strategies. 4.0 Appendices and Attachments (1) HLRR November 2015 Author(s) of paper: Gerry Phee Risk & Assurance Manager Date: 2nd November

118 Board 12 th November 2015 Attachment C4 To be completed as part of paper Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year): /10/2015 Executive team Issues arising from committee consideration Data Quality Statement By way of assurance to the Board, and in order to inform discussion / decision, the accountable executive director confirms that to the best of their knowledge, and subject to any exceptions identified, data contained in this report is: Data Quality Domain Complete Accurate Relevant Up To Date Valid Clearly Defined Description Comments / Exceptions / x Information is as comprehensive as possible to inform the board / committee and no significant known facts or statistics which may influence a decision are omitted. As far as can be reasonable ascertained or validated, information in the report is accurate. Information contained in the report is relevant to the matters considered in the report. Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written Information is presented in a format which complies with internal or national models or standards The meaning of any data in the report is clearly explained Executive Director Sign-Off This paper has been approved by the accountable executive director who is satisfied that (i) the implications for risks, (ii) quality/service/regulatory impacts and (iii) resource implications, have been considered. C Hawkins / x Company Secretary Sign-Off (Board papers only) This paper has been quality control checked and approved by the Company Secretary N/A 3

119 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising No. of risks with change in score since last report: 15 no change: Ref 150, Ref 199, Ref 226, Ref 263, Ref 267, Ref 272, Ref 302, Ref 306, Ref 309, Ref 340, Ref 130, Ref 141, Ref 182, Ref 241, Ref new risk, 0 escalated, 3 de-escalated: Ref 23, Ref 258, Ref 288 Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 150 Performance and Information HCT's right to use clinical systems (SystmOne and ipm) under the current arrangement ceases in July 2016 BW Performance and Information IT Strategy 2x5=10 4x4=16 4x4=16 2x1=2 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Risk Lead Lead Committe e Ref Finance & Commercial Business (FT Programme) Challenge of developing 2yrs detailed CIPs in current economic climate Leading to LTFM not meeting Monitor requirements PB Director of Finance FT Committ ee Board Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score 5x3=15 4x3=12 5x3=15 3x3=9 Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Direction of Change 1

120 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref Finance & Commercial Business (FT Programme) CCGs do not currently support Foundation Trust (FT) application Leading to TDA deferral of assessment of FT application PB Director of Finance FT Committ ee Board 4x4=16 4x4=16 4x4=16 2x3=6 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Risk Lead Lead Committe e Ref Finance & Commercial Business (FT Programme) CQC inspection rating worse than 'Good' will delay TDA assessment and Monitor submission Leading to FT application being deferred until 'Good' rating achieved CH Director of Quality & Governanc e FT Committ ee Board Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change 5x3=15 5x3=15 5x3=15 1x2=2 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. 2

121 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 23 - Specialist Palliative Care Service Low staffing levels due to vacancies, sickness and special leave leading to the inability to deliver high quality care to patients PB Service Manager SPC BUPR 4x3=12 3x3=9 5x3=15 3x3=9 Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 130 Community Diabetes Service DSN caseloads unacceptably high due to 10-20% increase in prevalence in diabetes since service was initially commissioned in Funding has not kept pace with increased prevalence / incidence of patients with diabetes. DH Service Manager Diabetes Exec 3x5=15 3x5=15 3x5=15 3x2=6 No Change 3

122 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 226- Wheelchair Service Uncertainty of the future of the wheelchair service that HCT provide due to HES serving notice to the CCGs for the repair and supply aspect of the wheelchair provision. MG Service Mgr Wheelchair Service BUPR, Exec, SRC 4x4=16 4x5=20 4x5=20 4x2=8 No Change 4

123 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 199 Human Resources Inability to recruit the numbers of staff needed to fulfil demand due to an increase in newly commissioned services and tight labour market AS Director HR Exec 3x4=12 3x5=15 3x5=15 3x2=6 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. 5

124 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 302- Pharmacy General Practitioners acting on advice from the Local Medical Council (LMC) Bedfordshire & Hertfordshire to no longer complete HCT medication administration charts from September SW Chief Pharmacist Healthc are Governa nce 4x4=16 4x4=16 4x4=16 4x2=8 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Risk Lead Lead Committe e Ref 306- Finance & Commercial Business Building environment does not deliver comprehensive fire safety systems at a range of sites, which may lead to breaches in legislation in relation to fire safety. PB Director of Finance Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Exec, 3x5=15 3x5=15 3x5=15 3x3=9 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. 6

125 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 309- Community Cardiology - Cardiac Rehabilitation/Heart Failure Service Staff shortages due to maternity leave and vacancies plus an increase in referrals into the service leading to remaining staff member having a higher than agreed (safe) caseload of patients, resulting in referral pathway for red and amber patients being breached along with heart failure medicines management guidelines. DE Head of Adult Services Herts Valley Healthc are Governa nce 3x5=15 3x5=15 3x5=15 3x3=9 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. 7

126 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref Health Visiting & School Nursing 1. Numerous confirmed pregnancies across the county within health visiting. 2. Expectation to deliver full Healthy Child Programme by March 2015 and on-going to transition to Local Authority. Leading to: 1. Negative impact on service delivery. It is likely that the delivery of full HCP offer will not be possible. 2. Low morale amongst staff with particular reference to WelHat and Stevenage teams. Risk of further staff losses due to increased workload and pressure. 3. Higher level of Safeguarding for remaining staff, including newly qualified health visitors. 4. Experienced staff on Maternity Leave which will have an impact on availability of support for newly qualified staff. KG Head of CUS BUPR 3x5=15 3x4=12 3x5=15 3x3=9 Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. 8

127 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref Community Diabetes Service High number of vacancies and sick leave means that Diabetes Specialist Nurse staffing levels are unacceptably low across the service - but particularly in East and North Herts. DH Service Manager of Community Diabetes Service BUPR 4x4=16 3x5=15 3x5=15 3x2=6 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 340- Quality & Governance Following the Care Quality Commission Inspection, the Trust was invited to a Quality Summit and received the final outcome report. The report identified seven regulatory areas requiring improvement actions for the Trust to undertake. CH Director of Quality Board 3x5=15 3x5=15 3x5=15 3x1=3 No Change 9

128 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref Health Visiting & School Nursing Long term difficulties recruiting to School Nursing Band 6 posts in Hertfordshire, leading to failure to deliver service specification, no visibility in schools, low staff morale and increased sickness. KG Head of CUS BUPR 4x5=20 4x5=20 4x5=20 4x3=12 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. 10

129 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 182 North Herts Integrated Community Team Shortfall of staff due to vacancies, sick leave and maternity leave, leading to a delay in patient visits. RM Head of Adult Services E&N BUPR 3x4=12 3x5=15 3x5=15 3x2=6 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref Royston Integrated Community Team Shortfall of staff due to vacancies, sick leave and maternity leave, leading to a delay in patient visits. RM Head of Adult Services E&N BUPR 3x4=12 3x5=15 3x5=15 3x2=6 No Change 11

130 Board 12 th November 2015 Attachment C4 Hertfordshire Community NHS Trust Summary of Risks on the High Level Risk Register - November 2015 Low Medium High Risk Scores = Consequences x likelihood of risk materialising Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. Risk Lead Lead Committe e Initial Risk Score Current Risk Score Previous Risk Score Residual Risk Score Direction of Change Ref 268 Finance & Commercial Business West Herts review may propose significant service change which impacts on HCT, leading to challenge or opportunities relating to long term organisational viability. PB Director of Finance BUPR 3x3=9 4x4=16 4x4=16 2x3=6 No Change Links to Risks on BAF: 11/13 (2) The safety, experience and clinical outcomes of care for patients may fall below the Trust s expected standards whereby quality of care is compromised to an extent which results in harm to patients, poor public reputation, punitive regulatory action and failure to deliver High Value Healthcare. 12

131 Board 12 th November 2015 Attachment D1 HERTFORDSHIRE COMMUNITY NHS TRUST CHIEF EXECUTIVE S REPORT November Executive Summary This paper provides an update from the Chief Executive Officer to highlight progress against the Trust s strategic objectives and key issues affecting the Trust in the external environment. 2. Recommendation The Board is asked to raise any issues about risk related to the delivery of strategic objectives and agree if these are fully reflected in the BAF. 3. Introduction Our focus on describing and communicating our strategy continues. Its consistency with the key themes of Your Care, Your Future is clear. We have started the process of engaging staff on how we deliver our vision of future service provision with two events to listen to staff feedback on what we are saying. There are some important messages emerging already, about being more specific about the impact of the changes we will make, the need to create a more permissive approach for staff and enable them to take forward their ideas. Our Board discussions at the end of October provided an opportunity to take stock of work that has been underway inside and outside the Trust and to identify our main priorities. There is also a clear sense of urgency about the need to build on changes already made by the Trust and partners organisations to make the NHS sustainable locally. 4. Current main areas of work and risks This section of the report identifies the main areas of activity against the Trust s five strategic objectives. Objective 1 Key actions that have or will contribute to developing services include: The meeting of west Hertfordshire health service Boards and the County Council on October 23 rd received an update on the strategy work from Your Care, Your Future. HCT s Board identified some key issues that need to be addressed to support delivery of the strategy, including the need for all organisations to state their position on delivering the strategy and agree the principles required for a collaborative approach to the work. The Trust has placed self-management as central to the delivery of its strategy for improved health and wellbeing in Hertfordshire and west Essex. The self-management approach is being tested in different services in the Trust 1

132 Board 12 th November 2015 Attachment D1 Work on outcome measures for community services appears to be gaining traction at a national level, with input from HCT and other stand-alone community providers. The TDA is co-ordinating a meeting of national bodies to take forward work that was initiated by the network of community Trusts. NHSE is also starting to work towards common definitions of indicators with a view to developing currencies for community provision. This will support HCT and others to demonstrate more clearly the value of what we do. Risks The risks which pertain to this work include: The implementation of the strategy is not yet described clearly and the proposed governance arrangements do not, at this stage, look fit for purpose There is a risk that whilst a collaborative approach is being promoted the CCG continues to tender aspects of service which make collaboration more complex to deliver The resources to support a broad programme of self-management are not available to the Trust and this would result in an extended implementation programme There remains a lack of coherence at national level on the approach to developing and applying community indicators. Mandating indicators is a lengthy process and commissioners continue to press for a high degree of local variation Actions The following actions are being taken to address the areas of risk: the governance arrangements will be reviewed in the Programme Executive. The Board needs to have a view on what is acceptable The local providers will raise this directly with the CCG and seek clarification about the overriding approach that will be taken The Executive will seek additional resource in the contracting round and also look at how resources internally can be applied to support this programme The community provider network will continue to lobby nationally and with commissioners on the development of indicators for community services Objective 2 The main areas of focus for the delivery of safe and effective care are as follows: Work on the actions required by the CQC continues, with each service having developed its own plans to respond to the report. There is no clarity yet about the scope of any re-inspection or indication of when that might be undertaken Three compliance notices were issued by the CQC and the Trust needs to demonstrate it has met the CQC s requirements in each area Workforce is the area that will be most difficult to address given the labour market position. 2

133 Board 12 th November 2015 Attachment D1 Risks The risks in this area include: Recruitment to our workforce. Our vacancy position includes posts that are part of new service developments and our overall vacancy rate is 13%. There are, however, two areas with vacancies above this level. These are the integrated community teams (22%) and children s specialist services (19%) Actions The following actions are being taken to reduce the risks: The risk in our community bed base in the west has been reduced following the temporary emergency closure of Gossoms End. We had 57 vacancies, representing 19% of our workforce. Thirty three people have transferred to other units, mainly SACH and this will considerably reduce our reliance on agency staff Recruitment continues to have a high level of focus and the changes described in previous updates to the Board continue to have a beneficial effect. We have reduced the overall number of vacancies by well over 200. The application of recruitment and retention premia is being assessed in some localities, particularly those close to London. Objective 3 The following areas are significant in the development of community services: The extension of the rapid response service into St Albans and in the east of the county is proceeding. The service went live in St Albans on November 2 nd. We have also been recruiting additional HCAs who will bridge a gap in domiciliary care provision and support discharge for patients in Watford and HCT s beds. The Executive took a decision not to pursue the tender for Bedford prison given the demands on the organisation within Hertfordshire HCC has indicated that it will not tender the health visiting service in the next two contractual years, and will work with us to deliver the service they specify. There is a market engagement event with respect to school nursing Risks The risks in this area include: The possibility that HCC could go to tender on the school nursing service Actions The following actions are being taken to reduce the risks: We have sought clarification from HCC about the market engagement work on school nursing. 3

134 Board 12 th November 2015 Attachment D1 Objective 4 The following areas are of note in ensuring the efficient use of resources: the Trust remains on track to deliver its surplus it also continues to work to deliver the stretch target to contribute to closing the overspend in the NHS the expenditure on wheelchairs will be reduced to live within the available budget. Risks The risks in this area include: the overspend in our bed base in west Hertfordshire is a considerable risk in delivering the stretch target. This has been driven by the need to have additional staff for people with a need further support, often those with cognitive problems the reduction in spend on wheelchairs will increase waiting times for the service and breach the 18 week standard. Actions The following actions are being taken to reduce the risks: options to reduce the overspend in the beds are being worked up by the business unit. Sustaining patient safety and supporting an effective flow of patients remain central. Reduced capacity in the bed base is being offset by CCG commissioning of additional social care bed capacity and actions in the Trust to support people to get home on a timely basis, as through the employment of HCAs to support social care the CCGs and TDA have been notified of impact of reductions in spend on wheelchairs Objective 5 The following are being undertaken in respect of the Trust s capability and capacity: recruitment priority has been given to capacity in the ICTs a review of projects to reduce the number that are currently running and focus efforts into priority areas the capacity and demand model that has been trialled in Berkhamsted and Stevenage is helping the services to profile the use of staff across the week listening events are being run with staff groups which have already identified areas where we can use our capacity more effectively Risks The risks in this area include: ICT capacity is the most pressing issue for the Trust, with turnover remaining high. Actions The following actions are being taken to reduce the risks: 4

135 Board 12 th November 2015 Attachment D1 Exit interviews are undertaken with staff to understand why turnover is high. These have identified that work-life balance is an issue for some staff, although many are leaving for promotion or relocation. The two business units continue to work on issues of retention and this is an issue that is reviewed at BUPRs to test the scope for further action. 6. The External Environment Simon Stevens recently made a speech in which he said: It s time to call time on the foundation trust pipeline. We are kidding ourselves if we think trusts are going to pass the criteria set out by Monitor. An awful lot of time is being spent mucking around on foundation pipelines. In my opinion it s time to free up that time to focus on the population-oriented health systems we want to create across the country. He also said that the acquisition process, by which successful trusts take over struggling ones, was often flawed and time-consuming. There was need to call time on acquisitions as means of solving problems in the NHS in some parts of the country. This is not formal policy but the Board should consider the import of this comment Urgent care the west Herts system has been chosen to be one supported by the Emergency Care Improvement Partnership because of its continued performance below the national standard. The first system meeting was held on November 5 th. NHS Finances the focus on financial management remains a very strong one in light of the national position. This has raised the question of when and how the 8 billion promised by the government will be released. The Comprehensive Spending Review will come out later this month. Simon Stevens has indicated that health systems with clear, joint plans will receive funding when it is available. Locally there is a need to prime many of the changes envisaged in the CCG strategies West Essex CCG held engagement events to discuss the future provision of services in the area. The future of HCT services in the area is not clear. The merger of SEPT and NEPT will have some bearing on the view of local arrangements. David Law Chief Executive 5 th November

136 Board 12 th November 2015 Attachment D1 Signing up to the Strategic Outline Case for Your Care Your Future ATTACHMENT 1 The Board has been kept updated on progress with YCYF over the months in which work has been taking place. The Strategic Outline Case (SOC) has been circulated to the Board. We have had the briefing on progress at the event on October 23 rd. As a Board we are being asked to support the SOC as a direction of travel. The proposals centre of five principles, which are that: There will be a focus on delivery of change through localities Care will be delivered closer to home wherever possible Services will be more joined up There will be a greater emphasis on self-management Specialist services will meet needs At the event on the 23 rd October the HCT Board identified a number of factors that need to be in place to take forward the implementation of the SOC. These were that there should be: Further clarity provided to all Boards about what we are signing up to, what is being agreed, and what is not. There should be a system approach to the behaviours that are required from each organisation to support collaboration, describing the principles of how we work together and creating a system to allow us to hold each other to account. The providers specifically will need to agree how they work together jointly All boards should set out their strategic objectives linked to YCYF There should be a statement of intent from commissioners (CCGs and HCC) about the framework/principles that they will pursue to support collaboration, with specific reference to the approach to tendering and longer terms for contracts There should be a clear mandate given to emerging GP provider federations and a statement of intent from them about how they will work to deliver YCYF Recommendation The Board is asked to consider its support for the Strategic Outline Case and sign up to support it. It should also identify any conditions that it wishes to see in place to sustain its support and promote effective delivery of the strategy. David Law November

137 Board: 12 th November 2015 Attachment D2 HERTFORDSHIRE COMMUNITY NHS TRUST BOARD Report from the Director of Finance 12 th November Introduction This paper provides an update from the Director of Finance to highlight items of interest/information arising since the last Board report. It is supplementary to the Finance Report and other reports from the Director of Finance on the Board Agenda. 2.0 Link to Trust Strategic Objectives This paper relates to strategic objective number 5 We will develop the organisational capacity to deliver our vision and objectives. 3.0 Recommendations The Board is asked to note the content of this paper and to raise any questions or observations. 4.0 Executive Summary The Finance, Estates, Performance and Information Team and Contracting and Commercial Team continue to be engaged in a significant amount of work as shown in the following sections. 5.0 Finance 5.1 Update The year to date financial position is just ahead of plan CIPs are behind plan year to date The year end stretch target forecast is at risk, to the tune of c 500k, due to the unfunded cost pressure relating to the need to provide 1:1 care to a growing number of patients in the west of the county bed bases The new Deputy Director of Finance, Kevin Curnow, has now commenced his role with HCT. 6.0 Estates and Facilities 6.1 Business Case Development There are two business cases in developmental stage which are Harpenden Memorial Development and the Hemel Hempstead Integrated Community hub. 6.2 Estates Improvements The capital development programme is delivering a number of estates projects to improve 1

138 Board: 12 th November 2015 Attachment D2 efficiency and patient environment. These include: The Avenue Clinic ground floor refurbishment to provide additional services and improved environment. Langley House Integration of Neuro rehab within the neuro rehabilitation facility St Albans City Hospital Improvements to Rapid Assessment Unit in line with CQC proposals and increased activity Nascot Lawns Improvements to kitchen and medical facilities Danestrete Clinic Improvements to ground floor area to improve infection control standards and efficiency. New works will be addressing the PLACE inspection requirements. 6.3 Facility Services A comprehensive monitoring tool has been developed and recently implemented to monitor, manage and improve services currently procured to deliver facilities from a number of providers. The tool will be used to monitor the services provided to HCT by: West Herts Hospital NHS Property Services Interserve East & North Herts Trust A performance report will be compiled from this exercise to the Executive Team in March Information Governance 7.1 Information Governance Toolkit The Information Governance performance update has been submitted with as score of 26%. This is a slight increase on the submitted baseline score with a targeted score of 87% by March 2016 The areas that may affect the target score are the non-completion of a data flow mapping exercise and corporate records audit. 7.2 Incident Reporting There has been one serious incident which has been reported onto the ICO and DH on the IG Toolkit reporting system. The incident has been completed and the ICO has been notified and we are awaiting the ICO s decision on how they will proceed. 7.3 Freedom of Information Requests The Trusts compliance level is currently at 100% within the statutory 20 working days. There has been an increase in requests relating to agency staff which has been reported via the media. No complaints have been raised via the FoI Act. 2

139 Board: 12 th November 2015 Attachment D2 A Freedom of Information Act Request Compliance Report covering the period October September 2015 is included in the supporting papers. 8.0 Performance and Information 8.1 Business Intelligence Weekly flu immunisations to all Hertfordshire GP s. Mini BUPR integrating activity, finance and workforce for each cost centre deployed. BUPR review started to automate BUPR reporting Performance Community indicators HCT full input into National Board. KPIs on track and agreed. Q2 CQUINS reporting all delivered on time. 8.3 IT Mobile working phase 4 ongoing. IT datasets finalised. SIMs data shared with operations. Community hospitals system project ongoing and train the trainer sessions organised. Sharepoint strategy implementation underway. Integration with ENHT re; Child health and SystOne ongoing. 8.4 Staffing IG Manager post offered to candidate but subsequently turned down. Post being re-advertised. 9.0 Commercial Opportunities 9.1 The business development pipeline management process and the annual assurance of commissioning intentions have highlighted a number of commercial opportunities in our core service areas as covered in the contracts and business opportunity paragraph. We have however been complimenting this standard business planning process by identifying the following future potential non-core commercial opportunities: Specialist Home commissioned by Hertfordshire County Council to provide an enhanced level of domiciliary care for those residents who have been discharged from hospital or to prevent those at risk of a non-elective admission from being admitted. The tender calls for the winning providers (the tender is divided into 5 geographical lots) to be able to co-ordinate their delivery with community health professionals (where applicable) to ensure service users receive a holistic and seamless service. This tender affords the Trust the opportunity to forge partnerships with traditional domiciliary care providers to capitalise on local authority commissioning, as opposed to traditional CCG commissioning, as they move more towards integrated care at home. Other commercial opportunities are being developed through partnerships with other providers in order to present an integrated care organisation approach to commissioners either formally or informally. 3

140 Board: 12 th November 2015 Attachment D Business Planning & Contracting 10.1 The proposed approach for Planning and Contracting for 2016/17 and the budget setting principles and process were shared with the Strategy and Resources Committee in October for approval. Good progress has been made in line with the plan. In particular: The Business Planning and Contracting Group has been established and has met twice so far, reviewing the proposed approach for 2016/17. The planned workshops on 28 September and w/c 12 October have been held ensuring Service Managers and corporate business partners have a good understanding of the approach and what is required of them. Feedback on these workshops has been positive. Commissioners shared their priorities and intentions for 2016/17 at the workshop on 28 September and have since followed up with written Commissioning Intentions (with the exception of Herts Valley CCG). These have been shared across the organisation. A template for service planning, together with business intelligence covering finance, activity and HR, has been shared with all service managers to inform the development of their plans. Service Managers have submitted plans and these are now being reviewed to inform discussions with commissioners. Next steps: Complete review of service plans and start contracting round discussions with commissioners. Prepare business cases to take to commissioners. Commence business planning within corporate functions PMO 11.1 A revised CIP Delivery Framework, Gateway Process and templates have been developed to cover future years. It is expected that the management and delivery of CIPs will, in future, will be more closely aligned to the management and delivery of change programmes and projects, with oversight provided by the PMO Steering Group. A proposed new reporting structure for HCT s portfolio, including use of a Prioritisation Model and Master Schedule to assist with programme and project planning are the subject of ongoing discussions with the Executive Team. The reporting of programme and project delivery is improving with 18 Highlight Reports submitted to the PMO for September out of a possible total of 24. In terms of next steps the plan is to: 4

141 Board: 12 th November 2015 Attachment D2 1. Introduce reporting for those projects that are not currently being reported. 2. Obtain approval and implement the revised CIP Delivery Framework for next FY. 3. Complete prioritisation exercise and Master Schedule for HCT s portfolio. 4. Introduce reporting in line with the Strategic Assurance Framework by agreeing the key objectives, goals and measures that will contribute the most to the achievement of the Trust s strategic objectives. 5. Develop a Project Manager s handbook comprising advice and guidance on HCT s approach to programme, project and change management. 6. Organise inaugural Project Manager s Network meeting in order to facilitate communications between the PMO and project managers within the Trust, helping to build expertise by discussing issues, sharing new ideas and any lessons learned Annual Audit Letter The Trust has received the Annual Audit Letter for 2014/15 from External Auditors, Ernst & Young. This was considered by the Audit Committee in September An unqualified opinion was given on the accounts and no significant issues have been raised for attention. A copy of the full letter is included in the supporting papers Risk Commentary 13.1 The following are the main risks within the Directorate; The cost pressures from the bed based units and their impact on the achievement of the stretch target, CIP delivery behind plan, and IG staffing. Phil Bradley Director of Finance November

142 Board 12 th November 2015 Attachment D3 HERTFORDSHIRE COMMUNITY NHS TRUST Report from the Director of HR and Organisational Development November Introduction This paper provides an update on workforce and organisational development items of interest/information arising since the last Board report. It is supplementary to the workforce data and commentary contained within the Integrated Board Performance Report, the key highlights of which are covered in this report. The report focuses on activities to deliver the Workforce and OD Strategy. 2.0 Link to Trust Strategic Objectives This paper relates to Strategic Objective number 5 We will develop the organisational capacity to deliver our vision and objectives. 3.0 Executive Summary Workforce KPIs show stable performance despite on-going staffing and workload challenges. Hot spot areas continue to be targeted. Trust vacancy rate has reduced. The number of posts going through the recruitment process has reduced substantially this month, with a large number of new starters in September Overall mandatory training rates reached 93% in September against a target of 90%. This is a significant achievement, with all BUs reaching the 90% target as well as each of the training competencies. A new series of Director Listening Events have commenced to enhance existing engagement opportunities with front line staff. Initial response has been positive. Significant leadership development activity continues. Two individuals have been shortlisted for the Health Education East of England Leadership Awards The Trust has published its Workforce Race Equality Standards report end October. 4.0 Recommendations The Board is asked to note the content of this paper. SECTION 1: Workforce KPIs & Operational Activity 5.0 Workforce Key Performance Indicators 5.1 Sickness, Turnover and Vacancy Rates The in-month sickness absence figure for September was within target at 3.82%. Staff turnover rates have decreased to 13.24% for underlying turnover and 19.83% for total turnover. Work is being done on reasons for leaving (see 8.2). The Trust s overall vacancy rate for September has reduced to 10.7% (293 WTE). The vacancy rate currently stands at 13.4% for nursing and 10.42% for AHPs. The highest rate is for medical staff at 18.5%, but this represents small numbers. The following graph shows vacant posts (excluding those in new services) set against a trajectory to reduce vacancy levels from 10.71% to 9% in year. 1

143 Board 12 th November 2015 Attachment D3 5.2 Mandatory Training Overall mandatory training rates reached 93% in September against a target of 90%. This is a significant achievement and work continues to ensure maintenance of performance and compliance at individual staff member level. compliance 92.0% 90.0% 88.0% 86.0% 84.0% 84.3% 84.5% 85.3% 85.3% 87.4% 89.0% 90% Mar-15 Apr-15 May-15 Jun-15 Jul % Aug % Sep-15 TARGET 5.3 Appraisal Appraisal rates compliance have stabilised at 81.25% and the numbers of staff receiving objectives continues to increase. Services have trajectories in place to reach compliance by end October, and training and active support for staff continues. SECTION 2: WF&OD Strategy Delivery. 6.0 Staff Engagement (WF&OD Strategic Objective #1) 6.1 Listening Events The HRD has commenced a series of Listening Events (staff open meetings) to meet with staff across the county to hear their thoughts on the positives and negatives of working for the Trust. The first two of these took place in October with good attendance. 2

144 Board 12 th November 2015 Attachment D3 6.2 Annual Staff Survey The 2015 annual staff survey launched on 21 st September and will run until 30 th November. It is again being run for the Trust by the Picker Institute as a full online census open to all staff. Work to encourage participation is ongoing. 6.3 East of England Recognition Awards The Trust submitted 12 nominations for these Regional recognition awards and 2 nominations have been shortlisted as Finalists to attend the end November Awards ceremony: Special Care Dental Service for NHS Leader of Inclusivity of the Year Tania Dunn for NHS Mentor/Coach of the Year. 6.4 Self-Managed Teams Approximately 70% of teams in Adult Services have now engaged or have firm plans to engage with the self-managed teams project. Feedback from the teams identifies particular impact on day to day work such as case management, team engagement and managing patient expectations. 7.0 Workforce Planning & Resourcing (WF&OD Strategic Objective #2) 7.1 Resourcing Plan A progress report against the Trust Resourcing Framework and Plan 2015/16 was discussed with the Board at Strategy and Resources Committee in September. The Trust s reconstituted Resourcing Group had its first meeting on 25 September and further oversight of resourcing activities is to be provided through the Trust PMO. The new Head of Resourcing role is out to advertisement and the consultation on the revised resourcing team structure/outsourcing closed on the 22 October with no changes made to the proposal. 7.2 Recruitment Pipeline The number of posts going through the recruitment process has reduced substantially this month, with a large number of new starters in September 2015 (including student Health Visitors). Of the 462 posts in the pipeline (not all currently vacant), there are 300 with offers made and 162 at advert and interview stage (75 in E&N Business Unit). 7.3 Temporary Staffing Nursing Agency Spend Following submission from the Trust setting out its requirements for temporary staffing and a Monitor/TDA recalibration exercise, the 8% ceiling on agency pay as a proportion of the total Trust pay bill has been raised to 9% for the remainder of 2015/16. 3

145 Board 12 th November 2015 Attachment D3 Proposals for a cap on agency hourly rates are being consulted on. Following a phased implementation, these plans would result in agencies being paid no more than 55% above the Agenda for Change rate for the band (including on-costs and agency cut). 7.4 Winter Planning The HRD has hosted three Hertfordshire system level meetings on temporary staffing provision in preparation for winter pressures, looking at a shared approach to incentives and the allocation of the limited resource. Partners include WHHT, HVCCG, HPFT, ENHT, NHS-P and Beds & Herts Workforce Partnership. 8.0 Employment Practices (WF&OD Strategic Objective #4) - Equality & Diversity 8.1 Staff Flu Campaign The 2015 staff Flu campaign is underway, with Flu Champions identified and OH led clinics held through October and continuing in the beginning of November. As at 30th October 2015 the uptake of patient facing staff was 29%. 8.2 Staff Exit Information There has been a renewed focus on the quality and availability of exit information as part of the Resourcing Plan. New mechanisms for gathering information include: additional questions on leavers form, structured telephone interviewing of staff leaving from hot spot areas and a new online exit questionnaire to allow staff to provide information anonymously. Each Business Unit is analysing its exit data and developing action plans to address negative trends. 8.3 Equality Delivery System2 & WRES Implementation of the newly mandatory Equality Delivery System2 (EDS2) commenced in October. The EDS2 is an assessment of performance undertaken by patients, public and staff. It consists of four goals and 18 outcomes which provide focus for progression across the equality and diversity agenda. A panel with representatives from protected groups was brought together on 19 October to review evidence and agree a grade for the nine patient-focused outcomes. The diverse range of organisations included: Herts Hearing Advisory service Carers in Herts HertsAid MIND Mid Herts HealthWatch National Autistic Society A second grading meeting will take place with staff side and staff on 17 November. The Trust has published its first Workforce Race Equality Standards (WRES) report with the data having been discussed by the Strategy & Resources Sub-Committee. Feedback from the EDS sessions and the WRES Report will be used to identify priority Equality & Diversity actions for Operational Services quality & diversity training Key staff in the Diabetes Specialist Service received Equality and Diversity training to ensure compliance with equalities legislation in every aspect of their work, and to embed the principles of equality and fairness into the day to day running of the service. 4

146 Board 12 th November 2015 Attachment D3 An update on learning disabilities was delivered to Dementia Champions with the aim to help them encourage staff to make a positive difference to the patient experience for people with a learning disability. 9.0 Leadership & Development (WF&OD Strategic Objective #6) 9.1 Leadership Engagement Over 60 senior leaders attended the Senior Leaders Quarterly Forum on 6 th October to hear Laura Hailes from Nottingham City University Hospital talk about Shared Governance, feedback from attendees was very positive with expressions of interest in how this concept can be used in HCT. The success from the Senior Leader s Forum has led to a Leaders Forum being set up. Attendees are band 6/7/8 who do not report directly to a General Manager/Deputy Director. The first forum was held on 20 October with strategic updates and record keeping being key topic areas. 9.2 Leadership Development The Senior Manager s Development Programme was reviewed with the Executive Team to ensure fit for purpose and generated discussion around CPD requirements for this level. 24 first line managers and team leads commenced the internal Making a Difference Foundations in Management and Leadership programme with another 24 waiting to commence in January National Actions 10.1 Pensions Changes Preparation is underway for communicating changes to the state pension which will end contracting out of a proportion of NI contributions and so impact financially on individual staff and the Trust Total Reward Statements This year s annual statement is now available to all staff Agency Costs The Trust is considering implications of the plans announced by the Department of Health that the hourly rate the NHS can pay for clinical agency staff will be capped at 55% above the pay levels of permanent staff. The cap will be phased in from 23 November through April 2016, subject to a consultation. SECTION 3: Risks & Challenges 11.1 Vacancies Vacancy levels remain a risk, with additional services adding these to the HLRR, despite the overall vacancy rate coming down slightly (see section 5.1). Alison Shelley Director of HR & OD November

147 Board 12 th November 2015 Attachment D4 Board Committee Chair s Assurance Report Strategy & Resources Committee Date of Board Meeting: 12 th Nov 2015 Committee Chair: Dr. Linda Sheridan Date of Committee Meeting: 27 th October 2015 Date of Report: 4 November 2015 Dates of Committee Meetings Held Since Last Board Meeting: 22 nd September 2015 Date of Next meeting: 24 November 2015 Item Ref Subject Director s Risk Assessment (H/M/L) (R/A/G) Committee Assurance Assessment (R/AR/AG/G) Risks Arising From Minutes / Tracker Updates: Tr1 None N/A Green Committee Chair s Observations Urgent Business 37/U Gossoms End Temporary Closure Strategic Overview, Core Strategies and Business Planning: 37/4 West Herts Strategic Review Verbal unrated Red Med/low Amber/ Red A clear process has been put in place following appropriate escalation of staffing concerns. While the committee was assured by the actions taken the underlying issue continues to be a concern. 1 A verbal update following recent joint boards meeting. Lack of clarity about the strategy continues to be a significant concern to HCT

148 Board 12 th November 2015 Attachment D4 37/5 Integrated Programme Boards update Verbal unrated Amb / Red Verbal reports of progress on both integration programme boards shows more clarity about future direction of travel and implication for HCT 37/6 Small Service Resilience Verbal unrated Amb / Red At request of the Healthcare Governance Committee this issues has been considered as a risk to the trust. We were assured that work is in hand to consider and improve the resilience of these services 37/7 Trust Strategy and Vision Communication Verbal unrated Amb / Red Good progress being made 37/8 End of Life strategy and CQC issues update Verbal unrated Amb / Red Some delays to this work 37/9 Marketing Strategy Med / Low Amber/ Red This strategy still lacks clarity about the trust s priorities Workforce and OD: 37/10 Workforce Race Equality Standard Med/ High Amber/Red A good report and starting point for work to address the issues raised. Demonstrates the benefits of the ESR and pulse surveys in understanding workforce equality issues. TDA: 37/11 TDA Self-Certification Submission (September 15) Med / Low Amber/Green The committee supported this submission 2

149 Board 12 th November 2015 Attachment D4 Performance & Metrics: 37/12 IBPR unrated Improvements around mandatory training, but concerns raised at red rating of community bed days lost due to delayed transfers of care, which seems to be a growing problem Finance and Estates: 37/13 Finance Report Month 6 (September 2015) Med / High Amber / Red Still forecasting that the trust will meet its financial targets for the year 37/14 PMO update Med / High Amber / Red Clear update with proposals to improve reporting structure for HCT s portfolio and for a prioritisation model which the committee supported 37/15 Estates Update Med / Low Amber / Green Good progress being made on estates strategy Contracts and Commercial: 37/16 Business Opportunities update Med / High Amber / Red The committee supported the new approach to the business development pipeline but there are continuing concerns about this work 37/17 Commissioning intentions Med / Low Amber / Green 37/18 Approach to Business Planning and contracting for 2016/17 Med / Low Amber / Green The committee welcomed sight of these documents but noted that there is no commissioning intentions document available for HVCCG The committee supported the approach to business 3

150 Board 12 th November 2015 Attachment D4 37/19 IM&T SystmOne Procurement update Standing Items 37/20 Urgent Care performance report Med / Low Amber / Green planning and contracting for 2016/17 The committee welcomed progress being made on IM&T procurement High Red The committee expressed concern at the current pressures on urgent care and lack of clear plans to address a predicted bad winter. Other Urgent Business: (List Below): AoB1 none Summary of Committee governance issues and any other points for the Board s Attention No items 4

151 Board 12 th November 2015 Attachment D4 Definitions and Key: Green Amber / Green Amber / Red Red (A) Executive Director s Risk Assessment High (Red) Risks associated with this issue: (1) Include high scoring risks (15+) which have been recorded on the appropriate risk register (ie HLRR (Operational) or BAF (strategic)) or (2) Will be recorded on the appropriate risk register following committee / Board / Executive Team deliberation. Medium to High (Amber / Red) Risks associated with this issue: (1) Include Medium scoring risks which have been recorded on the appropriate risk register (ie Business Unit (Operational) or BAF (strategic)) or (2) Will be recorded on the appropriate risk register following committee / Board / Executive Team deliberation. Medium to Low (Amber / Green) Risks associated with this issue: (1) Do not require recording on the relevant risk register but continued monitoring for any risks emerging required or (2) Associated risks have been recorded on the relevant risk register but circumstances are now such whereby de-escalation is proposed. Low (Green) (1) No risks or insignificant (low scoring: risks) not necessary to record on risk registers. (B) Committee Chair s Assurance: Red (Negative Assurances): The Committee considers that there are currently significant gaps / weaknesses in actions to manage risks, controls or assurances which are of sufficient concern to the Committee to require escalation to the Board for consideration and agreement on actions required 5

152 Board 12 th November 2015 Attachment D4 Amber / Red (Limited Assurances): The Committee considers that there are some gaps / weaknesses in actions to manage risks, controls or assurance which are of sufficient concern to require escalation to the Board for information at this stage Amber / Green (Reasonable Assurances): The Committee has received reasonable assurance on behalf of the Board as to actions to manage risks, controls and assurances. Green (Significant Assurances): The Committee has received significant assurance on behalf of the Board as to actions, to manage risks, controls and assurances. 6

153 Board: 12 th November 2015 Attachment D5 TRUST BOARD Title FOUNDATION TRUST PROGRAMME PROGRESS REPORT Meeting Date 12 th November 2015 Executive Lead Author For DAVID LAW, CHIEF EXECUTIVE Val Davison, FT Programme Manager INFORMATION 1 PURPOSE 1.1 To update the Trust Board regarding the progress in achieving Hertfordshire Community NHS Trust s aim to become a NHS Foundation Trust (FT). 1.2 The Board is asked to note progress to date against key milestones and the key risks to delivery. 2 BACKGROUND 2.1 The CQC Summit held in July confirmed a rating of Requires Improvement which resulted in the FT application timeline being put on hold pending reinspection. This is because a Good rating is a necessary precursor to the external Historic Due Diligence Review and TDA Readiness Review. 2.1 The date of the CQC re-inspection is not yet known. 3 FT APPLICATION PROGRESS 3.1 Although the formal FT programme timeline has been suspended due to the CQC rating, work continues on those elements of the FT application that are within the Trust s control with a focus on further developing the plans to support the Trust s strategy and self-assessment against the Well Led Framework. 3.2 The draft Integrated Business Plan, supporting strategies and Long Term Financial Model were submitted to TDA for informal review in September. Feedback is yet to be received. 3.3 A Strategy development workshop has been held in the Children, Families and Young Peoples division and a similar event is scheduled for the Adults Services Division later this month. 1

154 Board: 12 th November 2015 Attachment D5 3.4 An initial desk top assessment against the Well Led Framework has been completed which will be considered by the Board in November so that any gaps can be identified and an action plan developed. 3.5 The Board FT development programme has continued with sessions on Being an Effective Member Organisation, Strategy and Planning and Risk Management. 3.6 Although preparation for the Historic Due Diligence Review was completed in September, TDA have since confirmed that the review will not be scheduled until a Good rating is received from CQC. 4 RISKS AND ISSUES 4.1 The Board FT sub-committee routinely considers the key risks to achieving FT status and is responsible for agreeing and delivering mitigating actions to address the risks. 4.2 The FT Programme has a number of risks to delivery, the most significant of which are: The timescale for CQC re-inspection and the requirement for a rating of at least Good The timescale for the Historic Due Diligence Review which is outside of the Trust s control The impact of the West Herts review Your Care Your Future 4.3 As a result of on-going work to develop the Trust s long term financial plan and Cost Improvement Programmes the risk scores associated with these elements of the application have been reduced. 4.4 All other risks to the FT programme remain largely unchanged. 5 RECOMMENDATIONS 5.1 The Trust Board is asked to note progress with developing the FT application. 2

155 Board: 12 th November 2015 Attachment D5 Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year): FTC November 2015 Issues arising from committee consideration None Data Quality Statement By way of assurance to the Board, and in order to inform discussion / decision, the accountable executive director confirms that to the best of their knowledge, and subject to any exceptions identified, data contained in this report is: Data Quality Domain Complete Accurate Relevant Up To Date Valid Clearly Defined Description Comments / Exceptions / x Information is as comprehensive as possible to inform the board and no significant known facts or statistics which may influence a decision are omitted. As far as can be reasonable ascertained or validated, information in the report is accurate. Information contained in the report is relevant to the matters considered in the report. Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written Information is presented in a format which complies with internal or national models or standards The meaning of any data in the report is clearly explained Executive Director Sign-Off This paper has been approved by the accountable executive director who is satisfied that (i) the implications for risks, (ii) quality/service/regulatory impacts and (iii) resource implications, have been considered. David Law, Chief Executive Company Secretary Sign-Off (Board papers only) This paper has been quality control checked and approved by the Company Secretary 3

156 Board: 12 th November 2015 Attachment D6 Board Committee Chair s Assurance Report Foundation Trust Committee Date of Board Meeting: 12 th November 2015 Committee Chair: Alan Russell Date of Committee Meeting: 4 th November 2015 Date of Report: 4 th November 2015 Dates of Committee Meetings Held Since Last Board Meeting: 4/11/15 Date of Next meeting: 3 rd February 2016 Agenda Ref Subject Director s Risk Assessment (H/M/L) (R/AR/AG/G) Risks Arising From Minutes / Tracker Updates: 64/4 Tracker Items: 625i Strategy Co-ordination needed for final IBP Committee Assurance Assessment (R/AR/AG/G) Committee Chair s Observations H A/R Executive Team to review and follow up from Board away session in Nov /7 Well-Led Framework Foundation Trust Application 64/5i 64/5ii Timeline and Work streams update (including Q2 Readiness Assessment) FT Programme Risk Register A/G A/G Process and framework in place for March 2016 final sign off A/R A/G FT timescale still uncertain. Agreed that FTC meetings now be held quarterly rather than monthly. (Next meetings Feb and May 2016). A/G A/R Register reflects key risks. (Individual risks variable in terms of score). 64/5iii CIPs 2 year forward plan H A/R CIPs need to be strategic to achieve a two year programme 1

157 Board: 12 th November 2015 Attachment D6 64/5iv FT Board briefing programme G G Programme highly regarded and well-received. Communication & Engagement 64/6i No items FT Governance 64/7i 64/7ii 64/7iii FT Membership Quarterly update FT Budget Quarterly update FTC and FTSG meetings schedule G A/G Recruitment successfully continuing. A/R A/R Current overspend to be reviewed by SMT G G Meetings to go quarterly pending certainty. Information from Community Providers 64/8ii Update from events attended For Information Only CApp attended NHS Providers event on Membership and Governors on 2/ Noted that Monitor now places more emphasis on representative nature of membership rather than actual numbers. Any Other Urgent Business No Items Summary of Committee governance issues and any other points for the Board s Attention The Committee is working on a programme which is currently paused, pending CQC re-inspection. Consideration is being given as to how the FT model might evolve into, eg an accountable care organisation, so that as much FT work as possible is re-usable. 2

158 Board: 12 th November 2015 Attachment D6 Definitions and Key: Green Amber / Green Amber / Red Red (A) Executive Director s Risk Assessment High (Red) Risks associated with this issue: (1) Include high scoring risks (15+) which have been recorded on the appropriate risk register (ie HLRR (Operational) or BAF (strategic)) or (2) Will be recorded on the appropriate risk register following committee / Board / Executive Team deliberation. Medium to High (Amber / Red) Risks associated with this issue: (1) Include Medium scoring risks which have been recorded on the appropriate risk register (ie Business Unit (Operational) or BAF (strategic)) or (2) Will be recorded on the appropriate risk register following committee / Board / Executive Team deliberation. Medium to Low (Amber / Green) Risks associated with this issue: (1) Do not require recording on the relevant risk register but continued monitoring for any risks emerging required or (2) Associated risks have been recorded on the relevant risk register but circumstances are now such whereby de-escalation is proposed. Low (Green) (1) No risks or insignificant (low scoring: risks) not necessary to record on risk registers. 3

159 Board: 12 th November 2015 Attachment D6 (B) Committee Chair s Assurance: Red (Negative Assurances): The Committee considers that there are currently significant gaps / weaknesses in actions to manage risks, controls or assurances which are of sufficient concern to the Committee to require escalation to the Board for consideration and agreement on actions required Amber / Red (Limited Assurances): The Committee considers that there are some gaps / weaknesses in actions to manage risks, controls or assurance which are of sufficient concern to require escalation to the Board for information at this stage Amber / Green (Reasonable Assurances): The Committee has received reasonable assurance on behalf of the Board as to actions to manage risks, controls and assurances. Green (Significant Assurances): The Committee has received significant assurance on behalf of the Board as to actions, to manage risks, controls and assurances. 4

160 Board 12 th November 2015 Attachment D7 Board Committee Chair s Report COMMUNITY ENGAGEMENT COMMITTEE Date of Board Meeting: 12 th November 2015 Chair: Brenda Griffiths Date of Report: 22 th October 2015 Dates of Committee Meetings Held Since Last Board Meeting: 21 st October 2015 Date of Next meeting: 18 th February 2016 Red (Negative Assurances): The Committee considers that there are significant gaps / weaknesses in controls or assurance in respect of the following issues and which are of sufficient concern to the Committee to require escalation to the Board for consideration and agreement on actions required Issue(s): Committee Chair s Comments NONE Amber / Red (Limited Assurances): The Committee considers that there are some gaps / weaknesses in controls or assurance in respect of the following matters and which are of sufficient concern to require escalation to the Board for information at this stage: Issues: Committee Chair s Comments NONE Amber / Green (Reasonable Assurances): The Committee has received reasonable assurance on behalf of the Board as to controls and assurances in respect of the following matters: Issues: Committee Chair s Comments NONE. 1

161 Board 12 th November 2015 Attachment D7 Green (Significant Assurances): The Committee has received significant assurance on behalf of the Board as to controls and assurances in respect of the following matters: Issues: The Terms of Reference and membership of this new Committee were discussed and minor amendments agreed. The core Terms of Reference were agreed by the Board in July See below for minor amendments Summary of Committee governance issues and any other points for the Board s Attention This was the inaugural meeting of the new Committee. Items on the agenda were not risk rated at this stage. The Committee will seek to provide the Board with assurance that the organisation is engaging with the communities it serves. Future meetings will explore progress with external engagement with service users, partners and stakeholders. Brand recognition, new web site and issues regarding members and Governors will all be on future agenda. There will be a focus on engagement with GPs For the Board to note, the following minor amendments were agreed to the Terms of Reference: Director of HR and OD to be removed from Committee Members but will be welcome to attend Remove staff engagement as this will be reported via the Workforce and OD Group, reporting to Strategy and Resource Committee Inclusion of requirements around equality and diversity. It is accepted that our staff are absolutely critical to successful engagement at every level. However, this Committee will have a focus on external engagement. Internal communications and staff engagement will continue to be reported through SRC. The obvious overlap with be managed by close liaison with HR Director and CEC Chair s membership of SRC. Similarly, overlaps with matters regarding members and Governors will be covered by FT C Chairs membership this Committee. 2

162 Board 12 th November 2015 Attachment D8 TRUST BOARD Title: COMMUNICATIONS AND ENGAGEMENT STRATEGY Meeting Date: November Executive Lead: Author(s): For: David Law, Chief Executive Christopher Knibb, head of Communications and Engagement APPROVAL 1.0 Purpose & Recommendations 1.1 To ask the Board to: Approve the Trust s new Communications and Engagement Strategy which has been approved by the Community Engagement Committee, subject to minor changes being made. 2.0 Executive Summary 1. The existing Hertfordshire Community NHS Trust s (HCT s) Communications Strategy was approved by the Board in early Since then the Trust has invested in increasing its communications capacity and capability to ensure it actively engages with its stakeholders. 2. Too often, organisations focus the number of communications they issue rather than understanding the intended impact on key audiences. Strategic communications will support the Trust identify issues, set priorities, define strategies, and determine performance expectations. 3. Non-strategic communication activities are program-focused, activity-oriented and reactive. This approach relegates communications to a support function where value is measured by output rather than outcome. This strategy positions and identifies both the strategic and tactical communications needed to achieve a series of outcomes, targets and measurable actions. 3.0 Relevant Strategic Objective(s) / Strategies 6 Impacts on all Strategic Objectives 3.2 Links to: Influencing the Influencers Strategy 1

163 Board 12 th November 2015 Attachment D8 4.0 References, Appendices & Attachments References Hertfordshire Community NHS Trust website About Us NHS England Five Year Forward View Ipsos MORI s - Frontiers of Performance in the NHS report, 2004 DH - The Communicating Organisation, 23 November 2009 HSJ and Nursing Times - Top 120 Best Places to Work in the NHS, June 2015 Pat Oakley The Five-Year Forward Plan Summary of the Main Policies and Key Issues for Community Services presentation, June 2015 DH - NHS Act 2006 Central Government - Equity and Excellence Liberating the NHS White Paper, July 2010 Appendices & Attachments (1) Communications and Engagement Strategy Author(s) of paper: Christopher Knibb Head of Communications and Engagement November

164 Board 12 th November 2015 Attachment D8 Sign Off: To be completed as part of papers to Executive Team, Board Committees and Board Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year): Community Engagement Committee October 2015 Issues arising from committee consideration Approved subject to minor amendments such as Board date and reference to quantitative evaluation. Data Quality Statement By way of assurance to the Board, and in order to inform discussion / decision, the accountable executive director confirms that to the best of their knowledge, and subject to any exceptions identified, data contained in this report is: Data Quality Domain Complete Accurate Relevant Up To Date Valid Clearly Defined Description Comments / Exceptions / x Information is as comprehensive as possible to inform the board and no significant known facts or statistics which may influence a decision are omitted. As far as can be reasonable ascertained or validated, information in the report is accurate. Information contained in the report is relevant to the matters considered in the report. Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written Information is presented in a format which complies with internal or national models or standards The meaning of any data in the report is clearly explained Executive Director Sign-Off This paper has been approved by the accountable executive director who is satisfied that (i) the implications for risks, (ii) quality/service/regulatory impacts and (iii) resource implications, have been considered. David Law CEO Company Secretary Sign-Off (Board papers only) This paper has been quality control checked and approved by the Company Secretary 3

165 COMMUNICATIONS AND ENGAGEMENT STRATEGY 1

166 TABLE OF CONTENTS Paragraph Page 1.0 Introduction Purpose The Trust Vision Values Strategic Objectives Clinical Themes The Key Standards and Principles of Good Communications The Importance of Good Communications Hertfordshire Community Trust s Communications Pledge Four Attributes of a Communicating Organisation Excellent Understanding of Brand Excellence in Planning, Managing and Evaluating Communication Leadership Support for Communications Communication as a Core Competency Linking our Values to our Communications Aims of the Communications Strategy Communications and Engagement Objectives Strategic Positioning Audiences Internal External Stakeholder Map Key Messages Overarching Messages Key Messages Supporting Strategies and Action Plans Visual Brand Communications Channels Internal External Membership, Public and Service User Engagement Membership Patient and Public Engagement Engagement Model The Trust s Engagement Process Resources, Governance and Offer Governance Framework Monitoring and Evaluation Conclusion Next Steps References 17 2

167 1.0 Introduction The existing Hertfordshire Community NHS Trust s (HCT s) Communications Strategy was approved by the Board in early Since then the Trust has invested in increasing its communications capacity and capability to ensure it actively engages with its stakeholders. It is now timely to review the Communications and Engagement strategy. In October 2014 NHS England published a Five Year Forward View 1. The view set out a clear direction for the NHS showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions need new partnerships with local communities, local authorities and employers. The Five Year Forward View identified the need for a big improvement in helping people live healthier lives so that they don t get ill so much. It states the future will see far more care delivered locally. One new option will let groups of GPs join with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care the Multispecialty Community Provider, it says. It also highlights the need for the NHS to provide more support for frail older people living with multiple long-term conditions. 2.0 Purpose Too often, organisations focus the number of communications they issue rather than understanding the intended impact on key audiences. The NHS calls this type of activity SOS or Send out Stuff. Strategic communications will support the Trust identify issues, set priorities, define strategies, and determine performance expectations. Non-strategic communication activities are program-focused, activity-oriented and reactive. This approach relegates communications to a support function where value is measured by output rather than outcome. This strategy positions and identifies both the strategic and tactical communications needed to achieve a series of outcomes, targets and measurable actions. 3.0 The Trust The Trust was established in 2010, employs about 3,000 people and is responsible for delivering a wide range of community health services across Hertfordshire. It serves the communities of Broxbourne, Dacorum, East Herts, Hertsmere, North Herts, St Albans, Stevenage, Three Rivers, Watford and Welwyn/Hatfield. The Trust also provides children's specialist community services in West Essex. 3.1 Vision We will maintain and improve the health and wellbeing of the people of Hertfordshire and other areas served by the Trust 3.2 Values 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 at all times. Confidence - We do what we say we will do. 3

168 Improvement - We will improve through continuous learning and innovation. 3.3 Strategic objectives We will support the people we serve to manage their own health and wellbeing. We will improve clinical outcomes and enhance patient safety. We will support the substantial expansion of community services through the delivery of excellent core services for adults and children and the development of ambulatory services. We will use resources efficiently to enhance our ability to improve services. We will develop the organisation's capacity to deliver our vision and objectives. 3.4 Clinical themes The heart of our Clinical Strategy for providing care to our service users, both young and old, is to deliver services that: Prevent illness and intervene early. Maximise independence. Minimise the impact of Long Term Conditions. Respond in times of acute illness. Maximise health in the last year of life and plan for a good death. 4.0 The key standards and principles of good communication 4.1 The importance of good communication Good quality and effective communication is essential to any organisation. Effective communication will enable HCT to manage, motivate, influence, explain and create conditions for change. Good communication is not just the simple exchange of information, it requires involvement and the management of relationships to work and be effective. There is a wide range of evidence to support the significant contribution that effective communication can make to improving organisational effectiveness and performance. This evidence also applies to public services. In a study, Ipsos MORI found that better-performing NHS trusts committed more resources to communication, were more likely to have marketing strategies in place, and had communication teams that were more influential Hertfordshire Community Trust s communications pledge Hertfordshire Community Trust will be open and honest in all forms of communications at all times. The Trust will only withhold information when there is a risk that patient information, contractually sensitive information or legal processes will be compromised or where it will conflict with our duty of care to patients. It is essential that both internal and external communication is an integral part of the work carried out by the Trust and is everyone s responsibility. 4.3 Four attributes of a communicating organisation 4 In 2009 the Department for Health and the NHS commissioned the University of Leeds to conduct research into what makes an NHS Trust an effective communicating organisation. Below are four attributes that were developed as a result of the research and how these will be implemented by HCT Excellent understanding of the brand 4

169 The components of a brand are far more complex than purely the brand image. A communicating organisation brings its brand to life through the services it provides, as well as through its customer service, engagement and communication activity. The HCT Way The stakeholder relationships built and maintained by effective communication will provide intelligence which will help us to tailor our services to local needs. Capturing insights, working to our values, engaging with staff, partners, members and the communities we serve will ensure we understand how our services are perceived and make changes when needed. The role of the communications team will be to act as the brand guardian, protecting and enhancing the Trust s reputation Excellence in planning, managing and evaluating communication High-performing organisations ensure that their communication is proactive (planning and implementing strategies), reactive (responding to attacks on the organisation and taking advantage of opportunities to highlight its good work) and interactive (engaging in two-way dialogue through faceto-face, digital and other channels). The HCT Way By planning, managing and evaluating our communication activity, the Trust will gain a thorough understanding of its communities and stakeholders and anticipate and manage our reputational risks and ensure that our perception of performance matches the experience of the people who use our services Leadership support for communication Effective leadership can clearly express the organisational purpose to employees and set out how that purpose will be achieved at a local level. The HCT way We will ensure our leaders can articulate the Trust s vision in a way that resonates with patients and the public, as well as other external stakeholders. Our Board and senior managers will have an important role in explaining what the organisation is trying to achieve, defending it in the face of unjust criticism and, when things go wrong explaining how they will put them right. The communications team will play an increasingly active role in supporting the Trust by providing strategic advice and counsel Communication as a core competency The responsibility for good communication does not fall on the shoulders of the communications team alone. It is the responsibility of all managers and all staff, in the same way that good financial management is not just the responsibility of the finance department. The HCT way We recognise our staff as our greatest asset. We will engage with our staff so that the Trust continues to be an employer of choice 5. The communications function will support the Trust s leaders to ensure all staff have a clear understanding of our vision, future direction and narrative. In addition, it will emphasise the role all staff have of capturing service user and other stakeholder intelligence and enhance our reputation and brand Linking our values to our communications 5

170 Below are HCT s Standards and Principles of good communication, which link to our values of Care, Respect, Quality, Confidence and Improvement - and will be used as a basis of all our communication activity at Hertfordshire Community Trust: Communication is everyone s responsibility and not just the role of one team. Every member of staff shares the responsibility for effective communication. The Trust will regularly evaluate its communications and engagement mechanisms and messages to ensure it maintains high quality standards. Communications should always be a two-way process. As well as getting the right messages to the right audiences, through the most appropriate channels at the most appropriate times, the Trust will endeavour to capture feedback and act on it. We will communicate clearly and to professional standards, using methods appropriate for our different audiences, internally and externally. 5.0 Aims of the Communications Strategy The communications strategy is one of the key documents developed to support delivery of our five year strategic plan. Its key aims will be to: Engage and persuade audiences of the value of HCT Persuade audiences of HCT s commitment to provide high-quality, personalised care in the community Demonstrate the impact of our services and persuade audiences of the value we bring to the health economy Promote understanding of and support for the Trust s vision, strategy and five-year plan. Develop clear two-way communications with all partners and influential local opinion formers to support close working and understanding. Build trust in the organisation by users of the service, partners and the public and build and protect the Trust s reputation. Actively encourage people who use our services to provide feedback on their experience and to use this to continuously improve the quality of our services. Build loyal and lasting relationships and confidence in HCT through active patient, carer, member and public engagement. Ensure staff share in the values and strategic objectives of the Trust and understand their contribution to making these real. Support the Health and Wellbeing of all staff for the benefit of our workforce and the larger community and the rights and responsibilities of staff, as set out in the NHS Constitution 6.0 Communications and Engagement Objectives Describe the Trust s strategy to staff and partner organisations to engage them in its delivery, with dissemination to all staff and identified partners. Engage staff in the implementation of the Trust s strategy and also the communications work of the Trust. Use a suite of patient stories through a variety of channels to the public and stakeholders which demonstrate the value of the services provided by HCT. Engage members in the business of the Trust through a range of interest and focus groups Implement a corporate engagement plan with identified stakeholders that builds on mutual understanding, the reputation of the Trust and identifies opportunities for development. Develop a public engagement and involvement plan to inform and drive future service improvements. Work with Human Resources to develop and deliver a staff communications and engagement plan. Engage clinical and medical staff and strategic clinical/medical stakeholders across the sector to support integration and develop common understanding and direction of travel. Develop effective strategic and operational relationships within the system. 6

171 7.0 Strategic Positioning Our brand ambition is for Hertfordshire Community NHS Trust to be seen as the solution to the local healthcare system, delivering more care in the community and integrated services with statutory and voluntary partners. We will develop offers promoting our services as The Place in the Middle 6, We know from experience that understanding of our Trust and what it delivers is limited and the provision of healthcare generally can be confusing. Raising awareness of the Trust and what it does through proactive media communications and a redeveloped website will help. We also need to develop a systematic way to engage with our key stakeholders and partners with the aim of achieving our strategic objectives which will, in turn, improve our position and awareness in the community. 8.0 Audiences The Strategy is aimed at both staff and external stakeholders. It outlines our key communication objectives, how these will support us in delivering our five year strategy and in-year business plans and how our approach will be reviewed and evaluated. It also signposts the reader to key supporting documents, strategies, protocols and procedures. 8.1 Internal All staff groups Elected FT Staff Governors Trust Board Staff-side representatives Volunteers and Friends of HCT 8.2 External Public People who use our services and their families and carers Members Governors Media Healthwatch Local Strategic Partnerships Overview and Scrutiny Committees Health and Well-being Boards Population of Hertfordshire, West Essex and locations where the Trust provides services MPs and MEPs Hertfordshire County Council, Borough, District and Town Councils officers and councillors Herts Valley CCG, East and North Hertfordshire CCG and West Essex CCG NHS England Hertfordshire and South Midlands NHS England East Anglia Department of Health GPs and other health practitioners in our area Voluntary Community Other Hertfordshire and West Essex trusts 7

172 Key messages 9.1 Overarching messages Our ambition is to change the face of health and social care in Hertfordshire, delivering a 21st century service to respond to 21st century needs. We will continue to improve health and wellbeing for the population we service. We will improve people s experiences of our services and reduce the costs of care. We lead the development and delivery of community health services across Hertfordshire and beyond, ensuring they are personal, responsive and well-co-ordinated. 9.2 Key messages We will be at the heart of partnership working with organisations across health and social care delivering integrated, patient centred, services. We will become a successful NHS Foundation Trust with an engaged and active membership and Council of Governors. We will make full use of technology to support service delivery and patient self-management. We will more of our services in people s homes or on an ambulatory basis in the community. 9.0 Supporting strategies and action plans The following strategies and action plans complement the communication strategy and are available to download from the intranet and websites: Communications Plan Social Media Policy Membership Plan Stakeholder Map Key Stakeholder Strategy Communications Toolkit Clinical Strategy Media Handling Policy Market Strategy Workforce Strategy Integrated Business Plan 10.0 Visual Brand Staff are expected to adhere to the visual branding protocol which is available in the Communications Toolkit on the intranet. When creating their own materials, staff must seek advice from the communications and engagement team to help the Trust ensure all publication/online materials use our corporate visual branding. 8

173 12.0 Communication channels 12.1 Internal Noticeboard Team Brief Chief Executive s Briefing Clinical Matters HertBeat Trust Intranet Keeping In Touch visits Leading Lights Listening Events Leadership Conference Nursing Conference AHP Conference 12.2 External AGM Membership events Day-to-day service user contact Face-Face meetings with key stakeholders Service user involvement projects Public engagement events Media releases Social media updates bulletins HertBeat Online Surveys Trust website 13.0 Membership, public and service user engagement 13.1 Membership The Trust has a membership of more than 11,000 made up of staff, people who use our services, their families and carers, local residents and partner organisations. This membership has been developed as part of our process to become a Foundation Trust. The Trust is committed to the principles of effective community engagement and this group of people will be a key element of our engagement work in the next few years. During 2015/16 the Trust will develop a three-tiered membership model as it increases its engagement and recruitment activity. The model will be based on the offer below: Level three Level two Level one Members Magazine AGM Election Information Online Surveys Members events Option to support fundraising Members Magazine AGM Election Information Members Magazine AGM Election Information Online Surveys Members events Option to support fundraising Annual Planning/Strategy Tours Community Awards linked to strategy Training Opportunities Volunteering 13.2 Patient and public engagement True involvement provides our patients, their carers and the public with a real opportunity to influence the services we delivery by creating a culture where we actively listen and respond to their views. 9

174 Proactive patient and public engagement can also improve the experience of the people who use the Trust s services. Every NHS trust has a statutory duty to engage and involve patients in the planning of healthcare services under the NHS Constitution. Under section 242 of the NHS Act , it became mandatory for health service providers in England to involve and consult with patients in the development and planning of their local healthcare services. The last Government s White Paper Equity and Excellence Liberating the NHS 8 stipulated that services should be more responsive to patients and designed around them, rather than patients having to fit around services - "no decisions about me without me". In the statutory guidance, "involvement" is defined as a continuum, from giving service-users information to full decision-making collaboration between the Trust and the public and service-users. Different types of involvement use different techniques. For example, "giving information" might involve leaflets, radio adverts and public meetings; "getting information" might involve surveys, interviews and focus groups; "debate" might involve workshops or drop-in events; "participation" might involve service-users being on the management team. These methods are not by any means mutually exclusive and some service planning or change projects will incorporate a number of these techniques depending on the issue under consideration or the stage that the project is at. HCT is not statutorily bound to accept the outcomes of any involvement activity, but has to be able to demonstrate that these outcomes have been taken into account in the decision-making process. However, the Trust s position is that it will always consider the views of service users and other stakeholders when making decisions that affect services and the way they are delivered. The communications and engagement team will support engagement activity and should be consulted by those considering changes to services at the earliest opportunity. The team will provide advice on the level of engagement required, with particular focus on: Proportionality between the decision being made and the level of involvement activity. Whether the service change being made is temporary or permanent. The likely sensitivity of the group of service users affected by the change. The risk of reputational damage to the Trust Engagement Model HCT Engagement Model Patient Board Governors Manage Closely Carers Managers Council of governors 10 Keep satisfied Residents CVOs Public bodies Frontline staff Members Keep Informed

175 13.4 The Trust s Engagement Process Get engaged early Plan and initiate engagement at the earliest possible stage. Including lay reps from the outset builds shared ownership and commitment. Early engagement brings a lay perspective to setting the objectives and terms of reference. It assists the development of good working relationships and promotes the team. Looking at it from a different angle Think about the different perspectives the public and patients can bring: The individual s experience as a user or carer. The collective expertise of groups who support users and carers. The individual citizen as a potential service user. The individual as a participant in local democracy and as a taxpayer. Who to engage with Identify public and patient representatives or groups. Decide what sort of experiences might best suit your purpose. Consult the Communications and Engagement team for advice on engaging with whole groups. Always ensure there is more than one person; this takes the pressure off individuals, enables wider engagement and brings additional skills to the work. Valuing patient and public contributions Lay representatives expect to be active participants and take a share of the work. Engagement works best where people feel valued and part of a team effort. Take time early on to explain the purpose. Explain the process and how they can help. Specifically brief on the goals and how this work will affect local services. Help participants to understand the context, the issue and terminology. Introduce people: use badges and name plates. Share biographies. Get meeting papers out in good time. Bear in mind that not everyone has easy access to IT and printing can be expensive. Lay members will welcome the provision of longer documents in hard copy posted to them in good time. Responsibility to engage Engagement is a shared experience and shared responsibility. You need to ensure that your lay members are regularly briefed and as well-informed as their professional colleagues. Explain arrangements for travel and parking, expenses claims etc. Confidentiality: Ground rules about openness and transparency help to keep more items in the open. Acknowledge that there may be topics that are difficult to talk about at open meetings. When things aren t going to plan Reflect on the approaches used and the way meetings are conducted. Consider a buddy system whereby a lay person is supported by someone in the project group who can translate and provide a listening ear. If things are not working out, don t leave it; speak to the individual. It may be that an individual is not the right match for the project. Following up on engagement 11

176 Thank everyone for their contribution. Feedback: share findings, results, decisions made, what happened next. Use local patient participation groups, and other public and professional networks and communications. People are more likely to engage again when they receive feedback. Have we got it right? Reflect on the impact of engagement on the process, and the outcomes. De-brief participants on the experience. For large-scale projects always hold a lessons learned session Team s resources, governance and offer The Communications and Engagement team has been expanded over the past two years, with the focus on creating substantive roles. There are currently five members of the team. The function is part of the Trust s corporate services and reports directly to the chief executive. In 2015, the Board established a new sub-committee the Community Engagement Committee. The committee oversees the implementation of the Trust s communications and engagement strategy and annual action plans, providing assurance to the Board that HCT is successfully engaging with its stakeholders and communities. Following the changes in the team s capacity and capability, it is now able to offer: Engagement and membership 1 Engagement with public, patients, carers, communities and stakeholders 2 Customer insight 3 Formal consultation 4 Membership development and control 5 Membership communications 6 Governor elections and on-going communications Corporate Communications 7 Strategic advice and counsel 8 Clinical/staff engagement and internal communications 9 Reputation management 10 Media management 11 Intelligence gathering and briefing 12 Brand and corporate identity management 12

177 13 Emergency communications planning and preparedness 14 Crisis and issues management Campaigns and Products 15 Corporate and public campaigns 16 Graphic design 17 Event management 18 Editorial and publishing services 19 Digital and web communications and social media 20 Commissioning specialist services including photography, web design and video production 13

178 14.1 Governance framework Council of Governors Board as Corporate Trustee HCT Board Charitable Funds Committee Assurance Community Engagement Committee Executive Team Communications & Engagement Strategies (CEO) Delivery SMT Children s BU Briefing Herts Valley BU Briefing E&N BU Briefing Communications and Engagement network group Communications and Engagement steering group 14

179 15.0 Monitoring and evaluation If we are to ensure the Trust s communications and engagement work is evidence based and meets the needs of our key audiences, we need to continually evaluate and measure our activity and progress. Our key performance indicators will be: Positive reputation and brand recognition with the public and stakeholders via social media, surveys and media evaluation we will look for year on year improvements to their perception of our reputation. Staff satisfaction and engagement our work with staff, to inform and engage will be measured through both our own internal Pulse Survey and the annual independently run NHS staff survey. Changes to care and services as a result of our insight gathering we will track the impact of patient and public voices in our service development/transformation work and through performance management systems. Quantitative research focussing on 360 degree review of Trust reputation and GP engagement. If our work is successful, we will be able to track a shift in the behaviour of patients and the local community, such as an increase in self-management Conclusion The success of this communication and engagement strategy is dependent on the Trust s workforce. All our staff should be seen as the Trust s ambassadors and given the tools they need to protect and enhance the reputation of the Trust. Their interactions with service users, their families and carers, as well as the public and key stakeholders create a lasting impression about HCT Next steps The strategy will be reviewed in November 2015 by the Trust Board. The newly-established Community Engagement Committee will continue to monitor and oversee the delivery of the strategy on behalf of the Board References Hertfordshire Community NHS Trust website About Us NHS England Five Year Forward View Ipsos MORI s - Frontiers of Performance in the NHS report, 2004 DH - The Communicating Organisation, 23 November 2009 HSJ and Nursing Times - Top 120 Best Places to Work in the NHS, June 2015 Pat Oakley The Five-Year Forward Plan Summary of the Main Policies and Key Issues for Community Services presentation, June 2015 DH - NHS Act 2006 Central Government - Equity and Excellence Liberating the NHS White Paper, July

180 Board 12 th November 2015 Attachment D9 TRUST BOARD Title: INFLUENCING THE INFLUENCERS STRATEGY Meeting Date: November Executive Lead: Author(s): For: David Law, Chief Executive Christopher Knibb, head of Communications and Engagement APPROVAL 1.0 Purpose & Recommendations 1.1 To ask the Board to: Approve the Trust s new Influencing the Influencers Strategy which has been approved by the Community Engagement Committee. 2.0 Executive Summary 1. This paper outlines the stakeholder management strategy for Hertfordshire Community NHS Trust to support the delivery of its organisational objectives and its development over the course of the next five years. 2. It establishes why stakeholder engagement and management is important for HCT at this time, and sets out the current state of understanding of stakeholder power and impact, detailing key goals for each group. 3.0 Relevant Strategic Objective(s) / Strategies 6 Impacts on all Strategic Objectives 3.2 Links to: Communications and Engagement Strategy 4.0 References, Appendices & Attachments Appendices & Attachments 1. Influencing the Influencers Strategy 1

181 Board 12 th November 2015 Attachment D9 Sign Off: To be completed as part of papers to Executive Team, Board Committees and Board Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year): Community Engagement Committee October 2015 Issues arising from committee consideration Approved subject to minor amendments such as Board date and reference to quantitative evaluation. Data Quality Statement By way of assurance to the Board, and in order to inform discussion / decision, the accountable executive director confirms that to the best of their knowledge, and subject to any exceptions identified, data contained in this report is: Data Quality Domain Complete Accurate Relevant Up To Date Valid Clearly Defined Description Comments / Exceptions / x Information is as comprehensive as possible to inform the board and no significant known facts or statistics which may influence a decision are omitted. As far as can be reasonable ascertained or validated, information in the report is accurate. Information contained in the report is relevant to the matters considered in the report. Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written Information is presented in a format which complies with internal or national models or standards The meaning of any data in the report is clearly explained Executive Director Sign-Off This paper has been approved by the accountable executive director who is satisfied that (i) the implications for risks, (ii) quality/service/regulatory impacts and (iii) resource implications, have been considered. David Law CEO Company Secretary Sign-Off (Board papers only) This paper has been quality control checked and approved by the Company Secretary 2

182 INFLUENCING THE INFLUENCERS (Key Stakeholders) STRATEGY