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TRUST BOARD Meeting Date: 28th January 2016 Title: Supporting Papers Available electronically on the website at http://www.hct.nhs.uk/about-us/our-board/meeting-papers/ Executive Lead: Various Author(s): Various For: Noting The Board is requested to note the following supporting papers which are for information only and which are referenced in Executive Directors’ Reports. Lead Agenda
Link Title & Category Attachment
Clinical Services & Healthcare Governance
B1 (i) B2 (ii) B2(iii)
Log of Complaints Received Qtr 2 2015/16 Professional Clinical Leads Group Notes of the Healthcare Governance Committee Operational Review (End of Life Care) held on 10th December 2015
(J1) (J2) (J3)
(J4)
D2 (i) D4 (i)
(J5) (J6)
Board 28th January 2016 Attachment J1
Log of Complaints received 1st October 2015 31st December 2015: Total 62 East and North Herts CCG
ID Description Business Unit Service Locality
Is this a Red Flag
Complaint? Outcome
1073
2
Concerns raised about quality of loan wheelchair given to client. The chair has damaged the client's flooring. Also issues regarding the repair service provided.
Adult Services East & North
Wheelchair Service Herts Wide No
Apology provided for any distress caused. HCC will respond to request for compensation as the issue related to the repair of the wheelchair.
1075
2
ENHCCG leading - Concerns raised over the handling of a Continuing Care Retrospective Review case and assessment made by the community nurses.
Community Team
No Continuing Health Care paperwork was completed appropriately by the Nurses.
1077
2
Concern raised about difficulty in getting through to OT team on the telephone and that once phone was answered it was left on the side so that the caller could hear staff conversations.
Children’s Therapies
Children’s Occupational
Herts Wide No
Apology provided and appointment offered. Family did not wish to pursue the complaint any further. The Service is reviewing the Telephone system in order to improve functionality.
1
Is this a Red Flag
Complaint? Outcome
1080
2
ENHT Leading - Concerns raised regarding physiotherapy information provided pre operatively. Patient advised therapist that they felt the operation had not been successful and ENHT require information regarding post-operative care.
(Acute Therapies)
1084
2
ENHT leading - Concerns raised about the delay in receiving physiotherapy whilst an inpatient at Lister Hospital.
(Acute Therapies)
E&N Herts No Clinical care was appropriate as patient was medically unwell and unable to participate in therapy.
1086
2
ENHT Leading - Patient is very concerned with the waiting times to be seen by Women's Health Physiotherapy Service.
(Acute Therapies)
E&N Herts No
Explanation provided that the Women's Physiotherapy service received 4 referrals for patient for differing conditions which have different waiting times. Apology that the 4 referrals were not amalgamated into one.
1089
2
Complaint regarding difficulty in getting through to physiotherapy department to make a follow up appointment.
MSK Physio E&N / MSK
Triage E&N Herts No
Apology provided. Patient was offered an appointment and did not wish to pursue any further.
2
Is this a Red Flag
Complaint? Outcome
1090 2
ENHT leading - Concerns raised regarding the circumstances associated with mother's discharge from Lister Hospital. Specific concerns relating to dietician advice, lack of post hospital OT and physio and alleged disagreements at MDT meeting pre discharge.
Adult Services
Herts Valleys
Nutrition & Dietetics Herts Wide No
Therapy: Apology given that it was not clear in the notes that therapists had any active involvement in making recommendations or a clear plan for discharge. Action: Discussion with therapists involved requirement for accurate recording of their treatment, findings and to make clear recommendations and suggestion for further therapy. Dietetics: Action: Dietician should have checked formulary list prior to prescribing - is now aware of the importance of checking list.
1093
2
Concerns raised that letter was received stating that client had failed to attend an appointment and would be removed from the waiting list. Complainant states no appointment letter had previously been received. Difficulty in accessing the service via telephone also highlighted.
Service had wrong postcode on system for patient which could have accounted for appointment letter not arriving. Record amended with correct information. Issues regarding no return on phone calls were identified as not calls made to Wheelchair Service but to Herts Equipment Service.
1097
2
ENHT leading - Concerns raised about length of time to wait for physiotherapy appointment and referral for hydrotherapy but subsequently advised there is no facility for this. Also, a delay and confusion in getting required OT assessment.
MSK Physio E&N / MSK
Triage E&N Herts No
Clinical Care was appropriate. There are no Hydrotherapy Pools within the NHS in Hertfordshire. Confirmation received that no OT referral has been received by the service.
3
Is this a Red Flag
Complaint? Outcome
1098
2
Concerns regarding care mother received whilst in Herts & Essex Rehab Unit, ineffective therapy and sent home with limited care package and no home assessment.
1102
2
Concerns raised that the Specialist Diabetes Nurse has not returned their mother's call and she requires support and advice.
Adult Services
Herts Valleys
Service Herts Wide No
Agreed with complainant and patient that the patient would now be referred to the acute setting to manage their diabetes. Service confirmed that they had been contacting the patient as requested.
1107
2
Concerns raised about Stroke Early Support Discharge Team Services particularly relating to treatment received from SLT and that no Care Plan is in place.
No
Information Leaflets have been updated to ensure that they include accurate information regarding who will be attending home visits. Apology provided that care plan was not in place at the time of the complaint - processes have been reviewed to ensure that care plans are shared and completed in a more timely manner. SLT provided was appropriate based on clinical need.
1113
2
Concerns raised about lack of contact from the Wheelchair Service despite leaving messages about acquiring a replacement chair for complainant's son.
Apology provided that the administrator had noted down the wrong contact number for complainant and failed to cross reference. Complainant was offered an appointment and did not wish to pursue any further.
4
Is this a Red Flag
Complaint? Outcome
1114
2
Concerns raised regarding clinical care provided, patient felt they were in considerably more pain after session.
Awaiting correspondence from complainant - may not wish to pursue
1117
2
Concerns raised regarding ability to contact Health Visiting Team after a sudden child death and also concerns raised regarding response received from unexpected child death team.
Children’s Universal
No
Explanation provided that Rapid Response team only respond to unexpected child deaths and sadly this child had deteriorated and their death was expected. Apology provided that the GP was unable to speak to Health Visiting team but on review there was a fault on the line the GP used to call. The number is not provided to the public.
1127
2
Concerns raised regarding provision of equipment and continence products on discharge from hospital.
No
Explanation provided to the family that the community Nursing Team did not receive a referral from the discharge team. Assurance provided that carers could have referred patient for continence assessment.
1128
2
Concerns raised regarding lack of contact and involvement from ICT since discharge from Herts & Essex Hospital.
Is this a Red Flag
Complaint? Outcome
1132
2
Concerns raised via MP about Wheelchair Services. Significant delay in assessment and delivery of wheelchair. Complainant feels that he has limited independence due to lack of provision.
1133
2
Concerns raised that father has not received any physiotherapy whilst an inpatient.
(Acute Therapies)
Herts Valley CCG:
Is this a Red Flag
Complaint? Outcome
1076
2
Complaint regarding the way Family Health Visitor spoke to parents when making a home visit. Complainant's partner was very upset by a remark that was made, family felt that it was sarcastic.
Family Nurse Partnership Stevenage No Apology provided for any distress caused. Family
continue to be support by the FNP Team.
6
Is this a Red Flag
Complaint? Outcome
1078
2
Unacceptable wait and difficulty in chasing up OT referral for a replacement bath for son with Ehlers Danlos Syndrome. Unhappy with response from therapist that stated the complainant was unreachable and advised self-referral to Community OT. Also unhappy with therapist's recommendations to school. Community OT had no record of a referral. Complainant would like a new OT for son.
Children’s Occupational
Therapy Services
Herts Wide No Family were offered another therapist and they no longer wished to pursue the complaint.
1079
2
Complaint that Health Visitor was unprofessional. Telephone conduct lacked compassion and that concerns were raised over patient confidentiality and incorrect identification of the child that was being discussed.
No
Apology given for conduct of Health Visitor during telephone call to mother. Actions: Another Health Visitor has been allocated to the family and a targeted piece of work is being offered to family. Health Visitor concerned has reflected on the phone call and has accepted the learning from this complaint.
7
Is this a Red Flag
Complaint? Outcome
1081
2
Concerns that a copy of the child's advance care plan was put in child's school bag for all to see. Family are also concerned regarding child's communication book that was sent home with another child.
Children’s Specialist
West Herts No
Apology provided. All staff have attended a training day and discussed the concerns raised and a number of actions have been identified. All staff have been asked to file letters/reports appropriately and not to leave paperwork inappropriately in communal areas of the unit. All staff have been asked to review paperwork before placing it in school bags in order to ensure that it is appropriate to do so. Any paper information other than a communication book will be placed in a correctly addressed sealed envelope before being placed in a school / overnight bag. Shelving with in/out trays has been installed and will be used to manage the flow of paperwork within the unit.
1082
2
Concerns over the standard of care received by the community nursing team and problems in receiving the correct equipment at home in a timely fashion.
Adult Services
Herts Valleys
No
Service Lead met with patient and agreed that the nurse would not visit the patient again. The Nurse involved was spoken to and reflected on her practice.
8
Is this a Red Flag
Complaint? Outcome
1083
2
Concern raised that there is no wheelchair access at The Principle Health Centre in St Albans and that children's audiology clinic is situated there despite other clinics in the area having suitable access.
Children’s Audiology West Herts No
Principal Health Centre cannot provide full audiology services on the ground floor due to specialist equipment being required. An alternative venue is offered to wheelchair users. Estates are in contact with St Albans City Council and Commercial developers to deliver a new health facility which will replace the Principal Health Centre. This will provide an improved range of service within a high quality environment which will comply with all statutory and NHS standards.
1087
2
HCC leading - Concerns raised over discharge planning from Sopwell Ward, St Albans, to home.
Adult Services
Herts Valleys
Community Hospitals
Sopwell Ward No
Apology given that there was no communication to family member on day of discharge and that there was poor communication with social services. Actions: Discharge checklist changed to include - family have been informed of any potential changes to discharge process and assurance sought that care agency have visited patient prior to discharge.
9
Is this a Red Flag
Complaint? Outcome
1088
2
Concerns about the care and treatment given by community nurses during mother's final days of life.
Adult Services
Herts Valleys
No
Lessons learnt: Staff to reflect on the situation and acknowledge what they would do differently if in a similar situation, consider the 6 Cs Actions: Access Symptom management/control training for these nurses and for other staff as appropriate. End of Life Care as objectives.
1091
2
Adult Services East
Therapy Herts Wide No
Clinical care was appropriate. The decision for patient to have a Radiologically Inserted Gastrostomy Tube would have been made by the medical team.
1092
2
Family are concerned that the Health Visitor failed to take any action when it became apparent child had not met milestones. Child now requires an operation to a dislocated hip.
No
Appropriate clinical care given. Lessons learnt: The HV could have had a more robust plan in place to provide further support by offering regular phone calls or a follow up home visit during the difficult time. A new health visitor has been allocated.
1094
2
Complainant wishes to make a complaint of Discrimination under the Equality act 2010 stating that a health visitor, during a home visit, said that he had 'a mental illness which is
Is this a Red Flag
Complaint? Outcome
1095
2
Adult Services East
1096
2
NHS England leading - Concerns raised by grandmother that grandson is not receiving the appropriate medical attention whilst in prison and is suffering an episode of psychosis.
Adult Services
Herts Valleys
HMP The Mount West Herts No
Clinical care was appropriate. Patient had not been engaging with medical staff, despite extensive support.
1099
2
Adult Services East
MSK Physio & OT West West Herts No
Assurance provided that patient now has an appointment. Explanation provided regarding current waiting times for therapy in West Herts which is within the 18 week pathway.
1100
2
Concerns that no message on telephone line at Elstree Way Clinic to say that there is no receptionist working today. Feels it unacceptable that when one person is off sick the service does not run.
Adult Services
Herts Valleys
No
Apology provided that there was no receptionist available to answer calls. Complaint shared with team and apology provided that phone had not been transferred over in order calls should be picked up when receptionist is not on duty.
11
Is this a Red Flag
Complaint? Outcome
1101
2
Concerns regarding care provided to patient. Family feel an infection was ignored by staff who they felt were overstretched.
Adult Services
Herts Valleys
Community Hospitals
1103
2
Concerns raised about conduct of Consultant towards husband who is an inpatient in Langley House Neuro Rehab (Holywell).
Adult Services East
Neurological Rehabilitation Holywell No
Apology provided that Dr was perceived to be rude. Dr has met with family to apologise and family no longer wish to pursue.
1104
2
Complaint regarding the closure of inpatient ward at Gossoms End.
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
Explanation provided that it was felt necessary in order to ensure patient safety and the safe staffing of all of our Community Hospitals in the Herts Valleys area. Assurance provided that this is a temporary closure and Gossoms End is likely to remain temporarily closed until the beginning of April 2016.
1105
2
Complaint regarding the closure of the inpatient ward at Gossoms End.
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
12
Is this a Red Flag
Complaint? Outcome
1106
2
Complaint regarding the closure of Chiltern Ward at Gossoms End Hospital.
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
1108
2
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
1109
2
Complaint re closure Of ward at Gossoms End. Complaint forwarded on by journalist from Hemel Hempstead Gazette.
Adult Services
Herts Valleys
Community Hospitals
West Gossoms End No
13
Is this a Red Flag
Complaint? Outcome
1110
2
Concerns raised by daughter of terminally ill patient who has had several issues with Community Nursing Team. Complainant was ringing community nursing office for an hour trying to request an urgent visit and then was given a contact number for a nurse who is now on secondment in a different area of the country.
Adult Services
Herts Valleys
1111
2
Concerns regarding service provision for Wheelchair Service. Client has issues with lack of contact from repair service and general poor quality of the care received. Client waiting replacement chair and current chair does not fulfil her needs causing daily pain and discomfort.
Adult Services East
Service requested that Millbrooks undertakes repairs as matter of urgency. Repairs have been completed.
1112
2
Concerns raised by MP that their constituent feels the administrative team for the Paediatric Audiology Team at Principle Health Centre has inadequate provision now one member of the team is on maternity leave.
Children’s Audiology West Herts No
Assurance provided that HCT is taking action to reduce disruption to the service due to members of staff being on maternity leave. HCT has invested in providing cover for staff and will continue to support service in the current financial climate.
14
Is this a Red Flag
Complaint? Outcome
1115
2
Concerns about the Palliative Care Team. Complainant feels that the service is not fit for purpose giving examples of an incident with a broken syringe driver and no replacement being available. Also concerned that despite speaking to the CEO and being given the Team Leader as a contact, he has not received any further contact.
Adult Services
Herts Valleys
Specialist Palliative
1116
2
Complaint regarding an entry made in a letter that was sent by clinician to GP. Complainant concerned about the implication of the term used and that trust in the team has now gone.
Adult Services East
1118
2
Concerns raised that due to an administrative error patient was sent to the wrong location for CROPS appointment and therefore incurred parking and travelling costs.
Adult Services East
1120
2
Complainant unhappy with lack of information from the PALMS service about the work they have said they will do jointly with CAMHS.
Herts Wide No
All clinicians have been reminded to ensure that they communicate their plans clearly to families and checking understanding during conversations. PALMS is working jointly with CAMHS to review protocols and processes to ensure clear communication between the two services.
15
Is this a Red Flag
Complaint? Outcome
1121
2
Parent not happy with the content of the letter from child's Consultant Paediatrician. Unhappy that OT referral declined.
Community Medical Staffing
West Herts No
Apology provided and a separate report to school regarding his difficulties will be made as well as a referral to OT. Mother did not wish to pursue any further.
1122
2
Concerns regarding immunisation programme and that their child was not sent a reminder for their 16 week immunisations.
Child Health and
1123
2
Mother has raised concerns that the Health Visiting Service has recorded Domestic Violence on her records when she feels that this is not appropriate.
Complainant dissatisfied with son's Speech and Language Therapy received in school and unhappy that son has now been discharged.
West Herts No
Speech and Language Therapy appropriate for child's needs. Apology given that feedback between the SLT and SENCO was not communicated to the parents. Further SLT referral offered as parent feels that further help is required.
1125
2
ENHT Leading -Concerns raised over care father in law has received post discharge from Holywell Neuro Rehab Unit. Community Nurse failed to turn up on day following discharge and family unhappy with carers.
Adult Services
Herts Valleys
No
Discharge date was not communicated to community nursing team despite referral being made. Message received by team day after patient discharge. Complainant happy with explanation.
16
Is this a Red Flag
Complaint? Outcome
Adult Services East
Apology provided and explanation provided regarding arrangements for transferring patients between consultants. A review of this process is being undertaken.
1129
2
Adult Services East
1130
2
Concerns raised that patient has been contacted by a private physiotherapy company regarding therapy and he is concerned that they have obtained his details from the NHS.
Adult Services East
MSK Physio & OT West West Herts No
Assurance provided that HCT does not hold patients email address on our records and therefore can confirm that no information has been shared by HCT.
17
West Essex CCG:
/Theme Business
Complaint? Outcome
Parents raised concerns regarding inaccuracies contained within their daughter’s records. Concerns also regarding therapist’s knowledge and expertise.
Personal Records
East Herts/West
Essex No
Apology provided. Member of staff has reflected on behaviour and specialised support has been provided to the family. Complainant did not wish to pursue any further.
1119 2
Concerns regarding manner of Dr and information provided. Family have requested a different doctor
Staff Attitude Children’s Specialist
Community Paeds West Essex No Investigation on-going.
1131
2
Staff Attitude Children’s Specialist
Community Paeds West Essex No Investigation on-going.
Tricia Wren Mandy Massey Deputy Director, Quality & Governance Patient Experience and Complaints Manager
January 2016
Professional Clinical Leaders Group (PCLG)
1. Introduction
The NHS is facing major transformational changes over the next 5 years which will affect the care that patients receive. Professional clinical leadership is an essential requirement that will ensure patient care is co-ordinated, evidence based, safe and effective. HCT has a number of clinical and professional groups in place to support service change and delivery of clinical care but, as noted by the external CQC inspection in July 2015, ‘there is no Trust-wide committee structure or process in place for appropriately leading all professional staff in practice’. This paper sets out the proposed framework and governance structure to improve the effectiveness and coordination of professional clinical leadership across HCT. The approach will strengthen and formalise the existing clinical professional leadership, complete our senior leadership development objectives, and ensure a system wide focus on the delivery of safe, effective quality care for patients accessing services in HCT.
2. Background
Currently the Trust has in place a variety of professional groups including the quarterly Clinical Quality Leads forum led by the Director of Quality & Governance/Chief Nurse; the 6Cs group: Allied Health Professionals forum (AHP) and a Doctors and Dentists Forum. Although these groups are delivering professional changes in practice, there is limited engagement with all clinical leads across the services provided by the Trust. One of the key findings of the CQC inspection report in July 2015 noted that ‘staff lacked understanding on the strategic and clinical vision for the Trust’.
3. Professional Clinical Leadership
The proposed new Professional Clinical Leaders Group (PCLG) will replace the Clinical Quality Leads forum and act as the overall steering group to engage all clinical leads across the Trust. This will ensure improved understanding on current Trust vision and strategies and provide a platform for engagement with the co-production and delivery of future strategies that directly impact patient care. Key clinical professional groups including the Nurses’ Forum (6Cs group), AHP Forum, Doctors & Dentist Forum will report directly to the PCLG. This will provide wider understanding and on all clinical developments that affect patient care. The PCLG will complement the existing Senior Leaders’ forum which focuses on service delivery and the leadership development of staff.
Page 1 of 9
4. Purpose
An engagement event for the PCLG took place on the 18th December 2015 and clinical lead representatives from all services responsible for front line patient care in HCT were invited to attend. There was good engagement with 15 people participating. Discussions took place regarding the purpose and anticipated outcomes of the group and links with existing groups and work streams across the Trust were explored. Clinical leads welcomed the opportunity to form a bespoke group that focused on clinical leadership and patient care. Clarity on the purpose of PCLG was confirmed as a professional forum where clinical leads can: • Develop strong professional clinical leadership within HCT that influences the
delivery of safe, effective and improved care for patients • Create a professional forum where lead clinicians contribute to the development of a
learning organisation • Ensure a professional clinical voice is reflected in all Trust strategies that have an
impact on direct patient care • Act as a forum to capture the views of Clinicians in the Trust, to debate issues and to
make recommendations to other working groups, fora, sub committees and ultimately the Board.
• Share good practice and ensure implementation of local and national guidance on professional best practice across the organisation.
Terms of Reference (TOR) for PCLG have been developed by the group and require agreement by the Executive committee (TOR Appendix 1).
5. Reporting mechanism
The PCLG will be led by the Director of Quality & Governance/Chief Nurse and supported by the Deputy Director of Nursing and Lead AHP. The PCLG will report directly to the Executive Committee with relevant information shared with the Senior Management Team as required. The Nurses’ (6Cs) group, AHP forum and Doctors and Dentists Forum will report key outcomes to the PCLG to ensure clinical leads are made aware of changes that affect patient care. The intention is that the Doctors and Dentists Forum will also incorporate the Lead Pharmacist. Groups that report directly to the Clinical Effectiveness Group and Patient Safety & Experience Group will provide highlight reports only on matters that have an impact on delivery of clinical patient care (Appendix 2).
6. Recommendations The Executive and SMT are requested to: • Approve the proposed framework for Professional Clinical Leadership for the Trust
Page 2 of 9
• Agree the TOR for the Professional Clinical Leaders Group.
Tricia Wren Jill Callander Deputy Director, Quality & Governance / AHP Professional Lead Deputy Chief Nurse Clare Hawkins Director of Quality & Governance / Chief Nurse 7th January 2016
Page 3 of 9
PROFESSIONAL CLINICAL LEADERS GROUP
Version 3 – December 2015
1.0 TITLE AND FORMATION 1.1. Title: Professional Leaders’ Group (PCLG) 2.0 STATUS & DELEGATED AUTHORITY 2.1 The Professional Clinical Leaders’ Group of Hertfordshire Community NHS Trust (HCT) is a
Group of the HCT Executive Team (Exec) 2.2 The Professional Clinical Leaders’ Group is authorised to make decisions which are:
I. Within these Terms of Reference II. Specifically referred by Exec within the delegated authority of the members to
undertake on behalf of their area of representation including ratification of clinical policies and clinical SOPs. The PCLG is authorised to seek information it requires from any employee of HCT relating to professional leadership
III. Specifically referred by Exec 2.3 All procedural matters in respect of conduct of meetings shall follow the Trust’s Standing
Orders. 2.4 The PCLG may recommend actions which require financial expenditure but the PCLG itself
does not have any delegated powers of expenditure, and this rests with the relevant budget holder or otherwise in accordance with powers of authorisation as prescribed in HCT’s Scheme of Reservation and Delegation
2.5 The PCLG may establish such working groups or project teams as it considers appropriate to
support its objectives and duties. Any group or project team so established shall have terms of reference, including reporting arrangements approved by the PCLG.
3.0 PURPOSE
3.1 The purpose of the Professional Clinical Leaders’ Group is:
To bring together senior representatives of each healthcare profession within HCT to enable the organisation to:
• obtain the professional advice of the group to inform decision making about clinical practice that directly affects patient care
• strengthen clinical and professional engagement across the Trust • make recommendations and implement local and national professional guidance on
clinical practice • share best practice and ensure standards of clinical care are maintained • ensure a professional clinical voice is reflected in all Trust strategies. • create a learning environment were clinical practice can be improved • engage with all professions to capture the shared voice of the clinical workforce
Appendix 1
4.0 ACCOUNTABILITIES 4.1 The Professional Clinical Leaders’ Group is accountable to Exec. 4.2 The following will report into PCLG (see also paragraph 2.5):
I. Operational services, working groups or project teams set up to support its objectives and duties.
II. AHP Forum, Doctor/Dentist Forum, Nurse Forum (6Cs group)
5.0 DUTIES 5.1 The duties of the PCLG include but are not restricted to:
I. Body of professional advice: provide a forum for professional leaders to advise on: • Delivery of safe, effective patient care and sharing best practice • Improving quality and clinical care • Development of Trust priorities, including CQUINS, Quality Priorities, Business
Unit business plans, Quality Strategy • Innovation • Research and development • Professional regulations and code of conduct issues • Professional education, training and development • Collaborative working and learning • Specific initiatives as identified by the Board, the ET and the forum themselves
II. Voice for the professionals: to provide a means for all healthcare professionals across
HCT to contribute their expertise at all levels within HCT, in order to achieve the strategic objectives of the organisation in the delivery of improved care to patients and their families.
III. Body of professional opinion: to consider, horizon scan and provide a professional
view on national and local consultations, policies, priorities and strategies, and their impact on HCT.
IV. Professional resource: to provide professional expertise and recommendations on
particular issues.
V. Professional champions: to promote the professions and professional leadership in and outside HCT, enabling links with external professional networks.
VI. Professional network: provide a forum for sharing best practice and engaging with
HCT staff at all levels
VII. Duties or tasks as delegated from time to time by the Trust working groups and committees
5.2 In fulfilling the objectives and duties under 3.0 and 4.0 above, the Group shall:
I. Be mindful of the principles of integrated governance and where necessary consider and communicate risks and impacts that may extend to the wider organisation and which arise through the exercise of its delegated functions.
II. Link its programme of work to the strategic objectives of the Trust
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6.0 MEMBERSHIP AND ATTENDANCE
• Director of Quality & Governance / Chief Nurse (Chair) • Deputy Director of Quality & Governance / Deputy Chief Nurse (Vice Chair) • Lead Allied Health Professional • Clinical Quality Leads (nursing and therapy) Adult Services • Clinical Quality Leads Children & Young People’s Services • Clinical Quality Manager – Patient Safety • Clinical Quality Manager – Patient Experience • Lead Infection Prevention & Control Nurse • Named Nurses for Safeguarding Children and Adults • Chief Pharmacist • Learning & Development Lead • Palliative Care medical lead • Clinical Lead-Community Paediatrics • Learning & Development Lead
• Clinical Leads for services: • Clinical Psychology • Neuro Physiotherapy • Neuro Occupational Therapy • Musculoskeletal Lead • Nutrition & Dietetics • Bladder & Bowel Care • Podiatry • Dental • Tissue Viability • Wheelchair Therapies • Acute Therapies • Children’s Physiotherapy • Children’s Occupational Therapy • Children’s SLT • Children’s Specialist Nursing • Beds Manager • Prison services • PALMS/STEP2 • Adult SLT • Neuro- clinical lead • Skin Health
6.2 Additional members with specific expertise may be co-opted as required. Co-opted members
will not have voting rights.
6.3 Observers may attend meetings with the agreement of the Chair.
6.4 All members will be invited to each meeting and co-opted members will be invited to meetings (or part thereof) for the specific expertise they bring.
6.5 Members shall be assumed to be attending a meeting of the PCLG unless apologies are
sent in advance to the administrative support. If a full member cannot attend, they must
Page 6 of 9
appoint a suitably briefed alternate to attend in their place. Such alternates shall contribute to the quorum and have voting rights as per full members.
6.6 The Chair shall ensure that arrangements are in place for the provision of administrative
support to the PCLG. 6.7 All members shall read documents prior to attending the meeting and seek assurance from
their associated professional colleagues that: I. relevant impact is assessed II. management actions are agreed
III. progress towards implementation is sought for feedback at subsequent meetings IV. follow-up agreements from PCLG are reported back to their associated professional
colleagues. 7.0 MEETINGS
7.1 Meetings will be a minimum of 6 per annum and as required at the Chair’s discretion (extra-
ordinary meetings). Meetings will be 3 hours in duration.
7.2 Dates will be set with a minimum of one month’s notice. 7.3 Venues will be agreed and notified with a minimum of one month’s notice.
7.4 Apologies will be sent to the administrative support and Chair and members will arrange a
suitable alternate to attend in their place and notify the administrative support and Chair of their alternate.
8.0 QUORUM
8.1 Presence of the chair or co-chair and 50% of the voting membership shall form a quorum. 9.0 DECISION MAKING
9.1 The PCLG has joint and collective responsibility for agreeing decisions. Decisions shall be
reached by consensus where possible, and where there is not unanimous agreement a vote shall be taken and the results recorded. The Chair shall have casting vote where applicable.
9.2 Co-opted members and observers do not have voting rights.
9.3 Members with declared interests in items of the agenda will not have voting rights in respect
of that agenda item.
9.4 In the event of an urgent decision being required between meetings on any matters within the Terms of Reference of the PCLG, the Chair may take ‘Chair’s Action’. The action will be reported to the next meeting and recorded in the notes.
10.0 PAPERS 10.1 The agenda for each meeting will be agreed by the Chair and Co-Chair. 10.2 The deadline for agenda items will be communicated prior to each meeting, with any urgent
business beyond the deadline to be agreed with the Chair in advance of the meeting. 10.3 The agenda and associated papers/documents for each meeting will be distributed one
week in advance of the meeting to all members and co-opted members.
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10.4 Members have responsibility to manage the papers/documents in accordance with the Records Management Policy.
10.5 Minutes/notes of each meeting will be drafted and agreed by the Chair before distribution to
the members. 10.6 Actions arising from the meeting shall be noted within the minutes/notes. 11.0 REPORTING 11.1 The Chair shall draw to the attention of Exec any issues that require disclosure to the Trust
Board and any issues that require executive action.
11.2 The notes/minutes of the PCLG meetings will be held electronically and a chairs assurance report will be received by Exec with a Chair’s assurance report.
11.3 The PCLG will receive reports from any project groups set up to address areas of clinical risk
or implementation. Such groups include AHP Forum, Doctor and Dentist Forum, Nurse Forum (6Cs group) ICT Leads meeting, Ward Managers meeting.
11.4 The PCLG will integrate and coordinate with other groups overseeing the quality agenda in HCT.
12.0 TERMS OF REFERENCE – RATIFICATION AND REVIEW 12.1 The Terms of Reference will be agreed by the PCLG and ratified by Exec.
12.2 The Terms of Reference will be reviewed annually from date of ratification or earlier at the
Chair’s discretion. 12.3 Amendments to the Terms of Reference will not be required to be reported back to Exec
unless they are agreed by the Chair to constitute a significant change. 13.0 COMMITTEE EFFECTIVENESS 13.1 At least once per year, the PCLG shall undertake a self-assessment of its effectiveness, and
the outcome from this assessment shall be reported to Exec. 14.0 DISSOLUTION 14.1 The PCLG will only be dissolved with the agreement of Exec or by default in the event of
HCT ceasing to exist. Developed: December 2015 Revised: Jan 2016 Approved by PCLG Chair
Page 8 of 9
Appendix 2
Healthcare Governance Committee Operational Review
End of Life Care 10th December 2015 AM welcomed everyone to the review and explained that the aim of the event was to review and understand the progress made in light of the CQC report on End of Life and Palliative Care. SAFE (Good) Mandatory training targets (Palliative Care) Locality and Line Managers (LM) are responsible for ensuring staff training is undertaken and updated within their teams. It was reported that identified medical and administration staff have attained 100% training.
Safeguarding: new Trust policy The Trust’s new safeguarding policies have been amended ratified and disseminated. The training has been amended accordingly and training champions are in place.
Flowcharts to assist staff are available on the intranet and plans are in place to circulate a paper copy with the January 16 payslips.
Staffing levels and caseload (mitigation)
Palliative care staffing levels and caseloads are monitored daily against specific criteria. Issues are escalated when they occur to ensure that patient care is maintained. It was confirmed that the mitigations documentation is consistent across all areas in HCT.
Action: Staffing mitigation/ criteria form to be shared with all LMs PBr
Clinical Quality leads (CQL) and Locality Managers are working to expedite recruitment issues. In the interim robust caseload management is taking place. The main pressure areas were discussed together with the actions being taken to ensure patient management and service resilience.
JH advised that work is underway to develop partnership working with Hospices. Principles of adopting a fairer distribution of resources across the area linked to the population demographic have been discussed at executive level and will be discussed further with the CCGs. It was felt that if this model is not suitable the Board will need to review the resources required to ensure service resilience.
AD advised that once the Electronic Palliative Care Co-ordination Systems (EPaCCS) and coordination data begins to flow in January 16 it will be easier to understand the level of service provision, capacity and demand.
1
It was acknowledged that there plan to continue support to staff to ensure they retain competence and confidence to ensure a consistent robust level of service.
Incident reporting differential knowledge of what constitutes an incident
It was confirmed that there are still some limitations to incident and near miss reporting and follow up. Reasonable assurance was provided that work is underway to address this.
Effective (Requires Improvement) Summary
*Person centred end of life care planning process to replace LCP not in place The SystmOne template for the Individualised Care Plan for the Dying Person has been developed in conjunction with independent sector, GPs, CCGs and has now been signed off. The first information meeting to prepare teams is planned for 13 December. A further programme of train the trainer will be rolled out in conjunction with the McMillan project to the ICT and bed based units. The use of the Individualised Care Plan for the Dying Person will go live in January 2016. Plans are in place to record, review and show the improvement. It was confirmed that an additional tool would be available in patient’s home for use by other professionals/carers. Access to paper versions would be made available for those professionals that currently do not have access to or use of SystmOne. Resolving all the issues was not within the gift of HCT alone. However good progress has been made in conjunction with GPs, CCGs and HCT, it was acknowledged that Dr Mark Andrews had contributed significantly to this work. AM advised that she will undertake a review of the use of Individualised Care Plan for the Dying Person, towards the end of January 2016 to assess the level of implementation. Actions:
• Individual care plan for the dying person to be rolled out formally MD • Personalised individual care plan to identify the patients preferred preference of care
MD
• Check if individual care plans can be used on SystmOne and make sure a paper based system is available if not. MD/TW
• Review the use of Individualised Care Plan for the Dying Person AMc end Jan 16
* Specific End of Life Care Policy for staff to follow not in place
2
The End of Life Care Policy is in the final stages of drafting. SW has provided support in respect of information relating to medicines management and supply, a direct link regarding this has been included on the Individualised Care Plan for the Dying Person. Chair’s action will be required to sign off the policy to support the SystmOne rollout. Once finalised the policy will be rolled out to all staff and embedded to ensure that staff are able to verbalise and demonstrate the policy and any changes included.
• Chair’s action to sign off policy prior to SystmOne roll out. TW/AMc
Detailed Section
Pain Relief
No formal pain scoring tool to ensure most effective pain relief that had been audited quantitatively. A new national Information Standard that will be implemented throughout the whole organisation by June 2016. This will include several tools dependant on patient need.
Work is planned with the information team to ensure that the Information Standard requirements are included in the business change phase four electronic records roll out across the bed bases and beyond. It was advised that this will take some time; therefore paper versions will be available in the interim.
TW expressed the need for assurance of current practice and interim arrangements; this is to be undertaken during the next round of quality assurance visits in quarter 4.
Action: EOL lead to review and ensure pain score current position is within QAV EOL template. PB
It was noted that a universal pain score is not yet in place across the organisation MD to lead operationally on pain relief and JH to ensure the delivery of End of Life strategy.
Nutrition and Hydration
No formal structure or risk assessment in place to review or audit nutrition and hydration needs.
It was confirmed that there is and was a formal structure and risk assessment in place to review or audit nutrition and hydration needs at the time of the inspection. However the need for all Specialist Palliative Care Nurses to be competent and equipped to undertake core assessments has been reinforced to ensure holistic patient care.
Now that the Liverpool Care pathway has been removed the teams need to know and demonstrate what is in place now. PB advised that in early January and moving forward briefing sheets will be provided to cascade clear messages to staff to support the delivery of high quality end of life care.
The new Individualised Care Plan for the Dying Person requires the plans for nutrition and hydration to be documented when the patient is no longer able to eat or drink.
3
It was noted that there has been significant progress in development of a number of areas almost approaching the implementation stage to support the holistic care approach to all patients with personalised care plans
Monitoring Quality and people’s outcomes
Auditing systems to monitor and ensure evidence based practice implemented and regularly reviewed (End of life care audit planned but not yet initiated)
Staff unable to describe any quality audits
Palliative and End of life Care High Level Network 2014-2016 had no reference to audit and quality monitoring
The audit team presented and reviewed audits that have been undertaken and are planned at the Palliative Care team away day, staff are now fully aware. There are also ongoing regular discussions in team meetings on the use of audit outcomes to improve the service.
The outcomes of the audits are feeding into the action plan and will also be included in the new regular communication to teams commencing in January to inform learning and provide feedback. Healthcare Governance committee will require assurance that changes identified in audits have been achieved. It was also acknowledged that patient outcomes and patient acknowledgement of change should be evidenced.
Competent Staff
Clinical supervision The palliative care team have a robust system of clinical supervision, evidence can be provided to support this at the re inspection.
HCT is working in partnership working with MacMillan to provide training to all adult core staff ensure that core nursing staff are able to undertake a holistic assessment and provide confident and competent end of life care.
Appraisal only 50% in the West It was felt that robust evidence needs to be provided to CQC to show where staff has been appraised is disseminated to locality teams, where the appraisal responsibility lies and the improvement made.
Mandatory training is now well above the target.
Multi-disciplinary working
All positive
All positive
All positive with one comment on not auditing DNACPR forms – it was noted that DNACPR forms are audited.
Caring Good All comments are positive on caring in both the summary and the detailed section. It was felt that this is should be conveyed to the staff as this is not usually the case within CQC reports.
Responsive Good All positive in the summary
Detailed section
No evidence that the Trust had developed a plan to meet the needs of people with dementia. It was acknowledged that the Trust have been working on a plan to meet the needs of Dementia patients, staff need to be able to communicate and provide evidence of the plan.
Only 29% of patients have their preferred place of death recorded and no trust target in place also gaps in recording preferred place of care.
This was challenged as incorrect. It was acknowledged that the data collected on End of Life is incorrect, further review of records showed 60% of patient who had died had recorded the preferred place of death recorded and on a one day audit 51% of records audited stated the preferred place of death. The detailed audited data can be provided as evidence to CQC on re inspection.
It was acknowledged that there are issues and delays in respect of notification and recording of death which is a GP responsibility. There are also coding inconsistencies. It is hoped that this will improve with the implementation of the EPaCC sytem.
It was acknowledged that there will be a delay with the implementation of EPaCCs for EMIS users in the West of the county.
Time was needed to review educational support and engagement with GP’s to undertake end of life discussions with patients who have co-morbidity, and whose clinical records need to reflect End of Life Read coding. Such Read coding would therefore support integrated teams in delivery of timely personalised palliative care.
It was confirmed that patient preference needs to continue to be sought.
Action: • Business information reports to be reviewed to include the preferred place of death coding
and support is required from GPs to ensure accurate coding when a patient dies ( as only GP can code on SystmOne) MD/CS
5
Well –Led Summary
*Some disengagement between local leadership and staff working in palliative care services
It was reported that locality management visibility was variable. Where visibility has improved, integration has improved.
Not all the of Palliative Care Team members have been able to fully embrace integrated working due to staff vacancies notably in the West of the county. Representatives from the East & North expressed the view that the integration is working well for them and the joint working and learning is beneficial to patient care and staff development staff.
Baseline evidence has been collect over a period of time from focus groups, all the areas of concerns surveyed have improved and the results show that staff felt clinically supported in their role. One exception is that they do not feel supported in their development as Specialist Nurses. The overall improvement and staff engagement over the past 18 months has improved from 2 (not very satisfied) to 6/7 (reasonably satisfied).
There is marked improvement in general however vacancies in the West have hampered progress. Watford area continues to work on ways to encourage, support and improve the integration both with teams and individuals.
Discussions are underway to develop partnership working with local hospices in the West to improve service resilience and promote further integration.
Concerns were raised with the length of time that this integration has taken and still not fully resolved; it was highlighted that there are issues with Isabel hospice, who not engaging and have limited communication with local NHS teams looking after Palliative Care patients. The East & North CCG are aware of these issues.
The Care Coordination Hub in Herts Valleys will be a big driver for change.
CQC have acknowledged that work had been done to support staff with integration, there is still more that can be done.
Action: Work to continue to integrate community teams and embed the EOL policy MD/CS
Action: Contact to be made with the CEO of Isabel Hospice to foster closer working with HCT staff for the mutual benefit of patients and both organisations. DL
*Not a clear written development strategy or vision statement for the service
*No clear goals set for the service that the staff could describe to CQC
These are in place with aspirations and goals that have been developed in conjunction with staff.
It was acknowledged that further communication with staff is required to ensure staff can demonstrate and verbalise the strategy, vision and goals.
6
*Recent changes on integrating into the community locations had resulted in staff leaving- progress is being made with staff in line with HCT workforce plan.
* Staff had left as a result increasing the workload of the teams this is common throughout the NHS as a whole not just limited to this service.
*HCT Palliative and End of Life Care Network Plan 2014-16 lacked detail about what the tasks were and how they were going to be achieved
* Out of 48 actions in this Plan only 14 were marked completed. This plan was a 3 year plan; it was acknowledged that progress updates need to be clearly evidenced and demonstrated.
It was felt that progress has been made, and work will continue to address all points.
Additional Notes
AD asked for support and guidance for GPs to develop integrated unified care plans. AD suggested that the East of England checklist might be useful in the home to identify the main areas required in a care plan. DL suggested Integrated Care Programme board could be used to promote and on and take responsibility for integrated unified care plans encompassing Primary Care, Community Care and Nursing and Care homes.
Action: ICPB to lead on integrated unified care plans DL
HCT are in discussion with the CCG to review and promote End of Life care and the co-location of CNS’s within integrated care Teams and further discussions are planned to discuss psychology provision. Further support is required especially to more involve hospices in the East. DL/ AMc
It was reported that Children’s Services experience a similar patchwork of care provision involving the hospices with their different goals, objectives and drivers from the NHS.
Follow up –
• Quality assurance visits will be organised to review the developments which will include meeting with staff for feedback and obtain evidence and that the policy and strategy have been embedded. These visits will provide a balanced feedback report.
• HCT will negotiate with CQC the re inspection date, it was noted that there have been changes to the inspection team.
• Feedback will be given to the Health Overview and Scrutiny Committee
Support Required
1. Support and involvement from GPs to develop and initiate the implement the individualised care plan for the dying person.
o An education programme is underway with all GPs on a variety of areas in the West. Trust needs to be built up; this could be discussed further at the Gold Standard meetings.
7
o The End of Life template is now live in all GP surgeries on SystmOne in East &
North Herts. Lesson learnt to be shared with the practices in the West. o Community Nurses can provide clear communication links with GPs, all avenues
to be used to target the GPs. 2. Support to release staff from all the business units for the training programme
commencing in February. It was suggested that this training be made mandatory. All methods of training should be utilised and training should be consolidated to maximise exposure and uptake. Children’s Services advised they received a block of training and updates from Great Ormond’s Street. A number of ideas were suggested to address this priority a project lead has been appointed to take this forward.
3. Support and prioritisation of SystmOne changes are required to move this project forward. A designated performance data business partner would be beneficial to facilitate the improvement in data collection and reporting.
4. Support for the Communication team to stretch and improve both internal and external communication.
5. Support from Senior Management 6. Support in the future from Clinical Quality leads including Children’s Services to embed
Palliative and End of Life care in business units. 7. Support from the hospice CNS’s to support the HCT teams. HCT are inputting into a
meeting to discuss the discrepancies within the service provided by hospices and develop equity in core service delivery. Further support is required with hospices particularly in the East.
Any Other Business
JH express HCT’s thanks to the entire team for the immense amount of work and commitment shown, to address the areas for improvement within the CQC report. The End of Life and Palliative care service is a very good service and it should not just focus on the negatives.
Reflections:
• The meeting has been extremely helpful to the service and team as a whole. • More clarity around the format of the meeting would have helped to reduce anxiety.
Marina Sweatman Board Support Officer January 2016
8
INTEGRATED BOARD PERFORMANCE REPORT
Efficiency & Cost Effectiveness.
December 2015
Hertfordshire Community NHS Trust – High Value Healthcare December 2015 IBPR Final
1
Table of contents
Introduction Page 3 HCT Overall KPI Summary table Page 3 Trust Scorecard Page 4 Performance summary Page 5 KPIs Consistent and improving patient safety Infection control Inc. MRSA & C.Diff Page 7-8 Quality Inc. Incidents and Pressure Ulcers Page 9 Mandatory training Page 10 Safety thermometer Page 11 Outstanding Patient experience Complaints, PALs and Friends and family test Page 13 18 week waiting times Page 14 Nursing & Therapy Referral priorities Page 15 Excellent Clinical Outcomes Safeguarding Children & Adults Training Page 18 DOLS, MCA, PREVENT, IG and LAC assessments Page 18 New born hearing screening & Retinal screening Page 20 Community Hospital Readmission rates Page 20 Diabetes structured education sessions Page 20 Health visiting KPIS Page 21 National child measurement programme Page 21 HPV child immunisation programme Page 21 EOL pathway Page 22 Appraisal rates Page 22 Smoking KPIs Page 22 Highly efficient and cost-effective services Data Quality & rejected referrals Page 25 Community Hospital KPIs, Inc. Occupancy, DTCs & ALOS Page 26 Continuing Care Page 26 Nascot lawn Page 26 Workforce Inc., Headcount, WTE, vacancies and budgeted posts Page 28 Bank and agency spend Page 28 Staff turnover and absence rate Page 28 Finance Inc., Risk rating, balance sheet, Cash flow and aged debtors Page 30 Safe Staffing exec summary Page 32 Safe Staffing December data Page 33 Community hospital metrics Page 36
2
INTEGRATED BOARD PERFORMANCE REPORT
ABOUT THIS REPORT This report is split into four sections, reflecting the High Value Healthcare (HVHC) domains upon which performance within Hertfordshire Community NHS Trust (HCT) is based.
1. Consistent and improving patient safety 2. An outstanding patient experience 3. Excellent clinical outcomes 4. Highly efficient and cost-effective services
Each section provides a table of the key indicators, with commentary by exception only. Underperforming KPIs will have an exception report which includes an action plan and schedule to bring performance within target levels. Throughout the report Red, Amber and Green statuses are used to convey performance, where an indicator is not applicable or not available in the month grey is used. The trust RAG reflects the current performance in month, year to date position and a forecast position. The Trust is monitoring data quality routinely against a data quality plan and priorities. KPIs Summary Table December 2015
KPIs measured GREEN AMBER RED
On Target or within range%
1. Consistent and improving patient safety 24 21 1 2 92% 2. An outstanding patient experience 16 12 1 3 81% 3. Excellent clinical outcomes 33 25 5 3 91% 4. Highly efficient and cost-effective services 21 11 5 5 76%
94 69 12 13 86%
3
HCT Trust Scorecard
All patients to have smoking status recorded on system one
89% 90% 89% 89% A A G MRSA bacteraemia 0 0 0 0 G G G
C.diff cases > 72hrs 5 Full Year 6
Monthly trajectory 0- Nov
0 4 G G G
24 hr. Notification to GP 96% 95% 99.9% 99.8% G G G % of VTE Assessments 99.6% 100% 100% 100% G G G Patient-related incidents 4760 332-460 403 3518 G G G Av. mandatory training 86% 90% 93.1% 93.1% G G G Harm free care Compliant Compliant 93.3% 93.1% G G G CAUTI % infections 0.2% <1.00% 0.75% 0.46% G G G No of avoidable category 2 pressure ulcers acquired in HCT care
46 YTD 30% reduction on 14/15
3 5 G G G safeguarding children training
90% 95% 97% 97% G G G level 1 safeguarding adults training at Induction
95% 95% 96.3% 96.3% G G G Health Visiting - average caseload size 420 <500 370 370 G G G % 18 Weeks - Consultant led 98.0% 95% 97.0% 97.8% G G G % 18 Weeks - Non-Consultant led
99.5% 98% 97.3% 97.9% R R G Friends & Family Test 97% 90% 96% 96% G G G ALOS - Stroke (Rehab Pathway 29 days 30-35 days 36.2 32.7 A G G ALOS - Non stroke (Rehab Pathway)
21 days 19 days 19.9 18.9 G G G Community Hospitals - average occupancy
91% 82%-88% 87.1% 90.1% G A G Community Hospitals - % of NHS bed days lost due to delayed transfers of care
Total 8.6% (Health 4.8%
HCS 2.3% Both 1.5%)
5% for health delays
4% by Mar 16
HCS 5.6% Both 0.5%)
HCS 9.6% Both 0.2%)
R R G
COSR (Risk Rating) 4 4 4 4 G G G Appraisal % 86% 90% 87.1% 87.1% A A G Absence Rate 3.50% 3.90% 4.09% 3.71% A G G Underlying Staff turnover 11.70% 12% 13.66% 13.66% A A G % posts vacant (vacant WTE/budgeted WTE).
2.30% For Information 9.40% 9.40%
4
December Integrated Board Performance Summary
The December 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 and C.Diff cases reported in December under HCT care. • Three category 2-4 pressure ulcers acquired in HCT care reported in December, taking total to five; however still below trajectory reduction. • Staff mandatory training levels above target
Areas for board review
• 18 week Pledge 2 at 97% and below 98% target • Smoking Cessation indicators all below target. • DTOC rate above the 5% threshold for fifth consecutive month with 8.4% health delays recorded in December. • Stroke and Non-Stroke ALOS above thresholds in December. • Patients discharged on or before Estimated date of discharged is 41% in December against 90% target. • Staff turnover at 13% and over the 12% threshold. • Absence rate above threshold of 4.09% in December.
5
CONSISTENT AND IMPROVING PATIENT SAFETY
6
SAFETY SCORECARD (1 OF 3)
Ref Indicator 2014/15
year end Performance
S4
G
G
G
G
G
G
G
G
G
99%
Compliance with Hand hygiene in all Community Hospitals will be > 95%
Compliance with Commode Audit in all Community Hospitals will be > 95%
% of relevant patients screened for MRSA (excluding respite patients).
S7
S3
% of patients observing staff washing hands
Compliance with Essential steps urinary catheter care and ongoing care will be > 95% in all community hospitals
G
0.06
4
S1 Number of Avoidable MRSA bacteraemia cases in year for HCT
0 0 0 0 G GG
G

C.difficile cases occurring post 3 days following admission into HCT bed based facilities (i.e. acquired in our facility)
5
99%
0- Nov
7
SAFETY SCORECARD (2 OF 3)
R
0.29
R
GG
R
The percentage of SIs that have 72 hour report completed within 72 hours. Reported monthly
G
13
80%
G
<1
92
63
The total number of patient safety incidents that have resulted in severe harm (Quarterly)
Requires Improvement
Requires Improvement
2014/15)
A
0.37
S13
85%
1%Proportion of Si's to patient related incidents 7% For information 2%
Registered No conditions

GG
332-460 403 3518
The percentage of SIs that have 60-day RCA and action plans completed and submitted to PCT within 60 days. Reported monthly
CQC Registration
14/15 0.67
Registered No conditionsS19
The number of SI's that remain open to HCT 76 For information 262
50%
S14
82% Monthly
75% 89%
5S8 249 YTD For information 45 The number of Serious Incidents reported in month to the CCG against the SI policy
0
S18
S17 Reduction in the number of Falls with Harm (Quarterly)
A
0
0
R
S15
14
0
0
G
G
Number of incidents in quarter which allege abuse of patients in our care which have been reported.
0 Patient safety incidents that have resulted in a death whilst in our bed based units and Nascot lawn (Quarterly)
GS16
R
8
Director
Reduction in the number of falls with Harm (Quarterly) 10% reduction on 14/15 figures
Based on the 10% trajectory reduction set for 2015/16 we have currently reported a total of 97 injurious falls at the end of Q3 compared with 86 for the same period last year , this equates to a 12.8% increase. Overall there has been an increasing number of falls reported resulting in an increase in injurious falls classified as low harm which can include minor abrasions, bruising and skin tears. There has been a significant reduction in falls categorized as severe harm i.e. Those resulting in fractures with a total of eight reported by the end of Q3 across all bed based units- 43% under the trajectory of 14 set by end of Q3
Q4 2016 Clare Hawkins
Number of incidents in quarter which alleged abuse of patients in our care which have been reported
Three cases of alleged abuse of patients in our care were reported in quarter three. Two were reported at our Langley and QVM inpatient units and one for the Hertsmere Homefirst service. The cases have been fully investigated and reports have been submitted.
January 2016 Clare Hawkins
9
SAFETY SCORECARD (3 OF 3) Safety Thermometer / Harm Free Care
ST4
ST5 % of patients with a urinary catheter and a new urinary tract infection
0.2% 1.00%
1.88% For
information % of patients who have had a fall resulting in harm
2%
% of patients with a new pressure ulcer
For information
1066 10981
0.75% 0.46%
10
OUTSTANDING PATIENT EXPERIENCE
11
OUTSTANDING CUSTOMER EXPERIENCE SCORECARD (1 of 3)
Outstanding Patient Experience
P1 Number of complaints referred to the ombudsman in quarter from total complaints
1 (0.5%)
<5% 4.8%
100% 98% G GG
G0 0 G G
EMSA breaches reported in month
% of patients reporting positively about cleanliness of environment in a community hospital
Number of in patient survey returns received and % rating care received as good or better than good
% of Patient appointment letters including day, date and time (Quarterly)
Friends and Family test
Number of complaints received in month
Number of complaints closed in month
Number of PALS enquiries (for HCT services) reported monthly
Number of compliments received Quarterly
78%
99%
90%
12
Performance Issue Action By when Responsible
Director
18 Weeks - non-admitted patients - % of patients being treated within 18 weeks for HCT non consultant led services
HCT not achieving the 18 weeks pledge two with 97% recorded in December. MSK Physio and OT WEST have reported 90 breaches, a decrease from previous month. The service has reduced capacity due to staff vacancies. Recruitment is on-going with interviews taking place. This issue is on the Risk register and has been escalated to HV CCG, with the MSK pathway review underway.
Jan 2016
Julie Hoare
Trend over time
P18 RTT- 18 Weeks - number of consultant led patients waiting over 18 weeks
N/A TBC 1.3%
(22 patients) 1.3%
(22 patients)
0 0 G G GP19 RTT -No of patients waiting over 40 weeks
G
97.3% R G
100%P22 Minor Injuries Unit - Herts and Essex hospital - patients to be seen treated and discharged with 4 hours
95%
P17 RTT -18 Weeks - non-admitted patients - % of patients being treated within 18 weeks for HCT consultant led services
98.0% 95.0% G97.0%
P15
18 Weeks - non-admitted patients - % of patients being treated within 18 weeks for HCT non consultant led services
99.0% 98.0% R
13
P25
For supported self-care/priority 3 referrals, the patient will receive a face-to-face response within 7 days for nursing services and 2-4 weeks for therapy. All Herts
73% R
P28 Reduction in cancellation of outpatient appointments by provider (All services)
98
target
P24
For planned /routine/priority 2 referrals the patient will receive a face- to-face response within 24- 48 hours of HCT receiving the referral for nursing services and 1-2 weeks for therapy. All Herts
R86% (1186/1382)
92% G G
P23 44.8% For urgent/priority 1 referrals to the receive a face-to-face response within 2-4 hours of HCT receiving the referral. All Herts
100% (numbers)
90% (77/86)
60%
14
Director
P23,P24 and P25 Priority 1, 2 and 3 referrals. This includes Nursing & Therapy referrals.
HCT reported 90% for Hertswide for P1 (ENCCG 94% and HV 87%). This is after the data validation. Overall HCT are reporting 86% for P2, an increase of 3% from previous month. HCT reported 80% for P3 (ENCCG Priority 3s were all validated and 88% of referrals were seen within timescale. HVCCG Priority 3s have not all been validated and 81% were seen on time.) Currently the therapies element in Herts Valley has very long waiting times and a business case has been put to the CCG. Both EN and HVCCG business units will continue to focus on the validation of the referrals to ensure that data quality and referral exceptions have been reviewed.
March 2016 Julie Hoare
15
EXCELLENT CLINICAL OUTCOMES
16
EXCELLENT CLINICAL OUTCOMES SCORECARD (1 OF 4)
Excellent clinical outcomes
Trend over time
% of staff who have undertaken level 1 / 2 safeguarding adults training every 3 years
97.6%
% of all clinical and medical relevant staff (all clinical staff including staff in supervisory roles requiring a clinical registration) will undertake Level 2 safeguarding adults
90%
% of staff who have undertaken level 1 /2 safeguarding adults training at induction
G
A
80%
G
% Completed statutory review health assessments within 4 weeks (Paeds, CUS and CLA)
95% 92.5% 92.5% A
66%
77%
% Completed medical CLA Initial Health Assessments within 10 day timescale
92.3%
99.0%
G
G
G
90%
A
G
GC11
C14
C12
C15
C13
C10
C2
C3
90%
98%
G
G
G
G % of eligible staff who have undertaken safeguarding children supervision appropriate to their role
G97.0%
96.0%
% of eligible staff trained at appropriated level of safeguarding children in accordance with IC document Level 1, Level 2, Level 3
GC1 % staff who have undertaken mandatory training 86% 90% 93.1% 93.1%
83% % of relevant staff who have undertaken MCA training

95%
G
A
17
Director
Information Governance training
The training is now measured on a rolling month basis and expected to achieve the 95% target by March 2016.
Mar 2016 Phil Bradley
% Completed medical CLA Initial Health Assessments within 10 day timescale
Achieved 80% this month but YTD on target. Three missed timescales by LAC GPs due to one DNA by young person, a translator DNA to support asylum seeker and social worker failing to respond to appointment offered within timescale due to holiday period. Concerns have been raised with HCC. All assessments now completed.
January 2016 Julie Hoare
% Completed statutory review health assessments within 4 weeks (Paeds, CUS and CLA)
1% below target this month (84%). Delays due to Foster carers not responding to appointment requests or cancelling appointments at late notice and a delay in handover to appropriate professionals. LAC pathway being reviewed to reinforce process to all staff
January 2016 Julie Hoare
18
87%
C26
Number of patients accepted onto the Community Matron caseload who are offered a personal health plan with the aim of maximising self- management and confidence
RR
G
100.0%
913
G
100%
63.9%
C23
C16
C18
C17
GG
G
99.0%
C27 Diabetes -Number of patients attending structured education sessions - DAFNE
752
100%
<0.5%
99.0%
0.17%
% of babies requiring further assessment seen within 4 weeks of screening
Retinal screening - % of diabetic cohort that has been screened in 2015-2016
West Herts Newborn Hearing Screening - % of babies screened within 4 weeks of birth
100.0%100% G
Community Hospitals - Readmission rates within 30 days
Retinal screening - % of diabetic cohort that has been offered an annual screen
G
0.00%
Director
Diabetes – Number of patients attending structured education sessions - DAFNE
Patients attending DAFNE training sessions are below trajectory to achieve the 200 target for the year. The uptake of patients participating in DAFNE is low. The service is not getting the demand to translate into 200 actual attendances, due to the dropout rate from referral. This has been discussed with the CCG and highlighted to them. This is only an ENCCG target.
Mar 2016 Julie Hoare
19
G
% of children in reception year who have received vision and audiology screening (subject to school participation)
C38 HPV - % of eligible children immunised

Year 8 T 0% dose 1 T 0% dose 2
T Dec 10%

% of 2.5 year health review undertaken as a proportion of total cohort BEFORE VALIDATION
93.9%
95.0%
98%
% of 2.5 year health review undertaken as a proportion of total cohort VALIDATED
% of 1 year health review undertaken as a proportion of total cohort VALIDATED
For Information
C31
C34 % of 1 year health review undertaken as a proportion of total cohort BEFORE VALIDATION
C29
G
G
G
G
G
G G370
N/A 88.3%
G Health Visiting - % of babies who have had a face to face contact with health visitor within 14 days of birth - VALIDATED
Health Visiting - % of families with Children under 1 who transfer into area from other counties receive an offer giving them contact with a member of the HV service within 5 days of notification.
93.9%
99.0%
98.3%
90%98.1%
Health Visiting - % of babies who have had a face to face contact with health visitor within 14 days of birth - BEFORE VALIDATION
<500420
98.8%
School Nursing - % of children who have had height and weight monitored in reception and year 6
17.3%
98.8%
370
98.0%
97.7%
93.8%
G
G
G
G
G
G
20
1462Number of patients on end of life pathway
288 For information Number of patients with preferred place of death recorded
336
594
Herts Stop Smoking Service
C45 89%
A A % of staff who have received an appraisal in the last 12 months
AAAll patients to have smoking status recorded on system one
A89%
89%
C50
C51 All patients who smoke to be offered support to quit smoking
90% 95% by end Q3
99% 99%
90% by end of year
All patients who smoke to be given brief intervention advice which includes second hand smoking advice
RR
C52 Improvement in people using intermediate care bed based services. 90% of patients have recorded Northwick Park score (95% from Q3)
381 23
T 50
C54
Increase in the number of patients who have a planned discharge, by bed based unit at a weekend - % discharged
25%
Baseline to be established
11% 8% Increase in the number of patients who have a planned discharge, by bed based unit before mid- day where this enables an effective and safe discharge - % discharged
Baseline to be established

21
Director
Staff Appraisal Appraisal rates continue to increase and are 87% against the 90% target in light of the tiered appraisal approach by HCT this year. The target is expected to be achieved by Mar 2016.
Mar 2016
Alison Shelley
Smoking Metrics Performance remained at 89% of patient’s smoking status recorded in December, which is just 1% below the target for the year. New reports are being created by the performance and information team to ensure that all services are recording status and that advice is being provided and referrals to HSSS are being made. The new reports will enable managers to performance manage their teams and monitor staff activity in order to drive the performance in these KPIs.
Q4 2016 Julie Hoare
22
HIGHLY EFFICIENT AND COST-EFFECTIVE SERVICES
23
EFFICIENCY & COST EFFECTIVENESS SCORECARD (1 OF 4)
Trend
G
G
99.97%
% of rejected referrals recorded as insufficient capacity in East & West Core services
For information
0.07% (39)
99.96% 99.96% G
Efficient & Cost effective
G
24
EFFICIENCY & COST EFFECTIVENESS SCORECARD (2 OF 4)
G G

G
A
E11b
E14
Percentage of patients discharged on, or before, the Estimated Date of Discharge set upon admission
N/A 90% 40%
29.5 A
Community Hospitals - Average length of stay in HCT community hospital - Stroke (Rehab Pathway ONLY)
>95%
G
G
G
84.6%
G
G
Community Hospitals - Average length of stay in HCT community hospital - ALL Stroke
Community Hospitals - Average length of stay in HCT community hospital - Non Stroke
E13
E15
Patients admitted to a bed based unit who have an Estimated Date of Discharge set and recorded within 3 days of admission
Children's Continuing Care - 95% of allocated hours are delivered
Children's inpatient unit - Nascot Lawn - Bed occupancy
E12b
87.1%
45.4
32.7
Community Hospitals - % of NHS (health) bed days lost due to delayed transfers of care
Community Hospitals - average occupancy
A
G
R

25
Performance Issue Action By
Director
DTOC HCT are over the 5% Health delay threshold for DTOC with 8.4% recorded in December. This is a 4% reduction from previous month. Herts Valley units recorded 10.2% health delays and East and North 5.9%. In Herts Valley - Langley (20%) and Sopwell (15.6%) had the biggest health delays with a combined 225 bed days lost. In East & North – QVM and Herts & Essex had health delays of 10% which accounted for 125 bed days lost. The main delay reasons for these units were CHC Funding (157 days), Awaiting assessment (46) Self-funding residential placement (37) and Housing and Patient choice both (30). HCT have introduced CHC and Therapy lead roles to reduce health delays and increase flow through the pathway and this is already having an impact on DTOC.
Jan 2016
Julie Hoare
Average length of stay in HCT community hospital - Stroke
Stroke ALOS was over the threshold of 42 days in December with 45 days recorded. A reduction of two days from previous month. Of the 21 stroke patients in December, six stayed over 50 days and one patient was discharged over 150 days. The ALOS improved to 36 days based only on the rehab pathway.
Jan 2016
Julie Hoare
Average length of stay in HCT community hospital - Non Stroke
Non-stroke ALOS was over the threshold of 21 days with 28 Days recorded in December. A reduction of three days from previous month. Twelve patients were discharged over 80 days and one patient over 100 days. The cohort of patients includes sub-acute, DOLS and Specialing patients that require one to one care. Patients on the rehab pathway met the ALOS rehab pathway threshold with 19 days.
Jan 2016
Julie Hoare
Percentage of patients discharged on, or before, the Estimated Date of Discharge (EDD) set upon admission
Majority of non-met EDD are linked with delayed transfers of care issues with 40% of patients achieving their estimated discharge date. When patients who did not have a delayed transfer of care are excluded, 87% of patients were discharged on or before their EDD. Q4 Julie Hoare
26
Workforce (3 of 4)
259
0 For information 1
1
0
E26
E28
2471
WTE by bank/agency
Bank & Agency spend - per

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