for map and directions please see · 2019-10-01 · for . attachment : allocated . time: approx ....

Hertfordshire Community NHS Trust Board Meeting in Public

Thursday 29th September 2016

10.30am – 1.30pm

Room 104 Rothamsted Conference Centre

Harpenden Hertfordshire

AL5 2JQ

For map and directions please see:

http://www.rothamsted.ac.uk/sites/default/files/attachments/2013-09-24/location_0.pdf

Wifi Code: To be provided at venue

AGENDA

Lead For Attachment Allocated Time

Approx Timing

(0) Staff Story 30 mins 10.30-11.00

Overseas Nurses’ Experience of Working in England for HCT. Sara and Sanda (& Suzy Narroway, Clinical Quality Lead)

(A) Preliminaries 10 mins 11.00-11.10 DO’F DO’F DO’F Board 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):

3. Members’ Declarations of Interest (Members to declare any interests material

to items on the agenda) 4. Ratification of items of Chair’s and Chief

Executive’s Action taken since the last meeting under Standing Order 5.2

5. To approve the Minutes of the meeting held

To note

To note

To note

To ratify

To approve

(A1)

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http://www.rothamsted.ac.uk/sites/default/files/attachments/2013-09-24/location_0.pdf

DO’F

on 28th July 2016 6. Matters Arising from the Minutes of the

meeting held on 28th July 2016. (Tracker).

To note

(A2)

(B) Strategic Risks 15mins 11.10-11.25

DL 1. The Summary Board Assurance

Framework (Sept 2016)

To

review

(B1)

(C) Clinical Services & Healthcare Governance 20 mins 11.25-11.45

CH AM

1. Director of Quality & Governance / Chief

Nurse’s Report 1.1 Quality Report Qtr 1 2016/17 1.2 Safe Staffing Reports (June & July

2016) 1.3 Serious Incident Report

2. Chair of Healthcare Governance

Committee’s Assurance Report

To note and

discuss

To note for assurance


(C1)

(C2) (C3) (C4)

(C5)

5 mins

5 mins 3 mins 3 mins

4 mins

(D) Performance & Operations 15 mins 11.45-12.00 MD PB CH

1. Director of Operations’ Report

2. Summary Integrated Board Performance

Report (August 2016) 3. High Level Risk Register

To note and

discuss

To review

To review

(D1)

(D2)

(D3)

5 mins

5 mins

5 mins

Break 10 mins 12.00-12.10

(E) Strategy, Resources & Engagement 35 mins 12.10-12.45

DL PB AS JH JH BG

1. CEO’s Report, Strategy Update and

Strategic Framework 2. Director of Finance’s Report 3. Director of HR and OD’s Report 4. Director of Service Development and

Partnerships’ Report

5. Emergency Planning Core Standards Self-Assessment

6. Community Engagement Committee

Chair’s Assurance Report

To note and

discuss

To note and discuss

To note and discuss

To note and

discuss To Approve


(E1)

(E2)

(E3)

(E4)

(E5)

(E6)

12 mins

5 mins

5 mins

5 mins

4 mins

4 mins

2

(F) Board Governance & Leadership 10 mins 12.45-12.55 JP AM DO’F

1. Audit Committee Chair’s Assurance

Report 2. Note of the Remuneration Committee

Meeting held on 28th July 2016 3. To agree schedule of Board and

Committee meeting dates for 2017-18

To note

To note

To agree

(F1)

(F2)

(F3)

4 mins

3 mins

3 mins

(G) Healthwatch 5 mins 12.55-1.00 MC

A verbal report from Meg Carter, Healthwatch observer, on Healthwatch news and issues pertinent to the Trust.

To receive and note

(verbal)

(H) Urgent Business 5 mins 1.00 - 1.05 DO’F (As notified under Item (A) 2 above)

(J) Risks Arising / Observations 3 mins 1.05 - 1.08

DO’F 1. Summary of Risks Arising To discuss (Verbal)

(K) Supporting Papers / Items for Receipt and Noting Only 2 mins 1.08 - 1.10

CH AM PB PB AS BG

Clinical Services & Healthcare Governance C1 (i) Quality Report Qtr 1 2016/17 C1 (ii) Research Annual Report C2 Minutes of the Healthcare Governance

Committee meeting held on 19th July 2016

Performance & Operations D2 (i) Integrated Board Performance Report

(August 2016) Strategy, Resources & Engagement E2 Month 6 Finance Report (September

2016) E3 Learning and Development Annual

Report 2015-16 E6 Minutes of the CEC held on 18th August

2016 Board Governance & Leadership

To receive and note

(K1) (K2)

(K3)

(K4)

(K5)

(K6) (K7)

3

JP

F2 Minutes of the Audit Committee meeting held on 12th July 2016

(K8)

(L) Date, Time & Venue of Next Meeting(s) 1 min 1.10-1.11

DO’F Board meeting in public: Thursday 24th November 2016 1.30 - 4.30pm The Council Chamber Borough of Broxbourne Bishops' College, Churchgate Cheshunt, Hertfordshire EN8 9XQ

(M) Questions from the Public 5 mins 1.11-1.16

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.

(N) (All)

Informal Review of Meeting 2 mins 1.16 – 1.18

Please note that Board papers and Trust papers referenced in Reports are available on the Trust’s Website at: http://www.hertschs.nhs.uk/about-us/our-board/meeting-papers 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

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http://www.hertschs.nhs.uk/about-us/our-board/meeting-papers

Abbr'ns In Full Abbr'ns In FullA&E Accident & EmergencyaCFT Aspirant Community Foundation Trust GM General ManagerACS Adult Care Services GMC General Medical CouncilACSC Ambulatory Care Sensitive Conditions GP General PractitionerAD Assistant Director GRR Governance Risk RatingADD Attention Deficit Disorder GUM Genito Urinary Medicine Adm AdmissionAfC Agenda for Change H&SCA Health & Social Care Act 2012 AGM Annual General Meeting H&SMAT Hertfordshire & South Midlands Area TeamAHP Allied Healthcare Professional H&WBB Health & Wellbeing BoardALOS Average Length of Stay HBL Hertfordshire, Bedfordshire and Luton

ALTO Arms-Length Trading Organisation HB&LBU Hertfordshire, Bedfordshire & Luton Business Unit (part of CECSU)

AQP Any Qualified Provider HCA's Health Care AssistantsAT Area Team (of NHS England) HCAI Healthcare Associated Infection

HCC Hertfordshire County CouncilBAF Board Assurance Framework HCHS Hertfordshire Community Health ServicesBC Borough Council HCPA Hertfordshire Care providers AssociationBME Black Minority Ethnic HCS Health and Community ServicesBRE British Research Establishment HCT Hertfordshire Community NHS TrustBI Business Information HDD Historic Due DiligenceBU Business Unit HEE Health Education EnglandBUPR BU Performance Review HEI Higher Education Institution BURR BU Risk Register HGC Healthcare Governance Committee

HICSS Herts Integrated CSUC.dif Clostridium difficile HILS Hertfordshire Independent Living Service CAMHS Child & Adolescent Mental Health Service HLRR High Level Risk Register

HMRC Her Majesty's Revenue & CustomsCCG Clinical Commissioning Group HMP Her Majesty's PrisonCECSU Central Eastern CSU HPFT Hertfordshire Partnerships Foundation TrustCEO Chief Executive Officer HPMA Healthcare People Management AssociationCFT Community Foundation Trust HPV Human Papilloma VirusCHD Coronary Heart Disease HR Human ResourcesCHIS Children's Health Information Services HRD Human Resource Directors CIC Community Interest Company HSAB Hertfordshire Safeguarding Adults BoardCIP Cost Improvement Programme HSAU Hyper Acute Stroke Unit

CLAHRC Collaboration for Leadership in Applied Health Research and Care HSCB Hertfordshire Safeguarding Childrens Board

COPD Chronic Obstructive Pulmonary HSCIC Health and Social Care Information CentreCoS Continuity of Service HSJ Health Service Journal

CPD Continuous Professional Development HSMC Hertfordshire Supply Management Confederation

CQC Care Quality Commission HUC Herts Urgent Care (Out of hours GP service)

CQUIN Commissioning for Quality & Innovation HV Health VisitorCRR Contractual Risk Rating HV Herts ValleyCSF Children, Schools and Families HVBU Herts Valley Business Unit CSR Comprehensive Spending Review HVCCG Herts Valleys CCGCSU Commissioning Support UnitCWLG County Workforce Leadership Group I&E Income and expenditureCYP Children and Young People I/P or IP Inpatient

IBP Integrated Business PlanDH Department of Health IBPR Integrated Business Performance ReviewDHR &OD Director of Human Resources and ICPB Integrated Care Programme BoardDoF Director of Finance ICO Information Commisioners Office DOLS Deprivation of Liberty Safeguards ICS Intermediate Care Strategy

DoN Director of Nursing ICT Information and Communication Technology

DOps Director of Operations ICT Integrated Care TeamDoS Directory of Services 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 TechnologyDToC Delayed Transfers of Care IV Intravenous DVT Deep Vein Thrombosis

DW. M1 SLAM Data Warehouse-Month1-Service Level Activity Monitoring JNC Joint Negotiating Committee

E&N East and North KPI Key Performance IndicatorE&NHCCG East & North Herts CCGE&NHHT East and North Hertfordshire Hospital Trust LAC Looked After Children

EBITDA Earnings Before Interest, Taxes, Depreciation and Amortisation LCGs Locality Commissioning Groups

ECC Essex County Council LETB Local Education & Training BoardECIP Emergency Care Improvement Programme LIFT Local Improvement Finance TrustED Early Discharge LINks Local Involvement networksEDS2 Equality Delivery System LLV Lower Lea ValleyENHT East & North Hertfordshire NHS Trust LMC Local Medical CommitteeENT Ear, Nose and Throat LoS Length of stayEoE East of England LTC Long Term ConditionsEPR Electronic Patient Record LTFM Long Term Financial ModelESD Early Supported DischargeESR Electronic Staff Record M&E Midlands & East (Cluster of SHAs)EWTD European Working Time Directive MD Medical Director

MDT Multi-Disciplinary TeamFNP Family Nurse Partnership MIND Mental Health CharityFoI Freedom of Information MIU Minor Injuries UnitFRR Financial Risk Rating Monitor Independent regulator of FTs

FT Foundation Trust MRSA Methicillin-Resistant Staphylococcus Aureus

FYE Full Year EffectMSK Musculoskeletal MST Multisystemic Therapy

HERTFORDSHIRE COMMUNITY NHS TRUST

LIST OF COMMON TRUST AND NHS ABBREVIATIONS

Abbr'ns In Full Abbr'ns In FullNED Non-Executive Director R&D Research and Development

NEPT North Essex Partnership University NHS Foundation Trust RAF Risk Assessment Framework

NHS National Health Service RAG Red, Amber, Green (“Traffic Light” rating)NHSE NHS England RAS Remote Access ServiceNHSI NHS Improvement RCA Root Cause AnalysisNHSLA NHS England (previously “NHS") RCN Royal College of NursingNHSP NHS Professionals RFH Royal Free HospitalNI National Insurance RN Registered NurseNIB National Information Board RO Responsible Officer

NICE National Institute for Health and Care Excellence RR Rapid Response

NIHR National Institute for Health Research RTT Referral to Treatment Time (18 weeks)NMC Nursing & Midwifery CouncilNMP Non Medical Prescriber SASH SASH Surrey and Sussex Healthcare NPDA Nat Provider Development Agency SDIP Service Delivery Improvement PlanNPSA National Patient Safety Agency SEND Special Educational Needs and Disability

NQB National Quality Board SEPT South Essex Partnership University Nhs Foundation Trust

NTDA NHS Trust Development Authority SHA Strategic Health AuthoritySI Serious Incident

OBC Outline Business Case SI(RI) Serious Incident (Requiring investigation)OH Occupational Health SIMs SIMs Information Management System O/P or OP Outpatient SIP Staff In PostOD Organisational Development SIP System Integrated PlanOT Occupational Therapy SIRO Senior Information Risk Owner

SLA Service Level AgreementPACE Post Acute Care Enablement SLR/M Service Line Reporting/MgtPAH The Princess Alexandra Hospital SLT Speech & Language Therapy

PALMS Positive behaviour, Autism, Learning disability, Mental health Service SMART Specific, Measurable, Agreed, Realistic, Timely

PALS Patient Advice and Liaison Service SMT Senior Management TeamPASA Purchasing and supply agency SSNAP Sentinel Stroke National Audit ProgrammePBC Practice Based Commissioning SOM Single Operating ModelPCT Primary Care Trust SPC Statistical Process Control PDSA Plan,Do,Study,Act SRC Strategy and Resources Committee

PESTEL Political Economic Social Technological Environmental Legal SRIG System Resilience Implementation Group

PCOM Person-centred outcome measures STP Sustainability and Transformation Plans

PHE Public Health England SWOT Strengths Weaknesses Opportunities Threats

PID Project Initiation Documentation Systm1 HCT’s Clinical IT System

PLACE Patient Led Assessments of the Care Environment

PMO Project / Programme Management Office TCS Transforming Community ServicesPMR Provider Management Regime TDA Trust Development AuthorityPQQ Pre-Qualifying Questionnaire TDAAF TDA Accountability Framework

PREP Professional Registration Education Preparation TFA Tri-partite Formal Agreement

PROMS Patient Related Outcome Measures TUPE Transfer of Undertakings (protection of employment)

PSED Public Sector Equality DutyPSHE Personal, Social and Health Education WCF Working Capital FacilityPSPP Public Sector Payment Policy Welhat Welwyn HatfieldPT Physiotherapy WECCG West Essex CCGPWC Price Waterhouse Cooper Wf&OD Workforce & Organisational DevelopmentPYE Part Year Effect WHHT West Hertfordshire Hospitals NHS Trust

WHSR West Hertfordshire Strategic ReviewQIA Quality Impact Assessment WRES Workforce Race Equality StandardQUIP Quality in Practice Framework WSM Work Stress Management

QIPP Quality Innovation Productivity and Prevention WTE Whole Time Equivalent

QOF Quality Outcome FrameworkQRP Quality Risk Profile YCYF Your Care Your Future

YTD Year to Date

HERTFORDSHIRE COMMUNITY NHS TRUSTLIST OF COMMON TRUST AND NHS ABBREVIATIONS

Board 29th September 2016 Attachment A1


Minutes of the Hertfordshire Community NHS Trust Board Meeting Held in Public on 28th July 2016 at

The Focolore Centre, 69 Parkway, Welwyn Garden City, Herts AL8 6JG

Key Points from the Meeting for the Board to note:

* The following were approved / ratified:

(i) The Board ratified the accepted control total agreed with NHSI following the May

board meeting and by extension ratified the Budget for 2016/17. (ii) The Board agreed to sign up to the Hertfordshire Compact and that Stephen Heard,

Head of Business Development be the Trust’s Compact Lead/ champion (iii) The Board individually and collectively re-subscribed to:

(1) The NHS Constitution (2) The NHS Code of Conduct and Accountability (3) The NHS Code of Openness (4) The “Nolan” principles of governance. (5) Principles of Board Etiquette (6) Code of Conduct for NHS Managers. (Only applicable to Executive Directors).

* The following were received and considered:

(i) Minutes and Action Trackers from the Board meeting held on 26th May 2016 (ii) The Board Assurance Framework (July 2016) (iii) CEO’s Report and Strategy Update (iv) Standing Reports from Executive Directors (v) Assurance Reports from NED Committee Chairs (vi) Safe Staffing Report (May 16) (vii) Complaints Report Qtr 1 2016/17 (viii) Serious Incident Report for April - May 2016 (ix) Summary Integrated Board Performance Report (June 16) (x) High Level Risk Register (June 16) (xi) Annual Audit Letter for 2015/16 (xii) Board annual governance update (July 16) (xiii) The Board Register of Interests as at June 2016 (xiv) Note of the Remuneration Committee meeting held on 28th June

* The Board received :

(i) A patient story on problems and issues with mental health services for young people (Sky News also present)

(ii) A report on matters of interest to the Trust from Meg Carter, Healthwatch observer (iii) Additional supporting papers (See min:130/16 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 * Alan Russell (AR) Non-Executive Director (Vice Chair) * Jeff Phillips (JP) Non-Executive Director * Dr Linda Sheridan (LS) Non-Executive Director * Brenda Griffiths (BG) Non-Executive Director (Designate) David Law (DL) Chief Executive * Phil Bradley (PB) Director of Finance*

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Clare Hawkins (CH) Director of Quality & Governance /Chief Nurse * Marion Dunstone (MD) Director of Operations (Interim) Alison Shelley (AS) Director of HR & OD In Attendance: Meg Carter (MC) Healthwatch observer Clive Appleby (CApp) Company Secretary For item 100/16 Patient Story (PALMS and Multi-Agency Working in Child Mental

Health) Mr. J Lethbridge (JL) Mrs. S Lethbridge (SL) (+ Sky News present) And as observers only for item 100/16: Katie Blackburn Press & Social Media Officer, HCT Claire Breen Interim Team Manager, Disabled Children Team East, HCC Sarvjeet Dosanjh Senior Commissioning Manager (CAMHS), HCC Jane Fullard CAMHS Modern Matron Komal Keshavala Communications and Engagement Officer, HPFT Jennie Newman ISL Area Manager (North Herts & Stevenage) and County

Lead for SEN, HCC (00) Patient Story 100/16

PALMS and Multi-Agency Working in Child Mental Health. What Can We Learn As a System?

Action

The Board welcomed Mr JL (and Mrs SL) who presented on their experiences and health service shortcomings in relation to their 9 year old daughter, KL, who has complex mental health problems. Sky News were also in attendance and filmed Mr. L’s presentation with the prior consent of the Board. Mr. L recounted K’s mental health history which included meltdowns, violence and aggression, a suicide attempt and a significant number of suicide threats. He highlighted a number of issues of poor care throughout which included:

• Frustration at (i) the paucity of beds nationally for children and young people with mental health problems and (ii) lack of visibility of where promised increased spending by the government on mental health has actually gone.

• Inappropriate educational placement and environment. (The

school have been very good but have requested that K

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leave).

• Poor communications (including telephone not being returned despite being promised), lack of urgent response and indifference to a crisis from CAMHS and mental health emergency hotlines.

• Long wait for access to CAMHS (and K was discharged

without even being spoken to on first visit).

• Parents being excluded from a “professional meeting” (but later told that could phone in).

• Having to go to A&E in Barnet recently and K being admitted

to a children’s ward as the only available resource, but the Barnet CAMHS service couldn’t do much as they couldn’t access Hertfordshire case files

• A pre-discharge meeting was held but no post-discharge

meeting as promised and (i) no contact to date and (ii) no review of medication, as no doctor available to do this.

• Lack of service continuity and absence of a seamless service

whereby organisations don’t talk to each other and he has to recount K’s story repeatedly to different organisations and professionals. (K has had over 150 separate assessments and has been seen by more than 50 specialists, including never having been seen by the same doctor more than once at CAMHS and having had five different social workers).

• Sometimes different teams in the same organisation don’t

communicate and there have also been constant changes of staff involved from the same organisation because of high staff turnover.

• There was a lack of clarity between the respective roles and

remits of CAMHS (Child and Adolescent Mental Health Service) and PALMS. (Positive Behaviour, Autism, Learning Disability and Mental Health Service). PALMS was also not an appropriate service for K’s needs.

• A national survey conducted with parents in a similar position

received 1100 responses,192 of which were from Hertfordshire. The general outcomes suggested an overall negative view of services in Hertfordshire for young people with mental health problems. (Nationally, 70% or respondents did not feel supported by CAMHS).

• The cumulative and detrimental effects on the family’s own

health and their domestic and work lives and, also on K’s

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younger sibling, who has been given no professional support despite now also showing behavioural issues.

• Single Point of Contact / Access (SPOC) doesn’t work, as

the it is still necessary to make numerous phone calls to different organisations/ professionals.

• Some agencies / professionals involved have been very

good. In addition to the school, this includes the GP. Some charities have also been very supportive.

• Responsiveness and quality of care are better for physical

conditions than they are for mental health. It was noted that Mr. L has re-invigorated a national campaign aimed at improving services and he has written to his MP, The Secretary of State for Health and the Prime Minister. His key message was that the system was broken and it “doesn’t need a sticking plaster but it needs open heart surgery”. Observations and Questions from the Board: (a) On behalf of the Board, DO’F acknowledged that it was a

powerful and distressing story and it was quite understandable why Mr L felt both angry and frustrated.

(b) The biggest difference now to Mr and Mrs. L would be

availability of an in-patient bed (even if short term) plus (ii) appropriate schooling and (iii) urgent and responsive medical support.

(c) It was pointed out to Mr L that although HCT did not abrogate its responsibility for the PALMS service, which was provided by HCT, this was only a very small part of the wider issues.

(d) The Trust was not in a position to answer all of Mr. L’s questions or to address the issues raised which related to either national policy/funding, commissioning or the performance of other organisations, (such as CAMHS). HCT did however welcome that K’s story had been told and recognised the issues empathetically.

(e) The Trust also (i) had invited representatives from other organisations involved to hear Mr. L’s concerns (ii) would like to share the story with other relevant organisations and (iii) would do its best to address issues arising around joint working. To this end, it would be helpful if a copy of the film of the story could be supplied to HCT, which the Trust could then share (and Mr. L agreed).

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Decision(s), Outcome(s) and Actions: (1) On behalf of the Board, The Chair thanked Mr and Mrs L for

attending and giving their presentation and wished the family well for the future.

(2) Mr L to supply HCT with a copy of the film of his presentation

and HCT to share it accordingly with the relevant organisations which have been involved in K’s care.

(3) HCT to take forward relevant issues of joint working with the

partner organisations concerned.

Mr. L DL DL

(A) Preliminaries & Board Governance Action 101/16 Welcome, Introductions and Apologies

Apologies were received from Julie Hoare (JH) Director of Service Development and Partnerships and Marion Dunstone, Interim Director of Operations. DO’F also welcomed Lorelei Jones, from UCL Department of Applied Health Research, who was attending as an observer.

102/16 Chair’s / CEO’s Announcements & Notice of Urgent Business No items. 103/16 Members’ Declarations of Interest Relating to Business on the

Agenda / For the Register of Interests

No declarations. 104/16 Ratification of items of Chair’s and Chief Executive’s Action

taken since the last meeting under Standing Order 5.2

The Board ratified the accepted control total agreed with NHSI following the May board meeting and by extension ratified the Budget for 2016/17.

105/16 Minutes of the Meeting held on 26th May 2016

The minutes of the meeting held on 26th May 2016 were agreed as a correct record.

106/16 Matters Arising from the Minutes of the Meeting Held on 26th May 2016 (Board Tracker)

It was noted that: 41/16 The patient story re a family’s experience of PALMS /

CAMHS has featured as the patient story at the July meeting. (See 100/16 above).

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84/16 Reasons for staff turnover as being explored by the Resources Group will be reported to SRC in September. Preliminary indications were that work-life balance was the most significant factor.

There were no matters arising not otherwise included on the Tracker.

(B) Strategic Risks 107/16 Board Assurance Framework

The BAF as at July 2016 was received. It was noted that: (i) Key changes since the May version were as follows:

(a) Although risk 1 0316, staffing, retains top risk ranking, there has been a slight reduction in current impact.

(b) The specific west Hertfordshire health system leadership risk has been eradicated, although wider system risks are reflected in other risks. This risk as defined is therefore closed.

(c) Following Board discussion in May, Risk 10 0316, the secondary theme risk of “Not being able to evidence improved outcomes or patient safety” has been segregated, with outcomes and safety now as two distinct entities. The “outcomes” component has been escalated to the primary risks and the patient safety component is currently recognised in the secondary risk themes, as risks to patient safety may arise due to financial constraints, during the process of service transformation or through lack of internal escalation.

(d) Risk 12 0316: Not having visibility of information is now more specific in referring to management information (ie information required to effectively manage the business) and although still a secondary risk, has a higher score.

(e) Secondary Theme Risk 11 0316 has been redefined to include leadership capacity as well as capability.

(f) Some definitions have been amended in the “Likelihood Rating” to give more recognition of risks which have materialised but which are now receding, as opposed to being future risks or risks which are currently materialised.

(ii) An “annual cycle” of the BAF via the Executive Team, the

Board and Board Committees was proposed whereby the BAF would come to the Board and SRC, HGC, FTC three times per annum , to CEC twice per annum and to the Audit

6


Committee (for assurance as to process once per annum). Challenge, Response to Board Questions and Actions (a) The IM&T Strategy Group was leading on risk 10 0316

(Evidencing improved outcomes) and 6 0316 (Underdeveloped / ineffective use of technology). In respect of the latter, the Business Units have been asked to come up with ideas for taking forward. Work is also underway with HCSIC on telehealth and a pilot will be tested with a community team.

(b) 10 0316 needs to ensure that the focus is on outcomes and

not outputs, which are altogether different. Work on outcomes is underway and will come under the umbrella of the Health & Wellbeing Strategy. Consideration to outcomes has also been given at SMT and other forums, and it has been agreed that outcomes be defined under the four headings of safety, experience, effectiveness and efficiency. Further work is required on (i) engaging with front line staff, (ii) system wide considerations and (iii) recognition of patient reported outcome measures.

(c) There are a lot of possible outcome metrics available but

careful consideration will need to be given to being sufficiently selective. Although there will be different views, outcome measures selected will also need to be endorsed by commissioners, otherwise they will be a waste of time.

(d) Changes in the commissioning landscape and where HGC is

monitoring quality impacts is recognised in risk 2 0316 (national, local, system-wide and Trust financial and demand pressures).

(e) Tertiary risk 15 0316 (Staff engagement and morale) can be

incorporate into risk 1 0316, (“staffing”) and there may be potential for further consolidation of some of the risk themes currently identified.

(f) The Board was reminded that secondary and tertiary risk

themes were those that didn’t currently need detailed focus but were identified for visibility and as candidates for discussion as to possible escalation, de-escalation or consolidation.

(g) Although still evolving, the “new” BAF was much clearer in

enabling discussion on the key strategic risk issues and without being too pre-occupied with format, controls, assurances and scores. However, it is recognised that there is more to do on recording assurances.

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Decision(s), Outcome(s) and Actions:

(1) The proposed “annual cycle” of the BAF via the Executive Team, the Board and Board Committees was agreed, and this frequency will be kept under review.

(2) The BAF as at July 2016 was noted and agreed as a fair

reflection of the strategic risks facing the Trust subject to observations made.

CA and Execs to note

(C) Clinical Services & Healthcare Governance 108/16 Director of Quality & Governance / Chief Nurse’s Report July

2016 (CH)

The Director of Quality & Governance / Chief Nurse’s Report for July 2016 was received and discussed. Items reported on were: (1) Executive Summary

• Focused unannounced CQC inspection feedback is due to the Trust for factual accuracy check in August.

• Ofsted/CQC Inspection of Special Educational Needs and Disability (SEND) undertaken in July. Report awaited but feedback on HCT would seem to be positive.

• Work underway to review cause and impact of increasing rates of bank and agency staffing in Community Hospitals.

• Good progress and engagement across the Professional Clinical Leaders’ Group and associated sub groups.

• Limited capacity and additional workload resulting in increased prioritisation within the Quality Directorate.

• Morbidity and Mortality process review completed by the Patient Safety team, Associate Medical Director and myself. New systems and processes devised. Reporting agreed through the Quality Report.

• Good system leadership demonstrated by Chief Pharmacist with a number of long running issues nearing resolution.

• Substantial delivery noted within the last financial year, through the range of Annual reports presented for Board review, and good quality performance noted in the IBPR.

(2) Current Performance

• Overall quality performance remains strong. No C DIff cases reported in June, bringing HCT back onto trajectory. One avoidable pressure ulcer was reported in North Herts ICT – this is undergoing root cause analysis.

(3) Quality Annual Reports 2015/16

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• The following Quality annual reports for 2015/16 were

included in the supporting papers for the Boards and public’s information. The Research & Development Report is to follow in September. These give a give a give indication of the state of play and progress in each area over the year: Complaints, Clinical Audit, Infection Prevention and Control, Patient Experience, Safeguarding Children, Looked After Children and Safeguarding Adults from Abuse.

(4) Risks and Challenges

• Over 20% bank and agency rates in Community Hospitals - required to meet Safe Staffing levels.

• Oversight and actions required to manage components of the Medical Directors portfolio continue to impact on workload of senior quality team members.

• Reduced capacity continues within the Quality Directorate as a whole due to due to sickness absence, maternity and other special leave, resulting in prioritisation of workload.

Challenge, Response to Board Questions and Actions (a) The Professional Clinical Leadership Group and associated

forums for nurses and AHPs have now been launched and their focus is on (i) engagement on Trust strategy (ii) clinical leadership (iii) recruitment and retention and (iv) sharing good practice and learning. A work plan is not yet in situ but will be developed in due course. Further information on the work of the Group and forums will come to the Board in September.


(1) The Director of Quality & Governance / Chief Nurse’s Report

for July 2016 was noted.

109/16 Safe Staffing Report - May 2016 (Lead Director: CH)

The Safe Staffing Report as at May 2016 was received and discussed. It was noted that: (i) In May all units reported average staffing levels above the

HCT threshold of 90% threshold.

(ii) Although average staffing levels for all units were over 90% there was high bank and agency use on some units, with 4 units having a combined bank and agency rate of over 20%.

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(iii) HCT continued to require additional staffing hours to care for patients with complex needs, including escorting patients to 40 appointments off site.

Challenge, Response to Board Questions and Actions (a) Safe staffing was discussed and tri-angulated at HGC and

assurance is being sought that maximum effective use is being made of the e-roster system.

(b) 20% may seem high for bank and agency usage for a

community trust but a number of patients do present additional risks. However, it is not yet clear whether the bank/agency usage rate is patient-need driven and this is being explored by the Executive Team next week.

(c) The staffing position for the bed base units was not so much

about clinical risks as being about appropriate use of resources.

Decision(s), Outcome(s) and Actions: (1) The Safe Staffing Report for May 2016 was noted.

110/16 Complaints Report Qtr 1 2016/17

The Complaints Report for Qtr. 1 2016/17 was received and discussed. It was noted that: (i) A total of 53 complaints were received during the quarter

(Compared to 67 in Qtr 4 2015/16). The Trust made contact with 476,707 patients during the period.

(ii) A total of 1799 compliments were received.. (iii) 100% of complaints were responded to within the agreed

time frames. (iv) The report demonstrates the service improvements taken as

a result of complaints received. (v) 3 complaints received in this quarter were graded as

category 3 and are currently under investigation with PHSO.

Challenge, Response to Board Questions and Actions

(a) There was a declining number of complaints across the

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whole health system about poor care. This is positive, but the challenge will be to maintain this decline in the current NHS climate.


(1) The Complaints Report for Qtr.1 2016/17 was noted.

111/16 Serious Incident Report 1st April - 31st May 2016 (Lead Director: CH)

The Serious Incident Report for the period 1st April to 31st May 2016 was received and discussed. It was noted that: During the period 1st April to 31st May 2016 four serious incidents were reported. (Compared to three incidents for the period 1st February to 31st March 2016): Treatment delay meeting SI criteria x1 Death in custody x 1 Abuse/alleged abuse of adult patient by staff x 1


(1) The Serious Incident Report for 1st April - 31st May was

noted.

112/16 Chair of Healthcare Governance Committee’s Assurance Report (July 2016) (Committee Chair: AM)

The Chair of Healthcare Governance Committee’s report for July 2016 on the meeting held on 19th July was received and discussed. Risk / Assurance levels reported were as follows and Chair’s observations against each were noted:

Item Committee Assurance Assessment (R/AR/AG/G)

Committee Chair’s Observations

Safe Staffing Report (Apr)

Amber / Red

Met the standard but used increasing amount of Bank and Agency to do so above 20%. Work underway to review risk criteria

Safe Staffing Report Amber / Red Met the standard but used increasing

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(May)

amount of Bank and Agency to do so above 20%. Work underway to review risk criteria

High Level Risk Register (May 16)

N//A

Majority of clinical risk items relate to staffing deficits. Highest individual risk with the decommissioning of FPS and reduced capacity in HV service. New methods being designed to mitigate impact of risk on vulnerable children and service viability.

Complaints Report Amber / Green

No significant change. Three Category 3 complaints.

Serious Incident Report

Green

4 Si’s reported in April & May. Sharing of lessons in practice a strong element of improvement.

BUPR Assurance reports Amber / Red

Risks raised mirror risks in HLRR

Clinical Quality Review meeting minutes ENHerts CCG May 2016

N/A

External Review of MSK Services Amber / Red

Wide ranging report with detailed action to improve MSK services.

15 Steps Challenge Outcome Report Amber / Green

Good example of follow up to a complaint on baby clinics and the assurance provided.

Looked after Children’s Annual Report 2015/16

Green

Many examples of advances made in the past year such as LAC GPs to improve this service on an on-going basis.

Safeguarding Adults from Abuse Annual Report 2015/16

Green

Substantial number of changes implemented from new legislation plus a long list of achievements and definitive plans for

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2016/17

Safeguarding Children Annual Report 2015/16

Green

Achieved 95% Children’s Safeguarding Training and supported the introduction of a new Multi-Agency Safe Guarding Hub across Herts amongst a large list of achievements. Concerns identified for 2016/17 impact from decommissioning of FNP service and reduced capacity in HV Service.

Infection Control Annual report 2015/16

Amber / Green

Comprehensive Annual Report demonstrating year on year improvement in the reduction of HCAI’s. No MRSA for 4 years. Only downside is the need for Community Hospitals to achieve the 95% target for IPC training.

Clostridium Difficile Summary 2015/16 Green

Target met

Complaints Annual Report 2015/16

Green

Similar performance to previous years in numbers 250 and outcome. Notable continuing large and increasing numbers of compliments 6924.

Complaints Handling Toolkit and Gap Analysis

Amber / Green

Mostly achieved via good complaints handling systems and processes already being practiced by HCT.

Patient Experience Annual Report 2015/16 Green

FFT consistently above the national average.

Patient Safety & Experience Chair’s Assurance report and minutes from 23 June 2016

Red

Decommissioning of Family Nurse Partnership and reduced capacity of HV Service impact on vulnerable children.

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Palliative Care and End of Life Chair’s Assurance meeting

Amber / Red Operational Delivery Plan in developmental stage.

Clinical Effectiveness Audit Annual Report 2015/16

Green

100% delivery of National Audits. Substantial additional audits done to assure improvements from CQC Action Plan delivered. NO major risks identified.

Clinical Effectiveness Group Chair’s Report and Minutes from 16 June 2016

Amber / Red

National Diabetes audit 13/14 and 14/15 shows gaps in service. Recent local audit 2016 confirms these are in the process of being addressed

Medical Revalidation Decision Making Group (i) Terms of

Reference (ii) Chair’s

Assurance Report

Red

Lack of formal written SLA agreements with outside NHS organisations make managing concerns with individual clinicians problematic.

Challenge, Response to Board Questions and Actions (a) The Executive Team is aware of issues around MSK and this

is being addressed. This includes an action plan being in place. The issues are not linked to commissioning.

Decision(s), Outcome(s) and Action(s): (1) The HGC Chair’s report for July 2016 was noted.

(D) Operations & Performance 113/16 (Interim) Director of Operations’ Report (July 2016) (MD)

The Director of Operations’ (written only) report for July 2016 was received and discussed. Items reported on were: (1) Summary

• Pressure on service delivery as a result of contractual agreements, particularly in Children’s Services

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• Wide range of integrated service developments including the roll out of HomeFirst across East & North, Rapid Response in Dacorum and the Video Flouroscopy service for Children in West Essex

• Continued pressure on the Urgent Care system • Continued pressure of workforce levels in some services but

particularly in the ICT teams.

(2) Children’s Services

• Community Paediatrics (Staffing pressures) • Child Health Information Service (Bid submitted) • Support for Children and Young People at the End of Their

Lives. (Chair’s Special Award for Outstanding Leadership to Mary Heffernan).

• Video Fluoroscopy Swallow Study (VFSS) Service set up in West Essex. (Extension of service to Princess Alexandra Hospital).

• Services in West Essex CCG. (Universal Services tender). • Health Visiting Services. (Piloting greater integration) • Family Nurse Partnership (FNP). (Decommissioning) • STEP2 Service. (Waiting times and demand and capacity

Study). (3) Adult Services

• Diabetes. (Continued improvement in the service; HVCCG

specification). • Hertsmere ICT. ( Delivery of turnaround action plan) • ICTs. (Staffing challenges but ICT nursing services across

the county continue to perform strongly against activity targets and the Friends and Family scores).

• Community Hospitals. (Good performance on LoS and development of an HCT model for managing enhanced needs of patients referred for bed base Intermediate Care).

• MSK. (Staffing showing some signs of improvement; performance challenges and waiting times; action plan).

• Community Neuro Rehab. (work with CCG’s to develop a futureproof specification).

• Tissue Viability. (Addressing sustainability of a small service).

• Palliative and End of Life. (Implementation of the Strategy and Policy).

(3) Operational Risks and Challenges - Adults and Children’s Services:

• Workforce levels: Palliative care, Community Paediatrics,

Step 2, GP provision at HMP Mount, Royston ICT, MSK,

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ICTs Herts Valleys and Diabetes service. Although there has been recent recruitment success in Palliative, Diabetes and Step 2 service areas. Therapy in Stevenage ICT

• Health Visiting / FNP • ENHHT acute therapies and engagement with contract

meetings • ICT Hertsmere • Cost associated with specialing patients in bed bases.

(4) System Resilience

• The E&N system escalation has dropped and is now

routinely Amber (35%) / Red (65%). • HCC work to improve the Hertfordshire wide community bed

system challenges and HCT input. • System Resilience Implementation Group (SRIG) in HV and

improving picture) • HCT projects: (In-Reach Team at WHHT - HCT = Lead);

Frailty Service at WHHT - HCT = partner). • ECIP support to Herts Valleys • E&N development of a more Integrated Discharge Service. • Rapid Response in Dacorum

Supporting / linked documents are:

• IBPR • HLRR • BUPR assurance reports • Directors’ Board Reports

Challenge, Response to Board Questions and Actions (a) Staff in some services are being overstretched and these

services are at the point of being able to deliver the maximum that it is possible to do. The staffing position is also sometimes under reported as, eg maternity leave absences are not reported. It is also as helpful to have details of staff present as an indicator as much as staff absent.

(b) The above is a strategic issue and has also meant taking an

entirely different approach to CIPs, as the historical approach of “slicing and paring” services is not a solution.

(c) The following are currently on escalated status for regular

reporting to the Executive Team: HEH (and Stort Valley Locality), MSK, Hertsmere, Diabetes and Spend on beds.

(d) The In-reach team at WHHT is one person but a significant

reduction is evident in the number of inappropriate referrals.

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(e) The report is comprehensive, and good for MD’s first report,

although information on some areas is “left hanging”. For example LoS is doing well in E&N but there was no reference to Herts Valleys. Evolution of the report could include being a bit clearer on “what the Board needs to worry about”.

Decision(s), Outcome(s) and Actions: (1) The Director of Operation’s Report (July 2016) was noted.

114/16 Summary Integrated Board Performance Report (June 2016) (Lead Director: PB)

The Trust’s Summary Integrated Board Performance Report (Data for June 2016) was received and discussed. It was noted that: (i) The report had been considered in some detail by SRC and

the full report, including detailed analysis, is in the supporting papers.

(ii) Areas for attention in the full set of indicators were:

• DTOC rate above the 5% threshold for last nine months with

9.1% health delays recorded in June. • Non-Stroke ALOS above thresholds in June. • Urgent Therapy referral priorities 2 and 3 not achieving

response targets. • Staff turnover at 13% and over the 12% threshold. No

change from previous month

(iii) Performance highlights were:

• No MRSA breaches reported. • No C.diff cases reported in June bringing HCT back on

trajectory. • HCT achieving 96% for patients waiting within 18 weeks for

their initial appointment. • Smoking Status achieving the 91% target. • Stroke ALOS within thresholds for June. • All Urgent Nursing referrals achieving response targets. • Overall staff mandatory training levels above target. • Child safeguarding training achieved. • Child health promotion programme (immunisations, vision

and hearing screening, National Childhood • Measurement Programme) on trajectory to achieve target.

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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.

115/16 High Level Risk Register Summary (July 2016) (Lead Director: CH)

The High Level Risk Register (HLRR) summary as at 12th July 2016 was received and discussed. It was noted that: (i) 22 risks are currently held on the HLRR. 20 risks have not

changed since last submission and continue to be managed at their current scores of 15 and over.

(ii) Two risks have been escalated since the last submission: 381: Staffing – Dacorum ICT (iii) 427: Staffing - Community Nursing and Integrated Teams

West) (iv) No new risks have been added to the HLRR.

(v) 13 risks have been on the Register for more than 12 months.

Some of these have fluctuated according to circumstances. Risk Team will be contacting the owners of the 13 risks that have been on the HLRR for more than 12 months to review the rationale for retaining them on the register.

Challenge and Response to Board Questions (a) The HLRR was considered by HGC where decommissioning

of FNP (risk 433) was noted as already having an impact on safeguarding children. This is likely to increase and will be closely monitored. The Hertfordshire Safeguarding Children Board will also be kept aware.

(b) The score for the GP prescribing risk probably no longer

merits a score of 16. (c) Current risk scores are being reviewed and following this

piece of work there will be Board discussion around risk appetite as part of the work of addressing risks which have been on the HLRR for a long time. (Which is also an issue raised by the Audit Committee).

(c) As a minimum, risks which have been on the HLRR for more

than 12 months should be subject to total re-review.

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Decision(s), Outcome(s) and Action(s): (1) The Board noted the HLRR and actions being taken to

mitigate risks as at July 2016.

(E) Strategy, Resources and Engagement 116/16 CEO’s Report & Strategy Update (July 2016) (DL)

The CEO’s (verbal only) Report for July 2016 was received and discussed. Items reported on were as follows: (i) The Herts STP was considered to be a weak submission at a

meeting held by NHSI on 8th July and the system has got to revisit the plan. The biggest issue is closing the financial gap, and the financial plan has to be re-submitted by September.

(ii) For the Integrated Care Partnership Board (West) (ICPB),

HVCCG has more clearly defined to remit to focus on diabetes, stroke, end of life, integration and pathways. This has broadened the scope.

(iii) The GP federations in west Herts are forming an “umbrella” organisation, which is a positive move.

(iv) The first meeting of a provider collaborative in west Herts

has been held. The CCG has made it clear that the providers are responsible for taking on changes and the initial focus as expressed through the terms or reference is to create the environment and circumstances for making changes.

(v) The Trust’s Senior Management Team (SMT) is now taking

on a more focussed role in delivering the Trust’s strategy through oversight and reporting. SMT now meets every eight weeks as the Health & Wellbeing Strategy Group (H&WSG). Particular thanks are due to Antonia Robson, Jackie Davenport and Val Davidson for pulling this approach together.

(vi) The financial climate continues to be very tight and financial

constraints on commissioners means that there won’t be any funding that will contribute to CIPs. This means that some CIPs will require system-wide decisions.

(vii) The scale of change required will give rise to associated

risks which will need careful management , eg issues with the numbers of beds.

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Challenge and Response to Board Questions (a) It is right that some difficult system-wide decisions will be

required but the CCG will have to resource any desires to retain a status quo, eg with the number of beds. PB is looking at alternative options, but as any such changes would require consultation and may become a “quagmire” which delays change, consideration should be given to initiating informal consultations now,

(b) An irony could arise whereby beds are closed but then the

commissioners request opening of escalation beds. The CCGs should be pro-active in making early assessment of a need for escalation beds, so this doesn’t become a “last minute” requirement. However, although this is a part of business continuity, escalation beds are not likely to be affordable in the current financial climate.

(c) It may perhaps be possible to make an offer to the CCG

whereby a % of beds are re-commissioned but this is unlikely. At any event, it would be more viable for HCT if bed numbers can be sustained at current level until March 2017.

(d) If DToCs could be addressed, then bed closures would be

more viable. In respect of DToCs, there is a scheme in place for homecare agencies to employ HCAs, but they are struggling to recruit. Other initiatives include looking at the Sheffield model of “Discharge Home to Assess” (thereby freeing up beds) and also there is a proposal from social care for a night service.

Outcomes and Actions: The CEO’s Report for July 2016 was noted.

117/16 Director of Finance’s Report (July 2016) (PB)

The Director of Finance’s report for July 2016 and the Month 3 (June 16) Financial Position Report were received and discussed. Items reported on were detailed summaries of developments, performance and work in progress relating to: (i) Finance (a) Month 3 saw the Trust post an in month deficit of £55k which

is in line with the Trust’s plan. The Trust’s year to date deficit is £183k, £9k better than plan

(b) At the end of Month 3, the Trust had delivered £1,246k of Cost Improvement Programme (CIP) savings. The year to

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date target is £1,215k therefore £31k ahead of plan. Of the £1,246k CIP delivery £545k of this has been delivered non recurrently.

(c) The Trust has agreed a revised control total of £1,530k with NHS Improvement. The Trust is currently forecasting to achieve this position.

(d) The total capital spend at the end of month 3 was £556k, which is £39k underspent against the original phased plan of £595k.

(e) The Trust has a strong cash position at the end of month 3, being £15,683k against a plan of £14,500k.

(ii) Estates and Facilities

(a) Strategic: The Estate Strategy is currently being updated to

reflect the Health and Wellbeing Strategy, the STP and locality working principles.

(b) Rationalisation: • Watford: British Research Establishment (BRE): • St Albans integrated administration hub (Sandridge

Park) • St Albans: City Centre Opportunity Site

(c) Community Hubs: • Cheshunt Community Hub

(d) New developments: • Hemel Hempstead Integrated Health Facility: • Harpenden Memorial Hospital Development: • Elstree Way Development:

(iii) Information Governance

(a) Information Governance Toolkit The Information Governance Toolkit currently stands at 90%, a rise of 5% on last year’s submission.

(b) Incident Reporting

• Increase in no of incidents from 48 in Qtr4 2015/16 to 53 in Qtr 1 2016/17.

• One serious incident outstanding that occurred in January 2016 and which has been reported onto the ICO who have requested further information.

(c) Freedom of Information Requests: The Trusts compliance level is currently at 100% within the

statutory 20 working days. (d) Requests for Information (Subject Access Requests)

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The Trust stands at 58% compliance within statutory timescales. This is a significant reduction from the 87% achieved in the previous quarter. The reasons for this are (i) a change in reporting methods (all cases now being recorded solely on DATIX), (ii) a significant increase in the number of requests (iii) the complexity of requests and (iv) limited resources (1.14 WTE staffing, 1x Band 3 supported by 1 apprentice), processing an average of 130 new requests each month. The figures are of concern with the Head of Information Governance examining productivity and current resources to ascertain how this situation can be improved.

(e) Complaints There is currently one complaint made to the ICO under the Data Protection Act 1998 which is being responded to by the Company Secretary and Head of IG.

(iv) Performance, Information and IT (a) Business Intelligence: Statistical Process Control (SPC)

reports and referrals dashboard deployed (b) Performance:

• Service assurance framework KPIs drafted • Benchmarking report submitted to Strategy and

Resources Committee

(c) IT: • SystmOne contract started 7th July • MediPi project underway • HBL Business Change TUPE preparation

(v) Commercial Opportunities (a) HVCCG intend to test the open market for MSK,

Dermatology, ENT and Ophthalmology. (b) The level of activity, has highlighted the challenges of

resourcing tender response teams from within the Business As Usual teams.

(c) The opportunity in West Essex has stalled slightly as Essex County Council Cabinet have “called in” the procurement for further consideration.

(d) Decision by Hertfordshire County Council to extend their current Children’s Services contract until April 2018 to be co-terminus with their current Children’s Centres contract.

(e) Hertfordshire CCG’s are increasingly using alternative routes to market as they demonstrate collegiate working with the provider community. HV CCG is looking to HCT to be the lead provider in Diabetes and to work as a sub-contractor to West Herts in delivering stroke services.

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(f) Preliminary discussions have begun with GP Federations in order to assess their appetite for working with HCT.

(g) The following county-wide procurements are commencing: • Integrated Urgent Care procurement with HCT working

in partnership with Herts Urgent Care (incumbent provider); PQQ submitted in July.

• Integrated Rehabilitation Beds with HCT positioning as a potential partner to a prime provider.

(vi) Business Planning and Contracting (a) The Sustainability & Transformation Plan (STP) for Herts

and West Essex was submitted at the end of June. Feedback on the plan has been received and further work has been requested.

(b) There has been positive movement in negotiation of our Health Visiting, School Nursing and Family Nurse Partnership contracts with Hertfordshire County Council (HCC). HCC has confirmed that the re-procurement of both School Nursing and Health Visiting is deferred for one year, with the new contracts starting in April 2018.

(c) HCT has received a letter from HVCCG giving 6 months’ notice that they intend to withdraw CIP reimbursement on HCT Beds (£1.6m p.a.). This represents a significant risk to HCT.

(vii) Control Totals and the STP

(a) There has been much recent press speculation about the size of the 2016/17 NHS Provider deficit (c£550m deficit has been quoted)

(b) There is a requirement that STP footprints have been asked to respond by the end of July on: • Sharing Back office functions, (for information HCT

currently utilises shared services for; finance, procurement, IM&T, payroll and Occupational Health). HCT are exploring possibilities with HPFT.

• Merging Pathology services (not applicable for HCT), and • Reviewing those specialties / services that are heavily

reliant on locums / agency staff and seeing whether a neighbouring organisation is better placed to run this service leading to a better quality and cheaper service.

(c) The executive is currently reviewing services heavily reliant on non-permanent staff and will update the Board as this work progresses.

(vii) Risks

Key risks included: • NHSI feedback on the Operational Plan submission re

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capital • Potential change to the agreed financial control total • Lack of capital allocation impacting on the speed of

integration

Challenge and Response to Board Questions (a) A decision is awaited from NHSI on a request for an

extension of £2m to the Trust’s capital resource limit. (b) £500k of CIPs is non-recurrent and a first meeting has been

held to look at longer term CIPs. (c) HCT is the direct commissioner for the new SystmOne

contract. The business change team will be transferring to HCT under TUPE in October.

(d) The financial position is getting progressively tighter and the landscape has changed dramatically over the last six months, but the Executive team has done well to be in the current position.

Decision(s), Outcome(s) and Action(s): (1) The Director of Finance’s Report (July 2016) and Month 3

(June 2016) financial information were noted.

118/16 Director of HR and OD’s Report (July 2016) (AS)

The Director of HR and OD’s Report (July 2016) was received and discussed. Items reported on were: (1) Headlines: (a) Workforce KPIs: In month sickness is just above the stretch

target of 3.6% but continues to benchmark positively vs aspirant Community Trusts. Staff turnover has increased and focused retention work is underway. Trust appraisal rate is 88% vs 90% target.

(b) The vacancy rate target has been revised from 9% for 2015/16 to 8.5% for 2016/17. Current vacancy rate is 9.45%.

(c) Mandatory training compliance remains above target at 92%. (d) Compliance with the national Agency price caps is

progressing with the number of breaches on a continued downward trajectory. Wage cap compliance reporting has been introduced per national requirements.

(e) An enhanced work programme has been prepared on Staff Health & Wellbeing and in support of the new national CQUIN.

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(f) HCT was recognised as a finalist in the national HPMA Awards under the HSJ Innovative Recruitment Campaign category.

(g) HCT is now ranked joint first out of 450 Trusts in the National Workforce Data Ranking looking at the quality of data held on ESR

(h) The Trust held very successful annual staff recognition awards and its 4th annual leadership conference, during June.

(2) Detailed summaries of developments , performance and work in progress relating to:

(i) Workforce KPIs and Operational Activity:

• Sickness, Turnover and Vacancy rates • Temporary Staffing KPIs • Mandatory Training • Appraisals

(ii) Staff Engagement (WF&OD Strat.Objective 1): • “Leading Lights” Awards / Celebrating Community

Services. (21st June).

(iii) Workforce Planning and Resourcing( WF&OD Strat.Objective 2):

• Resourcing Plan • Recruitment Award • Recruitment Pipeline • Workforce Plan • Workforce Data Quality

(iv) Learning & Development (WF&OD Strategic Objective 3) • Accreditation to host a strategic NHS graduate

scheme trainee • Learning & Development Annual Report

(v) Employment Practices (WF&OD Strategic Objective 4) • Staff Health and Wellbeing CQUIN • Probation period • Incremental Progression • Pension Auto-Enrolment

(vi) Leadership (WF&OD Strategic Objective #6) • The 4th Annual Leaders Conference

(3) Risks and Challenges

• CQUIN: The Staff Health and Wellbeing CQUIN has been identified as an emergent financial risk for the Trust, particularly in relation to the Flu vaccination uptake target

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of 75%. £230k is attached to this one element across Herts (West Essex being an additional amount). A mitigation plan has been developed and the risk is being added to the risk register.

• Medical Staffing Support: An interim medical staffing lead

has been recruited to provide support to the Associate Medical Director/RO particularly with respect to revalidation requirements. This remains a risk regarding ongoing resource for this area.

Challenge and Response to Board Questions: (a) A report on the increase in turnover and underlying reasons

will come to SRC in September.

(b) Mandatory training being above target was very positive. (c) Work was underway and linked to the Health and Wellbeing

Strategy to free up clinical time and look at optimum use of healthcare assistants to free up qualified staff time. This was especially pertinent to ICTs, but was also increasingly relevant to AHPs. Part of this work will involve taking one clinical team and stripping away all non-essential work to free up clinical time.

(d) It may be possible to get more support and input from the

voluntary sector. Decision(s), Outcome(s) and Action(s): (1) The Board noted the Report from the Director of HR and OD

for July 2016. (2) The Board commended the HR and Comms teams for

organising the highly successful “Leading Lights” event and also commended the HR workforce information team for being joint first out of 450 Trusts in the National Workforce Data Ranking in respect of data held on the Electronic Staff Record.

119/16 Director of Service Development and Partnerships’ Report (JH)

The Director of Service Development and Partnerships’ (Written only) Report for July 2016 was received and discussed. Items reported on were: (i) A description of this new role as having two main

components:

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(a) to drive the transformation of services that will deliver

the Clinical Strategy and to (b) represent HCT as system leader establishing and

developing partnerships that support and enable HCT to optimise its contribution to the health and social care system.

(ii) Success measures as linked to:

• System • Locality • Pathways • Personal (eg self-managed care)

(iii) Current position and aims in respect of partnerships (iv) Relationship between the role and other directors / teams Challenge and Response to Board Questions: (a) Segregating the role from that of the Director of Operations

has been the right thing to do, as it will enable more focus on strategic delivery and give higher HCT visibility within partnership working.

Decision(s), Outcome(s) and Action(s): (1) The Director of Service Development and Partnerships’

Report for July 2016 was noted.

120/16 The Hertfordshire Compact (Lead Director JH)

The Hertfordshire Compact was received. It was noted that: (i) The Hertfordshire Compact is a written understanding

between the voluntary and community sector and statutory sectors about how they will co-operate and continue to develop positive working relationships for the benefit of Hertfordshire’s communities. The Compact process is one of learning, development and dialogue.

(ii) The Compact was developed by a multi-agency steering

group and a process of consultation in late 2015/early 2016. A “Launch Event” was held on 20th July 2016, which DO’F and Stephen Heard, Head of Business Development, attended.

(iii) Signing up to Compact aligns with Trust strategy and there is

an expectation that all statutory health bodies sign up to their

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local Compacts. (iv) Signing- up to the Compact does not create any onerous

resource or capacity implications for the Trust. (v) The Trust already has memoranda of understanding for joint

working with two voluntary organisations which are signed up to the Compact. (Carers in Herts and the Herts Independent Living Service).

Decision(s), Outcome(s) and Action(s) (1) The Board agreed that HCT sign up to the Hertfordshire

Compact. (2) Stephen Heard, Assistant Director, Business Development,

will be the Trust’s “Compact Champion”, a requirement for which is prescribed under the sign-up process.

(F) Board Governance & Leadership

121/16 Annual Audit Letter 2015/16

The Annual Audit Letter for 2015/16 from external auditors, E&Y, was received. It was noted that: (i) The purpose of the annual audit letter is to communicate to

Directors and external stakeholders, including members of the public, the key issues arising from our their work, which they consider should be brought to the attention of the Trust.

(ii) The results and conclusions were as follows:

(a) Financial statements – Unqualified. The financial

statements give a true and fair view of the financial position of the Trust as at 31 March 2016 and of its expenditure and income for the year then ended

(b) Parts of the remuneration and staff report to be audited

– No matters to report (c) Consistency of the Annual Report and other information

published with the financial statements - Financial information in the Annual report and published with the financial statements was consistent with the Annual Accounts.

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(d) Reports by exception: • Consistency of Governance Statement - The

Governance Statement was consistent with understanding of the Trust.

• Referrals to the Secretary of State - No matters to report.

• Public interest report - No matters to report in the public interest.

• Value for money conclusion - No matters to report. (e) Reporting to the Trust on its consolidation schedules -

The Trust’s consolidation schedules agreed, within a £250,000 tolerance to the audited financial statements.

(f) Reporting to the National Audit Office (NAO) in line with

group instructions - No matters to report. (g) The letter has been received and considered by the

Audit Committee at its meeting in July 2016. Decision(s), Outcome(s) and Action(s) (1) The Board noted the letter and commended Sally Scott and

Kevin Curnow of the finance team for their work resulting in such a positive audit outcome.

122/16 Audit Committee Chair’s Assurance Report (July 2016)

(Committee Chair: JP)

The Chair of the Audit Committee’s report for July 2016 on the meeting held on 12th July 2016 was received and discussed. Risk / Assurance levels reported were as follows and Chair’s observations against each were noted: Item Committee

Assurance Assessment (R/AR/AG/G)


Internal Audit Annual report Green

Management Report actions underway, especially IT back-up

Internal Audit plan for 16/17 Amber/Green

Plan agreed at Exec, and changes supported by Audit Committee. Clinical Records audit to be scoped, CQC taken out for current year, and Deprivation of

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Liberty audit scope revised

1516-09 BAF and Risk Management Internal Audit Report

Green

Report accepted, and clinical incidents content now complete

Key Financial Controls Internal Audit Report

Green Password access changes now completed

Annual Audit Letter Green

Very positive outcome – to be presented at the July Board

High Level Risk Register

Amber / Red

14 risks have been on the register for 12 months+. BAF/Risk Register needs alignment

Local Security Management Report

Amber / Green

Grid to be circulated when complete and trend data incorporated. Trust has a low level of criminal activity, but a security audit will be done by end of December.

Tender Waivers Green

Only one reported – sole supplier of bariatric kit

Review of Losses and Compensations 2015/16

Green

Need to have a more robust process for establishing the values of lost items

Local Counter Fraud Annual Report 2015/16

Green

Local Counter Fraud Work Plan 2016/17 Green

Fraud risk assessment to be prioritised, and actions agreed in respect of pre-employment checks and references

Local Counter Fraud Digest and Fraud Stop

Green Document received

Review of Terms of Reference N/A

3 year rule re NED members’ tenure to be removed and term of NED appointment to the Board to be substituted

Business Cycle 2016/17 N/A

Accepted

Challenge and Response to Board Questions:

30


(a) The meeting on 12th July wasn’t quorate and actions agreed were by virtue of Chair’s Action, subject to ratification at the next meeting.

(b) The Terms of Reference were reviewed and it was proposed that the committee membership period of three years be replaced by membership lasting for the duration of a NED appointment.

Decision(s), Outcome(s) and Action(s): (1) The Board agreed to the revision to the Committee’s terms

of reference as described under (b) above. (2) The Audit Committee Chair’s report for July 2016 was noted.

123/16 Board Governance Annual Update (As at July 2016)

The Annual Governance Update (As at July 2016) was received. It was noted that the update covered: • Board membership • SID • Executive Director portfolios • NED and Executive Director Board Lead Roles (and

definition of roles) • Board Committees • Board Committee Structure Decision(s), Outcome(s) and Action(s): (1) The Annual Governance Update was noted. (2) Any errors or amendments be notified to CApp

124/16 Board Register of Interests

The Register of Board members’ interests as at June 2016 was received. It was noted that:

(j) AM’s declaration entry in the register had omitted her role as a specialist advisor to the CQC and that this needed to be recorded.

CApp

31


125/16 Board Re-subscription to NHS and Internal Codes

(Lead Director DL)

Decision: Individually and collectively the Board re-subscribed their commitment to the following: (2) The NHS Constitution (2) The NHS Code of Conduct and Accountability (3) The NHS Code of Openness (4) The “Nolan” principles of governance. (5) Principles of Board Etiquette (6) Code of Conduct for NHS Managers. (Only applicable to

Executive Directors).

126/16 Note of the Remuneration Committee Meeting held on 28th June 2016. (Committee Chair: Anne McPherson)

A note of the Remuneration Committee meeting held on 28th June 2016 was received. It was noted that items considered were:

• Medical Director - Interim and Substantive Recruitment / Remuneration

• VSM: Annual Appraisals / Performance Reviews 2015/16 Annual Review National Guidance Inclusion of element of earn-back in the reward package

• Exit Payments Cap – Expected October 2016 • Changes to the Executive team roles

Decision(s), Outcome(s) and Action(s): (1) The note of the Remuneration Committee meeting held on

28th June was noted.

(G) Healthwatch Report (Lead: MC)

127/16 MC reported that: (1) DL and DO’F met with Geoff Brown (CEO) and Michael

Downing (Chair) for a general catch up

32


(2) Healthwatch have recently published their annual report for 2015/16 and this is available on the Healthwatch website (http://www.healthwatchhertfordshire.co.uk/wp-content/uploads/2016/06/Healthwatch-Hertfordshire-Annual-Report-v1.pdf)

(H) Urgent Business 128/16

The Board recorded their sadness at the recent and sudden passing of Beth Caulfield, Community Matron, and sent their sincere condolences to Beth’s husband, young family, friends and work colleagues.

(J) Risks Arising / Observations

129/16

Given the minor involvement of HCT in what was a much wider national and local issue, the reputational risk to HCT of the patient story and the presence of a national news channel camera and reporter was discussed. It was noted that: (i) Public perceptions of the media coverage may give rise to a

distorted view that HCT was accountable for all of the issues raised in Mr. L’s account. Caution also has to be exercised in respect of what HCT can realistically do to address any issues arising in this or any future story which were beyond the Trust’s control, remit and accountability.

(ii) Whilst Mr JL exceeded the brief given for the patient story, it

was a powerful story which raised big national and local issues and needed to be heard. It also needed to be shared with other agencies involved.

(iii) The Board could have perhaps been more resilient in pushing back on elements of the story which were not appropriate or beyond the brief.

(iv) Although HCT was aware of Mr. L’s national campaign and

previous publicity, notification that news cameras would be present was only received less than an hour before the meeting. Although short notice, this had also been discussed with the Board prior to the meeting starting.

(v) Other agencies involved had been made aware beforehand

of the story being given, hence they were invited to send observers/representatives but the NHSI and the DH would need to be advised of the media attention.

33

http://www.healthwatchhertfordshire.co.uk/wp-content/uploads/2016/06/Healthwatch-Hertfordshire-Annual-Report-v1.pdf




(vi) Caution also needs to be exercised for any patient story in

respect of anecdotal elements and especially if individuals or other organisations are not present to offer their own perspectives. Service Users presenting stories also need to be advised that they should not be critical of named individuals in their accounts.

(vii) Allowing the story and presence of the media demonstrated

that the Trust is fully prepared to be open and transparent and to hear about difficult issues in service provision. It also meant that the Trust wasn’t “side-stepping” any issues which may be a temptation for some organisations to do.

(vi) Should there be any feedback or follow-up from media

coverage, the Trust will have the opportunity to respond with the Trust’s (limited) role and position in the overall picture. A press statement should also be prepared in advance by way of being pro-active.

(K) Supporting Papers / Items for Receipt and Noting Only 130/16

The following papers in support of agenda items and reports were received: Clinical Services & Healthcare Governance C1 (i) Quality Annual Reports:

Complaints Safeguarding Adults Safeguarding Children Looked After Children Patient Experience Clinical Audit Control of Infection

C2 (i) Minutes of the Healthcare Governance Committee meeting held

on 17th May 2016 Performance & Operations D2 (i) Integrated Board Performance Report (June 2016) Strategy, Resources & Engagement E2 (i) Month 3 Finance Report (June 2016) Board Governance & Leadership

F2 (i) Minutes of the Audit Committee meeting held on 26th May 2016

F5 (i) The NHS Constitution

34


(ii) The NHS Code of Conduct & Code of Accountability (iii) The NHS Code of Openness (iv) The Nolan Principles of Public Life (v) The HCT Principles of Board Etiquette (vi) The Code of Conduct for NHS Managers. (Applies to

Executive Directors only)

(L) Date, Time & Venue of Next Meeting(s) 140/16

AGM (and engagement event) Tuesday 27th September 2016 4.30 – 5.45pm The Stanborough Centre 609 St Albans Road Watford , Herts WD25 9JL Board meeting in public: Thursday 29th September 2016 10.30am - 1.30pm Rm 104 Rothamsted Research Centre West Common Harpenden Hertfordshire AL5 2JQ

(M) Questions / Observations from the Public 141/16 No Questions Common Abbreviations AC = Audit Committee AHP = Allied Health Professional ARA = Annual Report and Accounts B2B = “Board to Board” meeting BAF = Board Assurance Framework BCF = Better Care Fund 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) CEC = Community Engagement Committee CEO = Chief Executive Officer CQC = Care Quality Commission CQUIN = Commissioning for Quality & Innovation Dir = Director of…. DD = Deputy Director DoH = Department of Health DoLS = Deprivation of Liberty Safeguards

35


E&N = East & North (eg E&N Hertfordshire) 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 HV = Herts Valleys (geography) or Health Visitor / Visiting 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) NHSI = NHS Improvement (The amalgamation of Monitor and the TDA effective from 1st April 2016). PAHT = The Princess Alexandra Hospital NHS Trust PLACE = Patient Lead Assessments of the Care Environment RAG = “Red/ Amber / Green” ratings RemCom = Remuneration Committee SIs = Serious Incidents SRC = Strategy & Resources Committee STP = Sustainability and Transformation Plan 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

36


HERTFORDSHIRE COMMUNITY NHS TRUST BOARD TRACKER (September 2016)

RAG Traffic Light Key:

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 Ref No.

Meeting Date

Item / Action Required Board Lead

Target / Finish Date

Progress R/A/G

100/16 28/07/16 Patient Story: (1) Mr L to supply HCT with a copy of the

film of his presentation and HCT to share it accordingly with the relevant organisations which have been involved in K’s care.

(2) HCT to take forward relevant issues

of joint working with the partner organisations concerned.

DL

DL

N/A

N/A

DL to meet with Healthwatch

107/16 28/07/16 BAF (2) The BAF as at July 2016 was noted

and agreed as a fair reflection of the strategic risks facing the Trust subject to observations made.

CA and Execs to note

N/A

BAF Updated to reflect Board observations

1

Board 29th September 2016 Attachment B1

TRUST BOARD Title: Summary Board Assurance Framework Meeting Date: 29 September 2016 Executive Lead: David Law Chief Executive Author(s): Clive Appleby Company Secretary For: DISCUSSION AND CHALLENGE Risk Rating: Mixed

1.0 Purpose & Recommendations

1.1 The Board Assurance Framework (BAF) is a tool by which the Board considers risks to the achievement of the Trust’s strategic objectives.

1.2 Attached is the summary BAF as at September 2016, which outlines

the risks with their associated scores and ranking. Changes to the previous iteration are also explained.

1.3 The ranking of risks was reviewed by the Executive Team in

September 2016. 1.4 The Board is requested to:

(i) Discuss the primary risks and identify associated issues

2.0 Relevant Strategic Objective(s) / Strategies

2.1 Impacts on all Strategic Objectives 2.2 Links to: Risk Management Strategy

3.0 Quality / Service / Regulatory Impacts: The BAF is subject to

internal audit governance assessment and key risks are identified in a number of corporate documents such as the Integrated Business Plan (IBP), Annual Governance Statement and Risk Management Strategy.

4.0 Resource Implications: None

1


5.0 Next Steps 5.1 Following the outcomes from the Board’s deliberations the issues,

actions and assurances will be updated on the detailed sheets for each risk. In accordance with the cycle agreed at the last Board meeting, (Attachment 1) during October and November, each Board Committee will then review the risks for which it is the lead committee, to assess and challenge actions and assurances.

5.2 Following Committee review, the BAF will again be updated by the

Executive Team and the full version will next be presented to the Board in January 2017.

5.3 The Audit committee will review and assess the “fitness for purpose” of

the BAF in December 2016. This will include taking into consideration the findings of an internal audit report on the BAF, publication of which is imminent.

6.0 References, Appendices & Attachments

Appendices & Attachments:

Annex 1: The BAF Cycle Annex 2: September 2016 BAF (Summary).

Author of paper: Clive Appleby, Company Secretary & Executive Directors September 2016

2


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): Executive Team Sept 16 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

Description Comments / Exceptions √ / x

Complete Information is as comprehensive as possible to inform the board and no significant known facts or statistics which may influence a decision are omitted.

√

Accurate As far as can be reasonable ascertained or validated, information in the report is accurate.

√

Relevant Information contained in the report is relevant to the matters considered in the report.

√

Up To Date

Information in the report is as up to date as reasonably possible in the context of the time at which the paper is written

√

Valid Information is presented in a format which complies with internal or national models or standards

√

Clearly Defined

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


Annex (1) THE BAF CYCLE

Executive Team receives the BAF as follows:

First week of :

May v1 Sept v2 Jan v3

The Board receives the BAF as follows:

May v1 Sept v2 Jan v3

Committees receive the BAF as follows:

SRC

March v3 (and to inform v 1) July v1 (and to inform v 2) Nov v2 (and to inform v 3)

HGC


FTC - TBC


CEC

Feb v3 (and to inform v 1) Nov v2 (and to inform v 3)

Audit

Dec v2 (To assess efficacy and robustness of process)

4

Annex 2 Attachment B1

Summary Board Assurance Framework (September 2016)

The Trust’s 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 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 Strategic Risks Summary

(Green Font = New entry in Framework; Brown Font = Risk redefined – See summary of changes; Purple Font = Risk identified for closure)

(Primary Strategic Risks)

Rank Ref. and Date Entered / Re-Defined

Summary Description (and full risk description)

Lead & Lead

Committee

(a) Current Status Rating

(b) Current

Likelihood Rating

(c ) Current Impact Rating

(d) Overall

Risk Score (a)+(b)+(c)

Previous Overall

Risk Score

Direction Of Risk Score

1 2 0316 March 16

National, local system-wide and Trust financial and demand pressures.

DL SRC

18 (6+6+6)

15 ↑

1


National and local system-wide financial and demand pressures impacts on both commissioners and providers thereby presenting a challenge to (i) achievement of financial targets / cost improvements and (ii) sustainability / improvement /expansion of services.

2 1 0316 March 16

Staffing:

AS SRC

16 (6+6+4)

16 ↔

Staffing resources are insufficient to meet demands thereby impacting adversely on (i) capacity to maintain / expand services and (ii) the health, wellbeing and morale of staff; thereby resulting in a significant challenge to (i) providing safe and effective services and (ii) the retention / recruitment of staff in specific areas/specialties.

3 3 0316 March 16

Well-Led:

CH HGC

13 (1+6+6)

13 ↔

Not meeting CQC Fundamental Standards or achieving compliance actions identified may result in regulatory action or failure to achieve a rating of “good” (or above) thereby delaying HCTs progress as a Foundation Trust and, in addition, having an adverse impact on (i) reputation with stakeholders and (ii) strength in the competitive market.

4 10 0316 July 16

Not being able to evidence improved outcomes

CH HGC

10 (2+ 4+4)

10 ↔

Not being able to adequately evidence improved patient health and wellbeing outcomes from HCT interventions leads to not being able to measure success or otherwise against the strategic objective and may result in (i) questions as to clinical effectiveness and value (ii) vulnerability for meeting outcomes-based contracts and (iii) inability to compete competitively for new business / retaining current business.

5 5 0316 March 16

Reliance on other orgs/ agencies for integrated service delivery (including partnerships).

JH SRC

9 (2+3+4)

9 ↔

Differences in organisational expectations, priorities, perceptions or governance lead to barriers to integrated, collaborative or partnership working resulting in inability to achieve the strategic objective of developing patient self-managed care (and other healthcare efficiency initiatives or successful tender bids).

6i 6 0316 March 16

Underdeveloped / ineffective use of technology.

PB SRC

9 (2+4+3)

9 ↔

Underdeveloped / ineffective use of technology will result in having antiquated technical systems and /or working practices thereby (i)

2


hindering delivery of modern, effective healthcare and (ii) presenting barriers to (a) efficiency and (b) market competitive advantages. 6ii 12 0316

March 16 Not having appropriate visibility of management information.

PB SRC

9 (2+ 6+1)

9 ↑

Risk to be defined

(Secondary Strategic Risk Themes)


Description (Summary Description Only)

Lead & Lead

Committee


(b) Current

Likelihood Rating


(d) Overall


Previous Overall

Risk Score

Direction

7i 7 0316 March 16

Weak Engagement with stakeholders DL CEC

6 (0+ 3+3)

N/A N/A

7ii 8 0316 March 16

Inefficient use of estate. (Quality, Cost, Locations)

PB SRC

6 (0+ 3+3)

N/A N/A

7iii 9 031 March 166

Threats from competition PB SRC

6 (0+ 3+3)

N/A N/A

7iv 11 0316 July 16

Leadership capability and capacity

AS SRC

6 (0+ 3+3)

N/A N/A

7v 18 0716 July 16

Patient safety CH HGC

6 (0+3+3)

N/A N/A

3


(Tertiary Strategic Risk Themes)


Description (Summary Description Only)

Lead & Lead

Committee


(b) Current

Likelihood Rating


(d) Overall


Previous Overall

Risk Score

Direction

8i 14 0316 March 16

Not making surplus PB SRC

4 (0+2+2)

N/A N/A

8ii 16 0316 March 16

Not meeting quality standards expected CH HGC

4 (0+2+2)

N/A N/A

8iii 17 0316 March 16

Inability to deliver on contracts and the reputational impacts

PB SRC

4 (0+2+2)

N/A N/A

8iv 18 0316 March 16

Inability to change culture / expectations of public and staff

JH HGC

4 (0+2+2)

N/A N/A

8v 19 0316 March 16

Ineffective deployment of staff AS SRC

4 (0+2+2)

N/A N/A

8vi 20 0316 March 16

Future of FTs as a model: Uncertainty of organisational form and possibility of not having FT freedoms and flexibility

DL FTC

4 (0+2+2)

N/A N/A

Summary of Changes: Change + Comments / Rationale Ref: Risk N/A N/A BAF Format Summary of changes and risks de-escalated/closed now include column for

more information on the rationale for change. N/A N/A BAF Format Date that risk added to the BAF (or redefined) now recorded 2 0316 National, local system-wide and Trust financial and

demand pressures. This risk has increased in score and now has top ranking on account of the STP system-wide financial gap.

12 0316 Not having appropriate visibility of management information.

This risk has increased in score and rank pending

5 0316

Reliance on other orgs/ agencies for integrated service delivery (including partnerships).

Lead / Lead Committee amended from “MD and HGC” to “JH and SRC”

4


Risks Closed / De-escalated / Merged

Ref: Description Lead & Lead Committee

Closed / De-escalated

/ Merged

Date Closed /

De-escalated / Merged

De-escalated To:

Comments / Rationale

4 0316 The health system in West Hertfordshire lacks leadership and direction.

DL SRC

Closed July 16 N/A No longer extant as a risk.

15 0316 Staff engagement and morale AS SRC

Merged Sept 16 N/A Merged into 1 0316 (Staffing) as is a “knock on effect” issue associated with this risk.

5


Status Rating Description RAG Ongoing The risk is continuous and is unlikely

to be eradicated in the foreseeable future

R

Imminent The risk has not yet materialised to its full impact but this is likely to be within the next one to six months

A/R

Ascending / Re-ascending

A risk which is ascending in its severity of impact or is re-ascending having previously receded

A

Emerging A risk which has been identified and requires monitoring, but it is too early to assess the likelihood / impact

A/G

Receding A risk where the impact is receding through having been managed or other factors

G

Residual / Risk Accepted

No further actions to manage the risk can reasonably be taken or the Board otherwise currently accepts the level of risk

Closed The risk is closed and will be removed from the next iteration of the BAF and archived

Likelihood Rating Description RAG Materialised The risk has materialised now and it is no

longer a future risk. Impacts are known rather than speculated upon and actions are required to manage the risk

R

Certain The likelihood of the risk materialising at a point in the future is inevitable

A/R

Probable The likelihood of the risk materialising at a point in the future is more likely than not on the balance of probabilities.

A

Possible The risk may materialise on the balance of possibilities but this is not a probability at this stage.

A/G

Unlikely / Receding The risk is unlikely to materialise on the balance of possibilities (but this cannot be ruled out completely) or, in the case of a risk which has previously materialised, the risk is showing indications of receding.

G

Unforeseeable / Unknown / Significantly Receding

It is too early or not otherwise possible at this stage to reasonably assess the likelihood of a risk materialising or, in the case of a risk which has previously materialised, the risk is now receding significantly.

Managed / Eradicated / Transferred

The risk has been managed, eradicated, or transferred to the extent that the likelihood of materialisation or re-materialisation is currently zero.

6


Current Impact Rating

Description RAG

Critical Effective management of the risk is essential in order to achieve the strategic objective and if not effectively managed, the risk may have impacts which spread wider than the single strategic objective alone.

R

High Effective management of the risk is essential in order to achieve the strategic objective.

A/R

Medium Effective management of the risk is desirable in order to achieve the strategic objective or overcome possible undue delays to the achievement of the objective.

A

Low Impacts are currently / likely to be low and resources to manage the risk need to be proportionate.

A/G

Insignificant The risk has been managed, eradicated or transferred to the extent that impacts are manageable or negligible.

G

None The risk has been managed, eradicated or transferred to the extent that there are no impacts as a consequence of the defined risk.

Scoring: Red = 6 Amber / Red = 4 Amber = 3 Amber / Green = 2 Green = 1 Blue / Black = 0 Overall Risk Score (0-18) = Status Score + Likelihood Score + Impact Score. (NB: The overall risk score is for prioritisation purposes only).

Action RAG Description RAG Action not yet initiated but within target Action in progress and on target Action in progress but not on target Action in progress but overdue or original target date expired

Action not taken or not possible and target date expired (explain)

Action deferred Action completed Action has been implemented and is continuous No action required / Beyond HCT control

7

Board 29th September 2016 Attachment C1


Report from the Director of Quality and Governance/Chief Nurse

September 2016

1.0 Introduction 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 also includes an update on the areas of responsibility which I am holding in the absence of a Medical Director.

2.0 Executive Summary

• Focused unannounced CQC inspection factual accuracy check is now complete. Response awaited from the CQC. HGC noted good progress made with the Quality Improvement Plan.

• All community hospitals compliant with required staffing levels over 90%. Programme of transformation underway to achieve financial balance and ensure safe and effective service delivery.

• Substantial delivery of Research and Development (R&D) noted within the last financial year as reported in the R&D Annual Report. (Supporting Paper K2).

• Review of Quality Impact Assessment completed. Seven CIP schemes require QIA.

• Quality performance remains strong. Diabetes CQUIN delivery for Q1 not achieved. Actions underway to bring delivery on track for Q2.

3.0 Recommendations The Board is asked to note the content of this report.

4.0 CQC Inspection

The focused unannounced inspection of the Trust took place in April and the Trust has returned the factual accuracy check to the CQC. Good progress has been made with the Quality Improvement Plan.

5.0 Safe Staffing report

The reports for June and July are provided for Board review. All units were complaint with the 90% threshold set by HCT. Four units had bank and agency staffing rates at over 20%, with Langton Ward at St Albans City Hospital carrying a vacancy rate of 50.48%. A programme of work in relation to the community hospitals has been agreed at the Executive team and HGC, and I will be working with the Director of Operations to oversee this delivery. This includes maintenance of quality delivery with achievement of financial balance.

1


6.0 Quality report

The full quality report Q1 is provided as supporting paper (K1). Performance is good for Q1, with the exception of delivery of the diabetes CQUIN in Herts Valleys Business Unit. Remedial actions are underway to ensure full achievement is made for the remained of the year.

7.0 Research and Development (R&D)

The Research Annual Report is attached as supporting paper (K2). The Board is asked to note the substantial programme of delivery within the Trust’s R&D portfolio. The team is now back at full capacity with no sickness absence. An additional research nurse has been appointed.

8.0 Quality Impact Assessment

Assurance on the Quality Impact Assessment of Cost Improvement Programmes has been reviewed. There are seven outstanding QIA’s to be completed and this work is underway.

9.0 External achievements

Congratulations to Simon Ward, our Medical Devices Contract Manager, who has accepted the position as Chair of the National Benchmarking Group for Medical Devices. Our work with the Integrated Community Teams and ‘QUEST for Community Health’ to audit and review the ICTs and develop a service transformation programme has been recognised by the Queen’s Nursing Institute at its Annual Conference. HCT won third prize for its poster presentation. Part of this work programme includes driving forward increased skills development for band 1-4 staff as part of their career development pathway, and clinical competency development for all clinicians in the ICTs.

10.0 Current Performance

Overall quality performance remains strong. No C Diff cases reported in August. 4 grade two pressure ulcers were reported in August. RCA underway. Initial analysis indicates a reduction in numbers of grade three pressure ulcers indicating effective clinical treatment of grade two pressure ulcers to prevent deterioration. Further analysis of falls rates is underway with reporting due in Q2.

11.0 Risks and Challenges

• Oversight and actions required to manage components of the Medical

Directors portfolio continue to impact on workload of senior quality team members.

• Diabetes CQUIN delivery requires improvement for Q2 to avoid further financial loss.

2


Trust Board Title: SUMMARY OF Q1 QUALITY REPORT Meeting Date: 29th September 2016 Executive Lead: Clare Hawkins Director Quality & Governance /

Chief Nurse Author(s): Tracey Westley Assistant Director Risk & Quality

Assurance For: DISCUSSION AND CHALLENGE, NOTING, Risk Rating: Not Applicable 1.0 Purpose & Recommendations

1.2 To advise the Board regarding the outcome of quality achievements and risks during Q1 2016. The full report is included in supporting papers.

1.3 To ask the Board to:

(1) Receive the report. (2) Note commissioners have received a draft report, caveat

subject to due governance process as per contract arrangements.

2.0 Key Points for the Attention of The Board Committee

2.1 Achievements in Quarter • A healthy increase in reporting of incidents • Maintenance good standards infection prevention and control

resulting in one C Difficile for the quarter. • Positive engagement of staff with 90% reporting an improved

understanding of the Safe Adult from Abuse policy. • Podiatry Service Queensway awarded the Purple Star award

providing good quality accessible services for people with learning disabilities.

• Partial met for CQUIN delivery, in part due to delayed agreements with ENHT and CCG, note there is opportunity to obtain full met subject to further work in Q2.

1


2.2 Risk and Opportunities • The Medical Director post became vacant in April 2016 and has

been vacant during Q1. In the absence of a Medical Director, the Associate Medical Director has continued to review bed based deaths in the absence of a Mortality Review Group. However, the Director of Quality and Governance/Chief Nurse has agreed to chair the Mortality Review Group on an interim basis.

• No concerns were reported last year however there has been an

increase in reporting of concerns in Q1 following focused communication to report all concerns. This affords the Trust the opportunity to analyse and learn from the serious issues raised therein, and reinforce a positive reporting culture for all staff. This work will continue during the year.

• Safeguarding concerns have been raised in regard to the

decommissioning of FNP. The safeguarding team are working closely with the FNP team to ensure the safe transition of these vulnerable clients back into Health Visiting Teams ensuring that additional supervision is offered and each client has their particular vulnerabilities assessed.

• The report will be redefined in year to reflect revised indicators and

enable development of a highlight dashboard.


3.1 This report impacts on all Strategic Objectives and links to Quality and Risk strategies.

4.0 Risks and Mitigation Plans Risk Mitigation / Action(s) CQUIN achievement end Q2. Quarterly meeting with Leads and CCG to

undertake agreed contract review Lack of Medical Director impacting upon work of Associate Medical Director and mortality review group

Chief Nurse chairing Mortality Review Group and supporting Associate medical Director in interim period.

Increase in concerns Reviewed by Chief Nurse & followed up to support staff and enable appropriate action.

8.0 Appendices & Supporting Information

(1) Appendix 1 Quality Dashboard Q1 (2) Full Quarter 1 Quality Report ( in Supporting Papers K1)

2


Author(s) of paper: Tracey Westley Assistant Director Risk and Quality Assurance August 2016 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: Health Care Governance Committee

Date (Month / Year): 20th September 2016

Director Quality & Governance Chief Nurse September 2016 Issues arising from committee consideration




√


√


√

Up To Date


√


√

Clearly Defined


√



Clare Hawkins Director Quality & Governance/ Chief Nurse

√


3


Quality 1 Quality Report Dashboard


To note: Increase in raising awareness for reporting of pressure ulcer grade 2 may be impacting upon the increase in number reported above. The number of pressure ulcers grade 3 (worsening ) is reducing thus indicating grade 2 pessure ulcers are being managed well to prevent deterioration. Whilst the number of falls and falls with harm has increased, there has not been an increase in significant injury requiring acute hospital intervention. A large proportion of falls result in no harm or minor harm such as bruising that is monitored and heals. Further analysis work will be completed when reporting in Quarter 2. There has been a continued drive to support recording of all medication incidents. Further work is underway to review all the level of harm related to medication incidents and will be reported in the quarter2 report. Nice standards are reduced in number – as those release not relevant ot HCT services.


Trust Board

Title: SAFE STAFFING UPDATE REPORT JULY 2016

Meeting Date: 29th September 2016

Executive Lead: Clare Hawkins, Director of Quality and Governance/Chief Nurse

Author(s): Jackie Sibson, Clinical Project Manager

For: NOTING

Risk Rating: Amber/Green


1. To advise the Board regarding safe staffing levels in HCT’s communityhospitals

2. To ask the Board:

(1) To note the safe staffing levels for July 2016

2.0 Key Points

2.1 In July all units were compliant with safe staffing metrics and reported average staffing levels above the 80% threshold set by NHS England threshold as well as the 90% threshold set by HCT.

2.2 However, staffing data indicates a high bank and agency usage on some units, with five units having a combined bank and agency rate of over 20%. High vacancy rates on several HCT units contributed to the need for additional staff.

2.3 HCT continued to require additional staffing hours to care for patients with complex needs, including 22 patients at high risk of falls and staff escorts for patients to 36 appointments off site.

2.4 Potters Bar Community Hospital required additional RN hours to help care for three extremely confused patients with a high level of medical acuity requiring palliative care.

Supporting Papers Appendix 1 - Safe Staffing community dashboard July 2016

Appendix 2 - Summary of complex needs by unit for July 2016

1


Appendix 3 - Langton Daily Fill Rate July 2016


3.1 This report links to the following Trust Strategic Objectives

2 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

6.0 Resource Implications

6.1 Workforce costs


(1) Appendix 1 - Safe Staffing community dashboard July 2016

(2) Appendix 2 - Summary of complex needs by unit for July 2016

(3) Appendix 3 - Langton Daily Fill Rate July 2016

Author(s) of paper:

Jackie Sibson Clinical Project Manager

5th September 2016

2


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 20th September 2016Issues 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



√


√


√

Up To Date


√


√

Clearly Defined


√



Clare Hawkins Director of Quality & Governance/ Chief Nurse

√ / x

Company Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Company Secretary √

3


1.0 Introduction

This report provides the Board with an overview of the safe staffing levels within HCT community inpatient units for the month of July 2016.

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 details of the reasons for the staffing variation, mitigating actions taken and any effect on patient safety.


In July all units were compliant with safe staffing metrics and reported average staffing levels above the 80% threshold set by NHS England and the 90% threshold set by HCT.

However, staffing data indicates a high bank and agency usage on some units, with five units having a combined bank and agency rate of over 20%. High vacancy rates on several HCT units contributed to the need for additional staff.

HCT continued to require additional staffing hours to care for patients with complex needs, including 22 patients at high risk of falls and staff escorts for patients to 36 appointments off site.

Potters Bar Community Hospital required additional RN hours to help care for help care for three extremely confused patients with a high level of medical acuity requiring palliative care.

Supporting Papers Appendix 1 - Safe Staffing community dashboard July 2016 Appendix 2 - Summary of complex needs by unit for July 2016 Appendix 3 – Potters Bar Community Hospital Daily Fill Rate July 2016

3.0 July data analysis

Staffing levels for all units, day and night shifts, Registered Nurses and Health Care Assistants (HCA), is included in Appendix 1, along with vacancy and sickness rates and bank and agency usage.

The data demonstrates that although average staffing levels for all units were over 90% there were high levels of bank and agency usage on some units, with five units

1


using bank and agency staff to cover in excess of 20% of their shifts. This was due to a combination of high vacancy rates, sickness and caring for patients with complex needs as detailed in Appendix 2.

In July Langton Ward at St. Albans City Hospital required bank and agency staff to cover 35.1% of nursing hours due to a vacancy rate of 30% and sickness rate of 6.5%. The ward reported 2 falls resulting in injury during the month.

Herts and Essex Hospital needed bank and agency staff to cover 27.6% of nursing hours due to a vacancy rate of 23.7% along with a sickness rate of 7.7%. The unit reported no falls, pressure ulcers or Health Care Associated Infections, despite caring for 10 patients at high risk of falls during July.

St Peter’s Ward, Hemel Hempstead General Hospital used bank and agency staff to cover 26% of nursing shifts. Their vacancy rate was 15.3% during the month along with a sickness rate of 2.1%. The ward cared for 4 patients at high risk of falls and reported no falls, pressure ulcers or Health Care Associated Infections.

Holywell had a sickness rate of 11.1% along with a vacancy rate of 14.8% and as a result required bank and agency staff to cover 26.1% of nursing shifts during the month. The ward reported one fall resulting in an injury during this time.

Potters Bar Community Hospital had a bank and agency rate of 20.7% and the unit reported 5 patient falls resulting in injury along with 1 pressure ulcer during this period. The vacancy rate on the unit was 13% with a sickness rate of 6.9%. Of patients in their care during July, 4 were reported at being at high risk of falls.

Additional hours

A summary of patients’ needs requiring additional hours by unit is shown in Appendix 2.

Daily Fill Rate Audit

A deep dive has been carried out to identify the daily staffing numbers for Potters Bar Community Hospital, see Appendix 3.

Reasons for low staffing levels and mitigating action taken, along with effects on patient safety for shifts reported as being below 80% fill rate were reviewed. During July five shifts on the unit were below NHS England safe staffing threshold, as detailed below.

Potters Bar Community Hospital Staffing Information July 2016

Shifts below NHSE 80% threshold

Reason for low staff levels

Mitigating action taken Effects on Patient safety

Tuesday 19th July Daytime RN

Agency DNA Co-ordinator covered RN shift

Nil

2


level 70.77% Thursday 21st July Daytime RN level 70.77%

Due to RN sickness

Co-ordinator covered RN shift

1 patient fall resulting in Low/minimal harm

Friday 22nd July Daytime RN level 70.77%

Due to RN sickness

Co-ordinator covered RN shift

Nil

Sunday 24th July Night time RN level 75%

Due to RN sickness

Unable to get cover for night shift – 1 RN short

1 patient fall - resulting in Low/minimal harm

Saturday 30th July Night time RN level 75%

1 RN Agency DNA

Unable to get cover for night shift – 1 RN short

Nil

Potters Bar Community Hospital required additional qualified nurses on nine daytime shifts during July. On seven of the shifts, an additional RN was required to help care for three extremely confused patients with a high level of medical acuity requiring palliative care.

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. Unresolved risks are escalated to the Director of Operations Monday to Friday and the Tier 1 Director/General Manager at weekends.

In addition, 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 monthly to the individual Business Unit Performance Reviews and to HCT board.

Author of paper


5th September 2016

3

Hospital/UnitStaff WTE(Funded)

Staff WTE(Actual)

Vacancy Rate

Sickness & absence

Rate% Bank Use

% Agency Use

FILL RATERegistered

FILL RATEUnregistered

FILL RATERegistered


Injurious Falls

All Pressure

Ulcers Sis HCAIs

≥90% ≥90% ≥90% ≥90%Herts & Essex 55.20 42.14 23.7% 7.7% 6.8% 20.8% 97.3% 158.0% 98.0% 144.3% 0 0 0 0QVM 42.50 30.29 28.7% 2.1% 6.6% 9.4% 91.4% 95.4% 100.0% 99.0% 1 0 0 0Danesbury 48.90 42.66 12.8% 4.8% 8.5% 7.9% 100.6% 118.7% 98.2% 101.3% 1 0 1 0Holywell 39.62 33.76 14.8% 11.1% 10.1% 15.0% 101.1% 129.5% 99.9% 120.4% 2 1 0 0Potters Bar 55.73 48.47 13.0% 6.9% 9.0% 11.7% 102.1% 132.8% 98.4% 168.9% 5 1 0 0Langley 41.29 37.49 9.2% 3.4% 0.6% 14.7% 96.8% 118.6% 101.1% 109.8% 1 0 0 0St Peters Ward 36.41 30.84 15.3% 2.1% 11.5% 14.5% 97.4% 168.4% 100.0% 191.9% 0 0 0 0Sopwell 41.45 37.00 10.7% 9.6% 4.9% 14.8% 93.1% 130.7% 101.6% 121.1% 3 0 0 0Langton 29.94 20.96 30.0% 6.5% 16.9% 18.2% 107.7% 163.6% 101.5% 152.7% 2 0 0 0Nascot Lawn 95.5% 108.8% 103.7% 104.9%

Safe Staffing Community Hospital Dashboard 16-17

Jul-16Day Night

Target

Appendix 2 - Summary of complex needs by unit for July 2016

Unit Patients with DOLS in place

Patients at high risk of falls

Patients requiring escorts off site

Patients with other complex needs

Danesbury Neurological Unit 5 0 2 0

Holywell Neurological Unit 2 2 3 0

Herts & Essex Hospital 3 10 4 1

Langley House 0 1 10 0

Langton Ward SACH 2 0 7 0

Sopwell Ward SACH 0 1 7 0

Potters Bar Community Hospital

2 4 0 0

Queen Victoria Memorial Hospital

1 0 0 1

St Peter’s Ward HHGH 3 4 3 0

Total 18 22 36 2

Fri 1 107.38% 124.13% 114.3% 100.00% 150.00% 116.7%Sat 2 80.00% 125.00% 100.0% 100.00% 150.00% 116.7%Sun 3 104.00% 125.00% 113.3% 100.00% 150.00% 116.7%Mon 4 102.31% 125.00% 111.7% 100.00% 150.00% 116.7%Tues 5 100.00% 124.57% 110.2% 100.00% 150.00% 116.7%Wed 6 97.69% 122.83% 108.1% 100.00% 199.13% 133.0%Thu 7 110.46% 150.00% 126.8% 100.00% 197.83% 132.6%Fri 8 106.15% 144.78% 122.2% 100.00% 200.00% 133.3%Sat 9 120.00% 147.39% 132.2% 100.00% 200.00% 133.3%Sun 10 120.00% 125.00% 122.2% 100.00% 250.00% 150.0%Mon 11 120.77% 150.00% 132.9% 100.00% 146.96% 115.7%Tues 12 120.00% 125.00% 122.1% 100.00% 150.00% 116.7%Wed 13 120.77% 125.00% 122.5% 100.00% 150.00% 116.7%Thu 14 118.46% 125.00% 121.2% 100.00% 150.00% 116.7%Fri 15 120.00% 119.78% 119.9% 100.00% 150.00% 116.7%Sat 16 100.00% 100.00% 100.0% 100.00% 150.00% 116.7%Sun 17 100.00% 125.00% 111.1% 100.00% 150.00% 116.7%Mon 18 106.15% 125.00% 114.0% 100.00% 150.00% 116.7%Tues 19 70.77% 124.57% 93.1% 100.00% 150.00% 116.7%Wed 20 90.00% 145.22% 112.9% 100.00% 145.65% 115.2%Thu 21 70.77% 125.00% 93.2% 100.00% 150.00% 116.7%Fri 22 70.77% 125.00% 93.2% 100.00% 150.00% 116.7%Sat 23 80.00% 125.00% 100.0% 100.00% 150.00% 116.7%Sun 24 107.83% 100.00% 104.3% 75.00% 150.00% 100.0%Mon 25 90.00% 150.00% 114.9% 100.00% 150.00% 116.7%Tues 26 106.15% 175.00% 134.7% 100.00% 200.00% 133.3%Wed 27 106.15% 174.57% 134.5% 100.00% 200.00% 133.3%Thu 28 111.54% 150.00% 127.5% 100.00% 199.13% 133.0%Fri 29 106.15% 175.00% 134.7% 100.00% 200.00% 133.3%Sat 30 100.00% 93.48% 97.1% 75.00% 196.96% 115.7%Sun 31 100.00% 145.22% 120.1% 100.00% 200.00% 133.3%

TOTAL: 102.11% 132.79% 115.1% 98.39% 168.89% 121.9%

PBCH - JULY 2016

DAY DATE

QUALIFIED DAY SHIFTS %

FILLED

HCA DAY SHIFTS %

FILLED

QUALIFIED NIGHT SHIFTS

% FILLED

HCA NIGHT SHIFTS %

FILLED

ALL DAY SHIFTS %

FILLED

ALL NIGHT SHIFTS %

FILLED


HCT BOARD MEETING

Title: SAFE STAFFING UPDATE REPORT JUNE 2016

Meeting Date: 29th September 2016

Executive Lead: Clare Hawkins, Director of Quality and Governance/Chief Nurse

Author(s): Jackie Sibson, Clinical Project Manager

For: NOTING

Risk Rating: Amber/Green


1. To advise the HCT Board regarding safe staffing levels in HCT’scommunity hospitals

2. To ask the HCT Board to:

(1) Note the safe staffing levels for June 2016

2.0 Key Points

2.1 In June all units were compliant with safe staffing metrics and reported average staffing levels above the 80% threshold set by NHS England threshold as well as the 90% threshold set by HCT.

2.2 However, staffing data indicates a high bank and agency usage on some units, with 4 units having a combined bank and agency rate of over 20%. High vacancy rates on several HCT units contributed to the need for additional staff, including Langton Ward at St. Albans City Hospital which had a vacancy rate of 50.48%.

2.3 HCT continued to require additional staffing hours to care for patients with complex needs, including 30 patients at high risk of falls and staff escorts for patients to 38 appointments off site.

2.4 Langton Ward at St. Albans City Hospital used additional RN hours to facilitate SystmOne training in preparation for the transfer to the electronic clinical record system.

1

Supporting Papers Appendix 1 - Safe Staffing community dashboard June 2016 Appendix 2 - Summary of complex needs by unit for June 2016 Appendix 3 - Langton Daily Fill Rate June 2016


3.1 This report links to the following Trust Strategic Objectives

2 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

6.0 Resource Implications

6.1 Workforce costs


(1) Appendix 1 - Safe Staffing community dashboard June 2016

(2) Appendix 2 - Summary of complex needs by unit for June 2016

(3) Appendix 3 - Langton Daily Fill Rate June 2016

Author of paper:


5th September 2016

2

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: Healthcare Governance Committee 20th September 2016

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



√


√


√

Up To Date


√


√

Clearly Defined


√




√

Company Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Company Secretary √

3


1.0 Introduction

This report provides the Board with an overview of the safe staffing levels within HCT community inpatient units for the month of June 2016. 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 details of the reasons for the staffing variation, mitigating actions taken and any effect on patient safety.


In June all units were compliant with safe staffing metrics and reported average staffing levels above the 80% threshold set by NHS England threshold as well as the 90% threshold set by HCT. However, staffing data indicates a high bank and agency usage on some units, with 4 units having a combined bank and agency rate of over 20%. High vacancy rates on several HCT units contributed to the need for additional staff, including Langton Ward at St. Albans City Hospital which had a vacancy rate of 50.48%.

HCT continued to require additional staffing hours to care for patients with complex needs, including 30 patients at high risk of falls and staff escorts for patients to 38 appointments off site. Langton Ward at St. Albans City Hospital used additional RN hours to facilitate SystmOne training in preparation for the transfer to the electronic clinical record system. Supporting Papers Appendix 1 - Safe Staffing community dashboard June 2016 Appendix 2 - Summary of complex needs by unit for June 2016 Appendix 3 - Langton Daily Fill Rate June 2016 3.0 June data analysis Staffing levels for all units, day and night shifts, Registered Nurses and Health Care Assistants (HCA), is included in Appendix 1, along with vacancy and sickness rates and bank and agency usage. The data shows that although average staffing levels for all units were over 90% there were high levels of bank and agency usage on some units.

1


High vacancy rates contributed to this usage with 4 units having vacancy rates of over 20%. Throughout June, Langton Ward St. Albans City Hospital, had a vacancy rate of 50.48% and Herts and Essex Hospital had one of 25.4%. During June Herts and Essex Hospital and Langton Ward, St. Albans City Hospital both used high levels of bank and agency staff, at 37.6% and 35.5% respectively, to fulfil their staffing needs. The bank and agency staff were needed to provide cover for high vacancy rates and to care for a large number of patients with complex needs. Neither unit reported any falls, pressure ulcers or Health Care Associated Infections during this time. St. Peters Ward at Hemel Hempstead General Hospital used 18.6% bank and agency staff and reported 1 fall and 1 pressure ulcer during the month. Sopwell Ward at St. Albans City Hospital required bank and agency staff to cover 25.8% of their hours and had a sickness and absence rate of 9.8%. They also reported no falls, pressure ulcers or Health Care Associated Infections, despite caring for 4 patients at high risk of falls during June. Danesbury Neurological Unit used 19.3% bank and agency staff and reported 2 pressure ulcers during the month. Potters Bar Community Hospital had a bank and agency rate of 17.7% and the unit reported 4 patient falls with low associated harm during this period. . In addition to this Langton Ward at St. Albans City Hospital required additional RNs to cover the unit on several day shifts, whilst staff completed SystmOne training in preparation for the unit transferring onto the electronic clinical record system. Additional hours A summary of patients’ needs requiring additional hours by unit is shown in Appendix 2. Daily Fill Rate Audit

A deep dive has been carried out to identify the daily staffing numbers for Langton Ward, St. Albans City Hospital, see Appendix 3. Reasons for low staffing levels and mitigating action taken, along with effects on patient safety for shifts reported as being below 80% fill rate were reviewed. During June only one shift on Langton ward was below HCT safe staffing levels as detailed below. Langton Ward Staffing Information June 2016 Shifts reported as below 90% threshold

Reason for low staff levels

Mitigating action taken

Effects on Patient safety

Wednesday 15th June Day time RN level

All scheduled RNs were on duty, but the Ward Manager was on W/C 13th June and the

Patient care prioritised and only essential management tasks

Nil

2


82.1%

RN covering the management of the ward was on a day off on this day.

only undertaken.

Langton Ward required additional qualified nurses on 11 daytime shifts during June to cover staff completing SystmOne training prior to the implementation of the electronic clinical record system onto the unit. 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, 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. Unresolved risks are escalated to the Director of Operations Monday to Friday and the Tier 1 Director/General Manager at weekends. In addition, 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 monthly to the individual Business Unit Performance Reviews and to HCT board. Author of paper: Jackie Sibson Clinical Project Manager 5th September 2016

3

Hospital/UnitStaff WTE(Contracte

d)Vac %

FILL RATERegistered


FILL RATERegistered


% Bank Use

% Agency Use

FALLSModerate & Severe

All Pressure

Ulcers HCAIs SIs

Sickness & absence

Rate

≥90% ≥90% ≥90% Herts & Essex 56.40 25.40% 102.3% 182.2% 104.5% 240.9% 4.58% 33% 0 0 0 0 5.8%QVM 43.50 20.40% 93.4% 101.5% 100.0% 98.7% 4.85% 8% 0 0 0 0 3.0%Danesbury 49.50 12.80% 106.3% 123.9% 98.6% 103.3% 5.29% 14% 0 2 0 0 5.3%Holywell 39.82 16.80% 97.4% 109.0% 100.0% 107.8% 3.50% 12% 1 0 0 0 3.9%Potters Bar 56.53 11.59% 108.9% 134.2% 100.0% 127.8% 7.67% 10% 4 0 0 0 2.5%Langley 41.53 12.91% 93.2% 123.9% 100.0% 112.2% 0.00% 5% 2 0 0 0 3.8%St Peters Ward 36.63 19.73% 98.1% 179.3% 100.0% 200.0% 14.55% 14% 1 1 0 0 2.7%Sopwell 41.89 21.62% 96.8% 162.7% 100.0% 171.7% 4.79% 21% 0 0 0 0 9.8%Langton 29.94 50.48% 114.8% 155.1% 101.8% 152.0% 16.45% 19% 0 0 0 0 5.5%Nascot Lawn 91.9% 101.0% 100.0% 102.0%

Safe Staffing Community Hospital Dashboard 16-17

Jun-16Day Night

Target

Appendix 2 - Summary of complex needs by unit for June 2016 Unit Patients

with DOLS in place

Patients at high risk of falls

Patients requiring escorts off site

Patients with other complex needs

Danesbury Neurological Unit

4 1 3 0

Holywell Neurological Unit

1 7 5 0

Herts & Essex Hospital

2 8 3 1

Langley House

1 1 13 0

Langton Ward SACH

4 2 5 0

Sopwell Ward SACH

0 4 6 0

Potters Bar Community Hospital

1 2 0 0

Queen Victoria Memorial Hospital

0 1 0 2

St Peter’s Ward HHGH

2 4 3 0

Total

15 30 38 3

Wed 1 108.33% 166.67% 134.6% 100.00% 150.00% 125.0% 131.0%Thu 2 109.52% 120.29% 114.4% 100.00% 150.00% 125.0% 118.4%Fri 3 104.76% 166.67% 132.7% 100.00% 150.00% 125.0% 129.8%Sat 4 133.33% 127.54% 130.4% 100.00% 150.00% 125.0% 128.3%Sun 5 100.00% 140.58% 120.3% 100.00% 150.00% 125.0% 122.2%Mon 6 102.38% 166.67% 131.4% 100.00% 150.00% 125.0% 129.0%Tues 7 107.14% 166.67% 134.0% 100.00% 150.00% 125.0% 130.6%Wed 8 102.38% 166.67% 131.4% 100.00% 150.00% 125.0% 129.0%Thu 9 107.14% 171.01% 135.9% 100.00% 200.00% 150.0% 141.2%Fri 10 108.33% 157.97% 130.7% 100.00% 150.00% 125.0% 128.6%Sat 11 100.00% 165.22% 132.6% 100.00% 150.00% 125.0% 129.6%Sun 12 100.00% 100.00% 100.0% 100.00% 208.70% 154.3% 121.7%Mon 13 107.14% 200.00% 149.0% 100.00% 150.00% 125.0% 140.0%Tues 14 100.00% 153.62% 124.2% 100.00% 150.00% 125.0% 124.5%Wed 15 82.14% 166.67% 120.3% 100.00% 150.00% 125.0% 122.0%Thu 16 108.33% 162.32% 132.7% 100.00% 150.00% 125.0% 129.8%Fri 17 104.76% 166.67% 132.7% 100.00% 150.00% 125.0% 129.8%Sat 18 133.33% 133.33% 133.3% 100.00% 150.00% 125.0% 130.0%Sun 19 133.33% 131.16% 132.2% 100.00% 150.00% 125.0% 129.3%Mon 20 98.81% 207.25% 147.7% 100.00% 150.00% 125.0% 139.2%Tues 21 116.67% 200.00% 154.2% 100.00% 100.00% 100.0% 133.9%Wed 22 116.67% 133.33% 124.2% 100.00% 200.00% 150.0% 133.9%Thu 23 136.90% 150.72% 143.1% 100.00% 150.00% 125.0% 136.3%Fri 24 130.95% 147.83% 138.6% 100.00% 150.00% 125.0% 133.5%Sat 25 100.00% 133.33% 116.7% 100.00% 150.00% 125.0% 120.0%Sun 26 100.00% 166.67% 133.3% 98.91% 150.00% 124.5% 129.8%Mon 27 132.14% 153.62% 141.8% 100.00% 150.00% 125.0% 135.5%Tues 28 132.14% 133.33% 132.7% 104.35% 150.00% 127.2% 130.6%Wed 29 147.62% 125.36% 137.6% 100.00% 150.00% 125.0% 132.9%Thu 30 122.62% 171.01% 144.4% 150.00% 100.00% 125.0% 137.1%

TOTAL 114.80% 155.07% 132.4% 101.78% 151.96% 126.9% 130.3%

ALL NIGHT SHIFTS %

FILLED

ALL SHIFTS % FILLED

LANGTON - JUNE 2016

QUALIFIED DAY SHIFTS

% FILLED

HCA DAY SHIFTS %

FILLED

ALL DAY SHIFTS %

FILLED

QUALIFIED NIGHT SHIFTS

% FILLED

HCA NIGHT SHIFTS %

FILLED


Trust Board Title: Serious Incident Report Meeting Date: 29th September 2016 Executive Lead: Clare Hawkins, Director of Quality & Governance / Chief

Nurse Author(s): Christine Stock, Clinical Quality Manager

Tricia Wren, Deputy Director of Quality & Governance / Deputy Chief Nurse

For: NOTING Risk Rating: Green


1.1 To (i) advise the Board regarding serious incidents occurring June and July 2016 and provide assurance of actions taken in response to learning that has been identified and

(ii) to ask the Board to note the report


2.1 Four serious incidents were reported during June and July 2016;

investigations are underway in line with policy. 2.2 Managing fluctuating capacity of patients in community hospitals

continues to be a challenge. The Adult Safeguarding team are raising the profile of fluctuating capacity in training delivered to HCT and via their newsletter. In addition guidance made available in October 2015 is to be re-issued

2.3 Work to implement the National Early Warning Score across

community hospitals to support the early recognition of the deteriorating patient has continued; this is in response to a small number of SIs which identified the NEWS was not being as reliably used as expected. Work includes; o Review of Intermediate Life Support training being rolled out to

community hospital staff has shown that it meets the needs of staff when identifying and managing the deteriorating patient

o 95% of all community hospital staff have now completed NEWS training, an increase compared to May, when 85% of staff had completed the training.

1


3.0 Relevant Strategic Objective(s) / Strategies 3.1 Trust 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

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

6 Impacts on all Strategic Objectives

4.0 References, Appendices & Attachments References

None

Appendices & Attachments None

Author(s) of paper: Christine Stock Clinical Quality Manager Tricia Wren Deputy Director of Quality & Governance / Deputy Chief Nurse Date: September 2016

2


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 September 2016 Issues arising from committee consideration




√


√


√

Up To Date


√


√

Clearly Defined


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SERIOUS INCIDENT REPORT

1st June - 31st July 2016

1. 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, NHS England-Midlands & East (Central Midlands), NHS England-East Anglia Area Team, West Essex CCG and the Local Authority, for the two month period, 01st June to 31st July 2016. 2. Summary analysis of Serious Incidents During the period 01st June to 31st July 2016 four serious incidents were reported. Reporting patterns may vary monthly and to help consider patterns of reporting, monthly data for 2016/2017 has been provided: 2016/2017

Apr’16 May’16 Jun’16 Jul’16 Aug’16 Sept’16 Oct’16 Nov’16 Dec’16 Jan’17 Feb’17 Mar’17 TOTAL

No. declared 3 1 2 2 8

No. de-escalated 0 0 0 0 0

No. confirmed SIs 3 1 2 2 8 Overview of new Serious Incidents (01/06/16 – 31/07/16) During this two month period, four serious incidents were reported. The category of SIs reported is identified below:

Reported SIs 01/06/15-31/07/16 Number reported Number down graded Total confirmed incidents

Sub-optimal care 1 0 1 Death in custody 1 0 1 Abuse/alleged abuse of adult patient by staff 2 0 2

Total 4 0 4

1 Serious Incident Report 01/08/2016

Board 29th September 2016 Attachment C4 3. Analysis and impact Abuse/alleged abuse of adult patient by staff (2) An inpatient at Danesbury Neurological Unit made an allegation of a sexual nature regarding a member of HCT staff. The investigation has a shorter timeline for completion in order for the HR management of this incident to take place in a timely way. The member of staff was removed from patient facing duties during the investigation process. A full investigation has been completed and does not substantiate the allegations, however learning regarding professional behaviour and robust use of the chaperone policy has been identified. A patient under the care of WelHat ICT was admitted to Lister Hospital following deterioration in her condition thought to be indicative of a stroke. The patient was diagnosed with severe infection in the right above knee amputation stump wound. The team at the Lister Hospital were sufficiently concerned about the condition of the patient on admission that they raised a safeguarding alert. The patient died a little over two weeks later. A formal written complaint was later received from the patient’s daughter regarding the care delivered whilst an inpatient at Potters Bar Community Hospital, Langley House Rehabilitation Unit and the WelHat ICT. The SI investigation and complaint investigations have been carried out by a single investigating officer and the outcome will be coordinated to ensure that the response addresses all the concerns raised. The CQC has expressed an interest in this investigation and information will be shared with them when the investigation is completed in September. Death in custody (1) When a prisoner in custody dies and their death is not anticipated, a serious incident must be raised. A prisoner was found in his cell with a ligature around his neck. He was resuscitated, transferred to hospital and died in hospital one week later. An investigation will be carried out by the Prison and Probation Service Ombudsman and a healthcare review commissioned directly by NHS Improvement. An internal review of the information supports that HCT staff provided the expected level of care and that effective liaison between prison staff, the Healthcare Team and the HUC GP service took place. Sub-optimal care (1) A patient’s pressure ulcer to the left heel deteriorated whilst in the care of the Dacorum ICT. Review of care identified a number of areas as having fallen below expected standards and HCT raised a Safeguarding Alert. The patient has since confirmed to the social worker that they do not wish for the safeguarding investigation to proceed. However, the serious incident investigation will continue to identify learning. 4. Learning from Serious Incidents 2016/2017 Managing fluctuating capacity Serious Incident 2016/6066 concerned a patient on Langton Rehabilitation Ward who fell and sustained a fractured rib. The investigation identified that staff on the unit should have considered carrying out a mental capacity assessment at night as this may have identified fluctuating


Board 29th September 2016 Attachment C4 capacity and aided decision making about how to further safeguard the patient, for example with the use of crash mats at night or a voice sensor alert. Managing patients with fluctuating capacity is a challenge and has previously been identified as an area where increased awareness needs to be in place. In October 2015 the Adult Safeguarding team circulated information via Clinical Matters on the importance of managing fluctuating capacity (Appendix 1) and further information was disseminated in January 2016. As a consequence of serious incident 2016/6066 information will be re-issued. In addition the SAFA team are also raising the profile of fluctuating capacity in training delivered to HCT staff, via their newsletter and during their visits to clinical teams. Fluctuating capacity will be discussed at the Safeguarding Adults Forum to identify further mechanisms to check and challenge staff. Other improvements in practice include:

- Ensuring members of staff are allocated responsibility for completion of mental capacity assessments in a timely way. - A Mental Capacity Act Competencies framework has been developed which will require line managers to review and sign off all staff’s

competency. - Processes developed for checking the working order of sensor mats as this patient was known to remove the batteries which are currently

being rolled out to all community hospitals. Managing the deteriorating patient Serious Incident 2016/9907 concluded in July and concerned a patient who was transferred from Herts and Essex Hospital and died shortly after admission to Princess Alexandra Hospital. The investigation identified failings in recognition and management of the deteriorating patient, use of the NEWs tool and communication with the emergency services. In response to this incident an SBAR tool (Situation, Background, Assessment, and Recommendation) has been developed to use during patient transfer to out of hours services and emergency services to ensure that comprehensive information is gathered and shared. A clinical working group was previously set up in response to two earlier SI’s where investigation identified concerns around the use of the NEWS tool. It was recognised early on that Serious Incident 2016/9907 involved the effective use of the NEWS tool and learning from this incident helped inform the work of the group which has coordinated the training of community hospital staff and advised on the content of Intermediate Life Support training to make sure training provides sufficient information around how NEWS should be used to support clinical decisions. A recent review of the Intermediate Life Support training currently being rolled out to community hospital staff has shown that this meets the needs of staff when identifying and managing the deteriorating patient in the community hospitals. The improvements identified and advised by the NEWS group have now been embedded in practice. Up to the end of July 2016, 95% of all community hospital staff had completed NEWS training, which is an increase compared to the end of May 2016, when 85% of community hospital staff had completed the training.


Board 29th September 2016 Attachment C4 Managing pathology results Serious Incident 2016/9930 concerned 1,774 pathology results that had not been filed correctly in the patients notes; the results involved patients whose tests had been requested by the Community Diabetes Service. The incident occurred following a change in process for requesting and filing results, where by blood test results were only made available to the clinician who had requested the blood test. Improvements made in response to the serious incident include the development of a Standard Operating Procedure (SOP) to ensure that all staff are aware of the correct procedure to file notes. In addition, as part of this SOP, a process has been developed to ensure that pathology results can be managed centrally via S1 and checked weekly to reduce the risks of a build-up of unassigned or unmanaged results which was identified as a problem as results were only previously available to those individuals who had requested the blood test. A process is also now in place to keep the information held by the Pathology Partnership (a joint venture between 6 NHS trusts in the East of England to provide pathology services to provider organisations) up to date with staff information ensuring that the assignment of results is to the correct clinician. HCT however needs to investigate further with the Pathology Partnership the Partnership’s requirement to identify individual staff via their NMC number, rather than through use of a central team identifier. 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. Position for June 2016 & July 2016

Herts Valleys CCG

East & North Herts CCG

West Essex CCG

Local Authority NHS England-Midlands & East

(Central Midlands)

NHS England East Anglia area

team

TOTAL

No. of new SIs declared during Feb & Mar

1 2 0 0 0 1 4

No. of patient contacts during Apr & May

103,721 107,455 4,656 13,556 51,905 281,293

No. of SIs per 1000 contacts 0.01 0.02 0 0 0.02 0.014

Cumulative 2016/2017 (01/06/2016 to 31/07/2016) Herts Valleys

CCG East & North Herts CCG

West Essex CCG

Local Authority NHS England-Midlands & East

(Central Midlands)

NHS England – East Anglia area

team

TOTAL


Board 29th September 2016 Attachment C4 Cumulative total of SIs declared 2 3 0 1 0 2 8 Cumulative no. of patient contacts

210,683 213,280 9,448 39,357 103,891 576,659

No. of SIs per 1000 contacts 0.01 0.01 0 0.025 0.02 0.014

6. Analysis of Serious Incidents reported

The type and number of SIs reported during 2015/2016 is provided as a total against the new categories as defined on STEIS*. Cumulative information provides a clear overview concerning the number of specific types of serious incidents 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 SIs; it is used & accessed by commissioners, DOH, CQC.

Category of Serious Incident as defined on STEIS* Number reported 2015/2016 Number reported 2016/2017 (yr to date)

Pressure ulcers meeting SI criteria 18** 0 Abuse/alleged abuse of adult patient by staff 12

(6xNeglect, incl.3xPUs & 1xMedication incident) (1xFinancial) (4xPhysical, incl 1xMedication incident) (1xSexual)

3 (2xNeglect / 1xSexual)

Slips/trips/falls meeting SI criteria 9 0 HCAI/infection control incident meeting SI criteria 3 0 Sub-optimal care of the deteriorating patient meeting SI criteria

2 1 (involving PU)

Death in custody 2 2 Information governance breach meeting SI criteria 2 0 Treatment delay meeting SI criteria 1 2 Never Events 0 0

TOTAL 49 8


Board 29th September 2016 Attachment C4 No Never Event incidents have occurred during 2016/2017 7. Monitoring Monitoring of progress against expected standards continues through a bi-weekly report which is made available to the General Managers and Locality/Service Managers. It is expected that information relating to individual serious incidents is updated within an Internal Incident Review (72 hour) report followed by the Investigation (60 day) report. The bi-weekly progress report reflects these expectations and provides details of open SIs including 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 progress in line with expected timeframes. The progress report has been developed to reflect the importance of the action planning stage, as only after completion of the investigation and findings can the recommendations be developed into actions to ensure full implementation of improved patient care. In addition to the bi-weekly progress report, the timeliness for completion of serious incident reports is monitored via the monthly Integrated Board Performance Report and monthly Business Unit Performance Reports. During June and July 2016 four Internal Incident Reviews (72hr reports) were due to be returned to the commissioners; all were returned on time. Three investigation reports were due to be submitted during June and July, for serious incidents declared 60-days prior. All investigation reports and action plans were returned within agreed timeframes. 8. Duty of Candour 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). This includes notifying the patient or their family when a serious incident occurs or has been identified and ensures that communication takes place within 5 working days or 10 days in exceptional circumstances. During May, June and July four SIs were reported. Serious Incident 2016/1667 (Safeguarding concern) – The family were invited to and attended the safeguarding strategy meeting when discussion identified the family’s concerns and confirmed that these would be investigated as a serious incident.


Board 29th September 2016 Attachment C4 Serious Incident 2016/19685 (Safeguarding concern) – the patient has been informed that an investigation is underway. They have requested telephone contact and a copy of the report when finalised. Serious incident 2016/14950 (Death in custody) - Due process is being followed for prisoners who die in custody which includes the Prison and Probation Ombudsman contacting the family to ask if they have questions to be answered by the prison or Trust staff as part of investigations that will be undertaken. Serious Incident 2016/19653 (Sub-optimal care) – This incident was initially reported as a safeguarding concern. However, the patient confirmed to the social worker in early August that they did not wish for the safeguarding investigation to proceed. Serious incident investigation will continue and the service has been asked to inform the patient of this and ask what information they wish to receive and their involvement going forward. 9. Serious incidents referred for closure or confirmed closed by the CCG At the time of writing this report (15/08/2016) eight serious incidents remain open, of which five are open pending completion of the investigation. The investigation reports for the remaining three were submitted in April (x1) and July (x2). For reports submitted in July the services are currently implementing the recommendations. In May, and on 2 further occasions, HCT requested that the incident whose report was submitted in April was considered for closure. Number of SIs reported by Commissioner and those that remain open

Number of confirmed SIs

declared 2013/2014


declared 2014/2015


declared 2015/2016


declared 2016/2017

Number of SIs remaining open at

15/08/2016

East & North Herts CCG 87 106 16 3 3 Herts Valley CCG 126 136 28 2 2 NHS England-Midlands & East (Central Midlands)

7 4 0 0 0

Local Authority 1 0 1 1 2 West Essex CCG 4 1 2 0 0 East Anglia Area Team 1 2 2 2 1

Total 226 249 49 8 8


Board 29th September 2016 Attachment C4 10. Going forward 1) As part of the 2016/2017 Quality Schedule, HCT is required to report on six protected characteristics for patients who have been affected by

serious incidents. The required protected characteristics are age, disability, race, religion or belief, gender and sexual orientation. The Protected Characteristic report for June and July 2016 has been prepared and is available to read alongside this report. The Protected Characteristic report however will remain separate to ensure that given the low numbers of serious incidents reported and considering the highly personal and sensitive nature of protected characteristics, the anonymity of individuals is preserved.

2) Set up meetings are now being organised at the start of an investigation with the Serious Incident (SI) Manager, the Investigating Officer (IO), Senior Manager (SM), Team/Ward Manager and any other relevant person i.e. SAFA lead. The SI Manager aims to make contact with the IO mid-point in the investigation to ensure they are on track with agreed timelines etc. and a further support meeting is offered if required. When the investigation report is finalised a handover meeting will be arranged with all interested parties, the report will be discussed and any recommendations agreed so that the action plan is developed with a panel approach. The final submitted report and action plan will then be discussed at the Serious Incident Panel.

3) The Serious Incident Panel terms of reference and membership have been reviewed and the first meeting in its new format was held on 28/7/16. The previous SI Panel had at times got too involved with the detail of actions which could have been dealt with elsewhere e.g. Nurse Forum. The new panel will focus more on ensuring that action plans are effective and that learning is embedded across the organisation effectively to provide assurance to the board and commissioners.

Tricia Wren Christine Stock Deputy Director, Quality & Governance, Deputy Chief Nurse Clinical Quality Manager, Patient Safety 15 August 2016



Board Committee Chair’s Assurance Report

Healthcare Governance Committee Date of Board Meeting: 29 September 2016 Committee Chair: Anne McPherson Date of Committee Meeting: 20th September 2016 Date of Report: 20th September 2016 Dates of Committee Meetings Held Since Last Board Meeting: 20th September 2016 Date of Next meeting: 15 November 2016

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 Assurance on correct use of

Fluid balance Charts

100% compliance required via on-going audits

Assurance: 4.1 CQC Factual Accuracy

Report

Factual accuracy report submitted. Awaiting final outcome from CQC. Detailed comprehensive Quality Improvement Plan completed apart from 2 minor actions as a result of capacity issues in the LD Team but on track to meet new target date plus EoL Strategy will start routine scheduled review at end of September.

4.2i Safe Staffing Report (Jun)

Compliance achieved in all community hospitals but with heavy reliance on

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bank and agency to reach safe staffing levels. Langton Ward vacancy rate 50.40%. Herts & Essex 25.4%. Quality Indicators monitored

4.2ii Safe Staffing Report (July)

Compliant with safe staffing metrics. Over 20% use of bank and agency staff in 5 units as a result of high vacancy rates, staff sickness and complex patients Vacancy level in Langton Ward 30% and Herts & Essex Hospital 23.7%.

4.3

Safe Staffing Review Red Red Risk assessment against a proposal to reduce nursing staff ratios across the Community Hospitals to mitigate the current over spend. HGC did not support a 1.10 ratio across the board and required further information on the acuity scores of the patient population to fully understand the care requirements and case mix. In addition, HGC suggested a number of potential actions to support a sustainable response to the financial and staffing pressures.

4.4 Quality Impact Assessment of CIPs

HGC assured that the system of Quality Impact assessment for CIPs is working as intended.

4.5 Quest Report on Community Nursing in Hertfordshire

Audit findings informing a programme of service and clinical effectiveness improvement in Community Nursing Teams outcomes and delivery of care processes.

4.6 BUPR Summaries and Risk Correlates with other sources of information on

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Escalation risk presented to HGC.

4.7 High Level Risk Register N/A N/A Estates fire risk at Herts & Essex Hospital & Potters Bar Hospitals discussed.

4.8 Risk Implementation Plan Mixed

Plan mostly on track.

4.9 Quality Report Q1 N/A N/A New format for reporting supported. Only a single C. Difficile case in the quarter.

4.9i Complaints Report (highlights)

4 PHSO Complaints had 1 upheld and another partially upheld.

4.9ii Serious Incident Report

Learning from SI’s being implemented.

4.10 Prison Healthcare Report

Lack of Mental Health week-end provision identified as a gap.

4.11 Clinical Quality Review meeting minutes Herts Valleys and East and North Herts CCG during June/July

N/A

N/A

Minutes of Quality review meetings with CCG Commissioners noted.

Patient Safety & Patient Experience

5.1 Patient Safety & Experience Chair’s Assurance report and minutes from 18 August16

5 Amber/Red limited assurance items all with actions against them.

5.2 Infection Prevention and Control Forum Chair’s Assurance report and minutes from the 13 July 16

2 Amber/Red limited assurance items both with actions to address gaps.

Clinical Effectiveness 6.1 Community Hospital

mortality Review update Progress made on

strengthening the Community Hospital

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Mortality review process.

6.2 Medical Revalidation update

Now following the correct governance framework with 6 outstanding items. Gaps exist in HCT support and resources for the RO, plus record keeping capacity. Still to commission an independent review of the processes relating to revalidation.

6.3 Clinical Effectiveness Group Chair’s Report and Minutes from 11 August 2016

4 Amber/Red items with some actions in the minutes but not definitive. HGC commented on the lack of poor clinical effectiveness identification in respect of professional clinical practice and service outcomes. Reliance on Audit as the sole medium insufficient.

6.4 Research Annual report 2015/16

Tremendous expansion in the amount of research and success in achieving substantial research funding.

6.4i Research Plan 2.16/17 KP1s Number of patient or staff recruits to NIHR Portfolio Studies and Number of CLAHRC studies the Trust participated in.

Other Urgent Business: (List Below): AoB

None

Summary of Committee governance issues and any other points for the Board’s Attention

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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):

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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.

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Board 29th September 2016 Attachment D1

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Director of Operation’s Report

September 2016

1.0 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 Summary The board is asked to note the content of this report, in particular:

• Progression of work to decommission FNP service • Focus on ICT developments and establishment of ICT Steering and

operational group • Ongoing risks and challenges

4.0 Service Delivery and Performance 4.1 Children’s Services

Nascot Lawn Watford MP Richard Harrington visited Nascot Lawn on Friday 16 September 2016. He met with staff and discussed the services provided before having a guided tour of the unit. Mr Harrington said: “It was an honour to meet the amazing staff at the service and find out more about what they do every day. It is a source of pride to have this facility in Watford.” Community Paediatrics Recruitment to vacancies within the Community Paediatric service remains a challenge and this is reflected across England. Despite this we have recently made successful appointments for a number of key posts across both the Hertfordshire and West Essex teams and a specialist nurse role is being developed within West Essex to support the work of the Paediatricians. In West Hertfordshire the waiting list for initial appointments continues to grow and we are working with commissioners to identify new ways to meet the demand. Family Nurse Partnership (FNP) Decommissioning of the FNP service is nearing completion and the children and families previously supported by this service have been transferred back into the


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Children’s Universal Locality teams. All FNP team members have taken up either training opportunities or permanent roles within the Children’s Universal Service. Health Visiting Services HCT and Hertfordshire Children’s Centres are continuing to work together to contribute to the re-commissioning process and to inform the development of the service specification. STEP2 Funding for two additional posts has been agreed with commissioners and recruitment is underway. The service is meeting the delivery targets set within the agreed trajectory for reducing waiting times and the new posts will provide additional support to improve the waiting lists. Step2 continues to work more closely with HPFT and a recent joint workshop including CAMHS, Step2 and PALMS provided an opportunity to share the progress of the Trusted Assessment pilot study and the plans for wider roll out. The SystmOne Community Module is being adapted for use across PALMS and STEP2 which will enable the required reporting of the Minimum Data Set for CAMHS services by beginning of February 2017. Best of West Awards The Best of Awards celebrates the exceptional work being done in West Essex to keep people well and are sponsored by West Essex CCG. Dr Soo Teo, Consultant Community Paediatrician in Harlow has been shortlisted in the “Caring Together” category as well as in category of “Overall Best of West Award” which will be presented on 29th September. This nomination recognises Soo’s hard work and dedication to both her clinical caseload in the Harlow area as well as the work that she has done in relation to her role as the Designated Medical Officer for Special Educational Needs and Disabilities in West Essex.

Paediatric Audiology This service is currently under pressure to meet a backlog of referrals which has occurred as a result of maternity, sick leave and vacancies. The Business Management team is working closely with Audiology service staff to review demand and capacity and to explore ways to increase productivity. Children’s Community Nursing The Communications department has recently made a film about end of life care which was delivered to a seventeen year old at home by the Children’s Community Nursing Team. This film reflects the excellent care provided by staff and was recently used at a National Conference at the University of Hertfordshire and was featured at the Trusts AGM.

4.2 Adult Services

Diabetes The lead provider service model is developing within HV with the CCG releasing their commissioning framework and timelines. The clinical lead position is being interviewed for in September and a new service manager also starts at the beginning of September.


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ICTs ICT nursing services across the county continue to perform strongly against activity targets and the Friends and Family scores for the ICT’s remain positive (90-100%). The Deputy General Manager for East and North has also started in post providing senior leadership across all of the ICTs. Staffing to manage demand remains an operational challenge but clearer operational plans have been put in place and are being led by the Deputy GMs. An ICT Steering and operational group has been set up with a Clear TOR across all ICTs and will meet every 2 weeks. HVCCG have requested and been given a breakdown of establishment for each locality ICT including Rapid response and IDAT funding. The therapy business case funding for ICT therapy was put on hold by the CCG pending this information. The RR service within the Watford locality have also been thanked for their input into the Frailty unit at WHHT and their support in being able to prevent admission to the hospital.

Community Hospitals The community Hospitals in E&N continue to perform well against Length of Stay (LoS) with a drop in August by 5 days (non-stroke). HV community hospitals had an increase non-stroke Los by 3 days. Delayed transfers of care (DToC) have seen an ongoing drop in health related delays since May across both sides of the county and now being at 12%. Social delays have been steadily increasing due to ongoing challenges with homecare provision mainly within the long term homecare environment.

MSK An action plan to implement the recommendations of the external review is now in place and progress is being made in particularly in relation to recruitment and the availability of self-management advice and information.

5.0 Emergency Planning Response and Resilience

HCT has submitted two EPRR Core Standard Statements of Compliance – reporting as substantially compliant. A work plan is in place to fulfill the remaining areas of compliance by March 2017.

6.0 System Resilience All three systems remain busy with each SRG moving to a Locality A&E delivery Board (LDB) that will now be chaired by the respective acute chief executive. Each LDB is at different stages with the governance being agreed and established. HCT have engaged with the East of England ambulance service to ensure closer links with Rapid Response and also ensure the service is listed on their DoS.


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The west Herts system has remained variable but there has been a slow and steady improvement in August against the 95% target with some days being above 90%. System calls remain deescalated to 3 times a week rather than daily. Work continues in partnership with WHHT, HVCCG and HCC to support improvement in system flow to enable A&E improvement.

7.0 Operational Risks and Challenges - Adults and Children’s Services:

• Workforce levels in particular on the HLRR – Palliative care, Community Paediatrics, Step 2, GP provision at HMP Mount, Royston ICT, MSK, ICTs Herts Valleys, Therapy in Stevenage ICT and Diabetes service. Although there has been recent recruitment success in Palliative, Diabetes, Step 2 and Community Paediatric service areas.

• Health Visiting / FNP • ENHHT acute therapies and engagement with contract meetings • ICT Hertsmere • Cost associated with specialing patients in bed bases. • HV CCG procurement and lead provider activity: Diabetes, MSK and Stroke

8.0 Linked Documents

8.1 IBPR 8.2 HLRR 8.3 BUPR Assurance 8.4 All Director Board reports.

Marion Dunstone Director of Operations September 2016


Trust Board Title: SUMMARY OF INTEGRATED BOARD PERFORMANCE

REPORT (August 2016) Meeting Date: 29th September 2016 Executive Lead(s): PHIL BRADLEY, DIRECTOR OF FINANCE Author(s): ROSHAN JHOREE – HEAD OF BUSINESS UNIT INFORMATION For: NOTING Risk Rating: Not Applicable 1.0 Purpose & Recommendations

1.1 This paper provides the Trust scorecard and headlines from the Integrated Board Performance Report for August 2016. The full report is included in 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

Performance Highlights • No MRSA breaches reported. • No C.diff cases reported in August, this is the fourth consecutive month

with no case reported. • 95% of patients waiting within 18 weeks for their initial appointment. • Smoking Status achieving the 91% target. • HCT achieving targets for patients with a planned discharge by Midday

and Weekends. • Stroke Average length of stay within thresholds for August. • Overall staff mandatory training levels above target. • Child health promotion programme (immunisations, vision and hearing

screening, National Childhood Measurement Programme) on trajectory to achieve target.

• Staff Appraisals now achieving 91% and achieving target Areas for Board review • Four Grade 2 Pressure ulcers acquired in HCT care in August. • DTOC rate above the 5% threshold for last 11 months with 12.3% health

delays recorded in August. • All Urgent Therapy referral priorities not achieving response targets.

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• Staff turnover at 13% and over the 12% threshold. No change from previous month

• Absence Rate over 3.6% threshold with 3.82% in August.

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 Summary Trust Scorecard (August 2016) SP2 Integrated Board Performance Report (August 2016) Supporting Papers K4 Author(s) of paper: Roshan Jhoree Head of Business Unit Information September 2016

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Committee Consideration This Report has previously been considered by the following committees: Committee: Date (Month / Year):

Strategy & Resource Committee

September 2016

Issues arising from committee consideration




√


√


√

Up To Date


√


√

Clearly Defined


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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

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Attachment D2

Indicator2015/16

year endPerformance

2016/17Target /

Threshold

Current period performance

YTD Performance

CurrentPeriodRAG

YTD RAG ForecastRAG

Trend from previous month

Trend over time

Qua

lity

Perfo

rman

ceL

& D

Wor

kfor

ce &

Fi

nanc

eTRUST SCORECARD 16/17

G G G FSRR (Risk Rating) 4 4 4 4

A A G Absence Rate 3.62% 3.6% 3.82% 3.76%

A A G Underlying Staff turnover (Voluntary resignations excluding retirements, redundancy and the end of FTCs) 13.4% 12% 13.3% 13.3%

R R G % posts vacant(vacant WTE/budgeted WTE). 8.90% 8.5% 10.12% 10.12%

G G G % of staff who have received an appraisal in the last 12 months 85.5% 90% 91.0% 91.0%

G G G % of staff who have undertaken level 1 / 2 safeguarding adults training every 3 years 98.3% 90% 91.1% 91.1%

A A G % of staff completing Information Governance training (Rolling Year) 95.5% 95% 87.7% 87.7%

A A G % 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

93.0% 90% 87.2% 87.2%

G G G % of eligible staff trained at appropriated level of safeguarding children in accordance with IC document Level 1, Level 2, Level 3 95.00% 95% 95.0% 95.0%

G G G % staff who have undertaken mandatory training 92.70% 90% 91.0% 91.0%

G G G Community Hospitals - Average length of stay in HCT community hospital - Non Stroke (Rehab Pathway) 18.7 21 days 21.3 20.4

G G G All patients to have smoking status recorded on system one 90.3% 90% 91.9% 91.9%

G G G Patient waiting list (including Consultant & Non-consultant led services) N/A 92% 95.2% 95.2%

G G G Health Visiting - average caseload sizeActual WTE caseload ratio 380 <400 397 397

G G G Community Hospitals - Average length of stay in HCT community hospital - ALL Stroke (Rehab Pathway) 29.5 42 Days 29.7 33.5

R R R No of avoidable category 2 pressure ulcers acquired in HCT care 1620% reduction

on baseline from 2015/16

4 11

G G G Friends and Family test 98% 90% 98% 98%

Number of complaints received in month 250 For information 13 84

G G G C.difficile cases occurring post 3 days following admission into HCT bed based facilities (i.e. acquired in our facility) 7

Full Year 6Monthly

trajectory 1- May

0 1

G G G % of patients receiving harm free care 93.1% Compliant 94.2% 92.7%

Attachment D2 HCT SCORECARD EXCEPTION REPORT ( 19 KPIs RAG RATED)

2 4 13

ACTION (Q18) Pressure Ulcers - avoidable acquired in HCT care Grade 2. There were four avoidable Grade 2 pressure ulcers acquired in HCT care in August. One was a friction sore in a bed base unit and another ill-fitting shoe causing a pressure ulcer within an ICT team. There are no Hertswide themes for this increase. Tissue Viability Nursing staffing has improved enabling improved response times for assessment going forward into Quarter Three

% 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 (Safeguarding Champions) The training figures have increased in August to 87% . The cohort of staff for this training is small and any non-compliant staff will impact immensely on the figures. HCT anticipate ongoing improvement as more training sessions are planned.

Information Governance training The training is measured on a rolling in-month basis and expected to achieve the 95% target by March 2017.

% Posts Vacant The Trust vacancy rate is currently above the target at 10.12%. There has been run of fewer starters than leavers over the last few months, which has impacted on overall staff-in-post numbers. A reduction in this rate is actively being worked on through planned recruitment activity in line with the Resourcing Action Plan, along with a focus on retention

Underlying Staff turnover The Trust’s underlying turnover figure reduced in August, down to 13.3% which is the lowest rate of the last 12 months. Work-life balance continues to be the main reason for leaving the Trust. A specific focus on retention is underway with the following actions:

• A Retention Report has been discussed at the Workforce and Organisational Development Group meeting and is going to the Strategy and Resource Committee in September, highlighting key issues for the Trust to focus on (including ‘hot spot’ areas in each Business Unit)

• A Trust wide retention action plan has been developed to tackle the key retention issues. Absence rate

HCT was above the target with a 3.82% absence rate. In addition to the ongoing management of absence, the Trust’s programme of work in relation to the national Health and Wellbeing CQUIN for 2016/17 is now underway, with the next update going to the Health and Wellbeing Group in September. Work on the 2016 staff flu vaccination campaign is also in progress


Trust Board Title: High Level Risk Register Meeting Date: 29th September 2016 Executive Lead: Clare Hawkins

Director of Quality & Governance/Chief Nurse Author(s): Suleiman Banian, Head of Datix Management For: Assurance 1.0 Purpose and Recommendations

To inform the Board of current status of Risk associated with activity and business across all Hertfordshire Community NHS Trust (HCT) Business Units.


2.1 HCT High Level Risk Register (HLRR) is compiled from the risk registers of all

Operational 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 is currently 24.

2.2 The HLRR attached is that reflecting the position as at 1 September 2016. The

summary paper outlines changes to the HLRR from 2016 and progress with management of the risks.

2.3 There are no emergent risks identified, although staffing risks remain a

recurring theme. 2.4 24 risks are currently held on the HLRR.

18 risks have not changed since last submission and continue to be managed at their current scores of 15 and over. 2 risks have been escalated since the last submission (Refs: 429 and 436) with 2 risks de-escalated (Refs: 332 and 427).

2.5 4 new risks have been added to the HLRR (Refs: 447, 449, 450 and 454).

The table below gives detail of any new and escalated risks.

1


Ref Service Description N

EW

447 Positive Behaviour, Autism, Learning Disability and Mental Health Service

A number of operational issues (high referral rate, impact of staff resignations, difficulty in recruitment and insufficient Estate capacity to see CYP in health settings) are leading to a failure to meet 14 and 28-day targets, increased waiting times, low staff morale and concerns from the commissioners.

449 Estates Fire compartmentation defects at Potters Bar Community Hospital have been identified within the first-floor part of the inpatient unit, leading to the possibility of smoke and combustible products spreading through the unit in the event of a fire, resulting in difficulty in safely evacuating or containing patients.

450 Estates Significant fire compartmentation defects at Herts & Essex Hospital were found as part of the Jan16 FRA. The in-patient unit is now a sub-acute unit with over 25 high risk patients, most of which are unable to get up and out of the building without significant assistance.

454

MSK & Physio OT West HVCCG procurement of MSK services in West Herts may lead to a potential decommissioning of the HCT MSK iCROPS, Chronic Fatigue & Pain Management services in Herts Valley resulting in loss of business, with subsequent impact on HCT finance, business reputation and loss of critical mass of AHP staff potentially impacting on recruitment and retention in other HCT services.

ESC

ALA

TED

429 Community Hospitals West Risk that absence of consistent comprehensive SLA in place to secure medical staffing for community hospitals will lead to potential insufficient medical cover for community hospitals which has the potential for adversely affect patient safety.

436 Community Nursing & Integrated Teams East & North

Shortfall of therapy staff due to vacancies leading to potential delay in visits, resulting in reduction of quality of patient experience and loss of reputation.

2.6 The chart below indicates the number and length of time risks have been managed on the risk register.

2


It should be noted that although a number of risks have been held on the risk register for a considerable period of time, they may have been escalated and de-escalated throughout this period both within the business units and high level risk register depending on emerging concerns and mitigations. Nonetheless, the Risk Team have been contacting (and will continue to contact) the owners of the risks that have been on the HLRR for more than 12 months to review the rationale for retaining them on the register.

9

3

2

1

9

0-3 months 3-6 months 6-9 months 9-12 months + 12 months

Risks by time on Risk Register

3



The Statement impacts on all strategic objectives and links to all Trust strategies.

4.0 Appendices and Attachments

(1) Corporate HLRR and synopsis paper August 2016 (2) Operations HLRR and synopsis paper August 2016

Suleiman Banian Head of Datix Management 9 September 2016

4

Board 29th September 2016 Attachment D3 Committee Consideration This Report has previously been considered by the following committees: Committee: Executive Team Date (Month / Year): August 2016 SMT August 2016 Healthcare Governance Committee Sept 2106 Issues arising from committee consideration



Complete 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.

√


√


√

Up To Date


√


√

Clearly Defined


√



C Hawkins Director of Quality & Governance and Chief Nurse

√


5


SYNOPSIS for the Trust Board

HIGH LEVEL RISK REGISTER - Corporate

August 2016

Position as at: 1 September 2016

Key – Risk Scoring/Grading Low

Medium

High

Risk Scores = Consequences of Risk x Likelihood of Risk Materialising

Breakdown of Risks on the HLRR – Corporate

No Change in Score/Grade 7 Ref 199, Ref 263, Ref 268, Ref 302, Ref 366, Ref 412, Ref 439 (these are listed on pages 2-6 of this report)

New Risks 2 Ref 449, Ref 450 (these are listed on page 7)

Escalated 0

De-escalated 0

Re-emerging 0

Total Corporate High-Level Risks 9

8-12 15-25 1-6

Page 1 of 7


August 2016

Synopsis Table - Corporate Risks on High Level Risk Register

Ref Business Unit Lead Executive

Lead Committee Previous

Risk Grade

Current Risk

Grade

Direction of

Change

199 Human Resources

AS Director of HR Director of HR Executive 15 15

Date of Entry onto Risk Register: 10 September 2014 Length of Time on Risk Register: + 12 months

Risk Description

Inability to recruit the numbers of staff needed to fulfil demand due to an increase in newly commissioned services and tight labour market leading to higher vacancy rates and difficulties in delivering both new and established services resulting in potential service delivery/safe staffing breaches and reputational issues with commissioners.

Mitigation/Update of Action in Month

UPDATE: June 2016

1. Recruitment initiatives are ongoing and TRAC training continues to be offered to streamline process.

2. Band 5 Resourcing Advisor joined the team 13 June so now extra resource to focus on recruitment generally and hard to fill areas specifically.

UPDATE: July 2016

Current recruitment initiatives include:

• bus advertising for nursing; • targeted advertising for OTs; • trialling of CV searching via LinkedIn; • regular activity on our Twitter recruitment page and planning of recruitment campaigns to be managed by

Stirling Cross on HCT's behalf.

TRAC training now available on a quarterly basis and a recruitment training programme is being developed to be offered later in the year.

UPDATE: August 2016

More recruitment initiatives are underway:

- AHP Forum to discuss new ways to attract AHPs to HCT.

- Facebook recruitment page to be introduced.

- Attendance at Jobs Fair in Dublin booked for October.

Page 2 of 7




Risk Grade

Current Risk

Grade

Direction of

Change

263 Finance and Commercial

Business (FT Programme)

PB Director of Finance

Director of Finance

FT Committee/

Board 16 16

Date of Entry onto Risk Register: 9 February 2015 Length of Time on Risk Register: + 12 months

Risk Description

Revised description in light of NSHI changes

CCG support for Foundation Trust status is compromised by the national policy emphasis on integration and 5YFF alternative organisational forms leading to deferral of FT application Resulting in delay in assessment of FT application by NHSI (Monitor)


UPDATE: June 2016

1. Priority for 2016/17. Stakeholder Relationship Management Plan focuses on GPs, County Council, patients and staff – plan approved by Community Engagement Committee which will monitor delivery.

UPDATE: July/August 2016

1. Plan approved by Community Engagement Committee which will monitor delivery

2. Task and Finish Group to be established to implement Stakeholder Relationship Management Plan



Risk Grade

Current Risk

Grade

Direction of

Change

268 Finance and Commercial

Business

PB Director of Finance

Director of Finance BUPR 16 16


Risk Description

West Herts review may propose significant service change which impacts on HCT leading to challenge or opportunities relating to long term organisational viability and resulting in noncompliance with FT authorisation criteria.


UPDATE: July 2016

1. Executive Directors continue to be involved in development of STP. June submission made in accordance with national timetable

UPDATE: August 2016

1. Executive Directors continue to be involved in development of STP. CCG STP submissions made in accordance

Page 3 of 7

Board 29th September 2016 Attachment D3 with national timetable.



Risk Grade

Current Risk

Grade

Direction of

Change

302 Pharmacy SW Chief Pharmacist

Director of Quality and Governance

HCG 16 16

Date of Entry onto Risk Register: 20 May 2015 Length of Time on Risk Register: + 12 months

Risk Description

General Practitioners acting on advice from the Local Medical Council (LMC) Bedfordshire & Hertfordshire to no longer complete HCT medication administration charts from September 2015, leading to community nurses not having access to appropriate documentation and supporting policies to administer medication to patients. Resulting in patients not receiving medication as prescribed by Doctors.


UPDATE: June 2016

The new IPA form is being trailed week beginning 04/07/2016. Chief pharmacist to await feedback from transformation team for any additional changes to IPA form before implementing new process of using SCR as written conformation across Hertfordshire for referrals for medicines administration.


The IPA work is now being led by the operational manager. There is work with both HVCCG and ENHCCG to ensure new IPA template can be set up on DXS and Map of Medicine so that it may be completed electronically. Once this is set up full roll out of using SCR as written confirmation of medicine administration referral will be implemented.



Risk Grade

Current Risk

Grade

Direction of

Change

366 Quality and Governance

CS Associate MD

Director of Operations Executive 20 20

Date of Entry onto Risk Register: 11 December 2015 Length of Time on Risk Register: 6-9 months

Risk Description

A variation in the existence of recruitment checks and written contracts for Doctors within the Trust is leading to uncertainty in clinical governance arrangements including accountability, recruitment, appraisals, revalidation and management of standards, performance and quality of outcomes. This could result in potential poor reputation, poor clinical outcomes, loss of opportunity to learn and enhance quality and safety, interest from commissioners, regulators and non-compliance with regulatory requirements.


UPDATE: June 2016

1. Agreement to recruit Interim Medical Staffing support to set up suitable systems to support requirements of

Page 4 of 7

Board 29th September 2016 Attachment D3 revalidation - recruitment checks, written contracts, management of concerns, job planning.

2. The list of Doctors working for HCT in some capacity is currently 112, and being updated regularly.

3. A Medical Revalidation manager role has been identified to help improve systems to support the Responsible Officer.

4. Further issues have been identified in Medical Structure and lack of local medical leadership to support and monitor Doctors working for HCT.

5. Terms of Reference for a new Decision Making Group have been agreed and there are plans to set up the first meeting. This will support the Responsible Officer in decisions regarding revalidation and concerns about Doctors.

6. An action plan is documenting all above actions and others required to meet the Regulatory requirements on Medical Revalidation.

UPDATE: August 2016

1. Lead and replacement appraisers are in the process of being recruited with interviews expected in September.

2. Decision Making Group has now been created.

Ref Service Lead Executive Lead Committee Previous

Risk Grade Current

Risk Grade Direction of Change

412 Finance &

Commercial Business

Kevin Curnow

Director of Finance SRC 15 15

Date of Entry onto Risk Register: 28 April 2016 Length of Time on Risk Register: 3-6 months

Risk Description

The Government is introducing an Apprenticeship Levy on 1/4/17 of 0.5% of the employers’ payroll bill (total employee earnings subject to Class 1 secondary NICs). This is currently unplanned within Trust Budgets, leading to an unexpected reduction in the funds available to Trust and increasing the CIP requirements recurrently from 2017 resulting in decreasing funds available to services


UPDATE: May 2016

Business Planning processes identify financial demands reporting to SRC and Board. Additional resource requirements not yet accounted within Budget plans for 16/17.

UPDATE: June 2016

Ensure discussions with commissioners for 2017/18 funding – update not expected until Dec 2016.


Further update not expected until Dec 2016.

Page 5 of 7



Risk Grade Current


439 HR Alison Ryder

Alison Shelley

Workforce & OD 16 16

Date of Entry onto Risk Register: 26 July 2016 Length of Time on Risk Register: 0-3 months

Risk Description

Inability of Trust to engage staff and provide sufficient opportunity for 'flu vaccination uptake of 75% of clinical frontline staff leading to staff working with patients without immunisation and failure to meet CQUIN requirements.


UPDATE: July 2016

Action Plan:

1. Sign off draft Action Plan.

2. Develop Communication Plan.

3. Identify opportunities for incentivising Champions and staff.

4. Resolve logistical issues around fridges and transportation.

5. Ensure sufficient Champions are available to cover all sites.

6. Identify events where mass vaccinations can be carried out.

7. Book OH clinics.

UPDATE: August 2016

1. Draft Action Plan to Business planning and Action group.

2. Communications to include posters, screen saver, info with payslip, case study video, social media, photos of 'flu champions.

3. Possible prize draw and 'Work Perks' being investigated.

4. Estates identifying whereabouts of any medical fridges. Cool bags and packs to be bought and administrators to be volunteer drivers for vaccine collection.

5. 15 trained staff agreed to be champions. Possible incentives to be used to encourage uptake.

6. Suggestions of staff meetings, lunchtime sessions.

7. All clinics now booked.

Page 6 of 7



Risk Grade Current


449 Estates Eric Beach

Director of Finance

Non-Clinical Risk Group 15

Date of Entry onto Risk Register: 9 August 2016 Length of Time on Risk Register: New Risk

Risk Description

Fire compartmentation defects at Potters Bar Community Hospital have been identified within the first-floor part of the inpatient unit, leading to the possibility of smoke and combustible products spreading through the unit in the event of a fire, resulting in difficulty in safely evacuating or containing patients.


UPDATE: August 2016

L1 fire alarm system, Fire Evacuation Procedures and Staff Training are in place, although Fire Assessment needs updating.

Action created to carry out the necessary repairs to bring the unit up to the required standard.


Risk Grade Current


450 Estates Eric Beach

Director of Finance

Non-Clinical Risk Group 15

Date of Entry onto Risk Register: 9 August 2016 Length of Time on Risk Register: New Risk

Risk Description

Significant fire compartmentation defects at Herts & Essex Hospital were found as part of the Jan16 FRA.

The in-patient unit is now a sub-acute unit with over 25 high risk patients, most of which are unable to get up and out of the building without significant assistance.


UPDATE: August 2016

L1 fire alarm system, Fire Evacuation Procedures and Staff Training are in place, although Fire Assessment needs updating.

Action created to carry out the necessary repairs to bring the unit up to the required standard.

Page 7 of 7


SYNOPSIS for the Trust Board

HIGH LEVEL RISK REGISTER - Operations

August 2016

Position as at: 1 September 2016

Key – Risk Scoring/Grading Low

Medium

High

Risk Scores = Consequences of Risk x Likelihood of Risk Materialising

Breakdown of Risks on the HLRR - Operations

No Change in Score/Grade 11

Ref 61, Ref 139, Ref 142, Ref 254, Ref 323, Ref 332, Ref 358, Ref 381, Ref 400, Ref 427, Ref 433 (these are listed on pages 2-10 of this document)

New Risks 2 Ref 447, Ref 454 (these are listed on pages 14-15)

Escalated 2 Ref 429, Ref 436 (these are listed on pages 10 and 11-12)

De-escalated 2 Ref 332, Ref 427 (these are listed on pages 16-17)

Re-emerging 0

Total Operational High-Level Risks 15

8-12 15-25 1-6

Page 1 of 17


August 2016 Synopsis Table - Operational Risks currently on High-Level Risk Register

Ref Service Lead Executive Lead Committee

Previous Risk

Grade

Current Risk

Grade

Direction of

Change

61 MSK

Physiotherapy & Occ.

Therapy West

RM Director of Operations BUPR 15 15


Risk Description

Staff vacancy and lack of capacity may lead to increased waiting times within 16 weeks resulting in having to offer appointments within 18 weeks and a potential increase in complaints.


Mitigation

1. Recruitment process underway

2. Waiting list analysis and initiatives

3. Workforce planning to be undertaken

4. Appointment of 'Waiting List Champion' to monitor waiting list county-wide, alert clinical service lead of potential breaches and monitor the correct application of the Access Policy

5. Ring fencing of assessment appointments to ensure patients are seen within 18 weeks

UPDATE: July 2016

1. Appointed to 4 wte of 7.32 vacancy. Not yet in post.

2. Senior band 7 staff delivering extra Assessment clinics.

3. Agreed informally with CCG that if recruitment trajectory continues the backlog will be cleared by end Dec 16 ( however, predicted no further turnover and ability to continue to recruit).No official feedback from CCG.

4. 477 breaches

5. Average waits are 9.5 weeks. Longest wait 23 weeks.

UPDATE: August 2016

Position paper to HV CCG: backlog of breaches will be cleared by Oct 16 as staffing position improves due to recruitment. However, this is subject to no further turnover. CCG aware that this is not guaranteed, but this position was considered acceptable at last meeting. However, this will be challenged if the position deteriorates.

Page 2 of 17



Previous Risk

Grade

Current Risk

Grade

Direction of

Change

139 Community

Medical Staffing

SJ Director of Operations BUPR/HGC 15 15

Date of Entry onto Risk Register: 17 April 2014 Length of Time on Risk Register: + 12 months

Risk Description

Insufficient medical staffing capacity to meet demand in West Essex – potential to breach 18 week wait.


Mitigation

1. Optimum allocation of appointment slots (H) 2. Regular staff support from Clinical Director (M) 3. Validation of 18 week data by service (M) 4. Additional fixed-term consultant and speciality doctor capacity. P/T Specialty doctor stated in Jan 16, commenced seeing pts Feb 16 Locum Consultant remains in place as a result of a vacant Consultant post. (H)

UPDATE: July 2016

1. New locum consultant commencing 1.8.16. Speciality doctor post been offered to applicant - awaiting response.

Still waiting for Royal College approval for Clinical Lead post

2. Clinical and administrative validation now in progress

3. Discharge criteria SOP in development

4. Working on referral criteria for GPs. Referral acceptance letter developed - for agreement by commissioners

UPDATE: August 2016

1. Locum consultant(s) in post - booked until November 2016 whilst vacancy and sickness still active

2. Still awaiting approval from Royal College for Clinical Lead role - to ask medical staffing to chase

3. Speciality doctor post being readvertised

4. Validation continues

5. Discharge SOP now being used

6. Referral criteria - meeting arranged with GP

7. Referral acceptance letter now being sent to all families when their referral has been accepted and they are waiting for an appointment

Page 3 of 17



Risk Grade Current


142 Community

Medical Staffing

SF MD HGC 15 15

Date of Entry onto Risk Register: 21 April 2014 Length of Time on Risk Register: + 12 months

Risk Description

Inadequate medical staffing capacity to meet demand in West Herts, leading to inability to attend clinical governance and training for a resulting in potential for deterioration of clinical care and breach in referral to treatment KPIs.


UPDATE: July 2016

1. New set of adverts being put into medical press.

2. HR update – NHS Professionals can recruit medical locums - to discuss with Clinical Director

UPDATE: August 2016

1. Speciality doctor recruited - awaiting pre-employment checks and confirmed start date

2. Locums in place


Risk Grade Current


254 Step 2 KG MD HGC 15 15


Risk Description

A 50% increase in referrals since April 2015 with a National increase in referrals across all tiers of Child and Adolescent Mental Health Services (CAMHS which nationally review only 22% of CYP; with long term sickness management leading extended waiting times for some clients requiring an outreach appointment in their home or school. Resulting in breaching 18 weeks in providing therapeutic intervention, and potential inability to deliver the current contract provision.


UPDATE: June 2016

1. Action: Provided business cases to commissioner regarding ADHD work within Step2 and working with HPFT to improve interim arrangements - not fully funded. Update: C & D modelling demonstrates shortfall within STEP 2 and commissioners are fully aware and accept this information.

2. Action: On-going discussion re resource issues with the commissioner. Update: Reviewed monthly contract

Page 4 of 17

Board 29th September 2016 Attachment D3 performance notice monitoring.

3. Action: Business Team to re-review capacity and demand for whole service - Completed 2015 revision June 2016 in line with improved data and productivity expectations. Update: Basic data produced showing IA and Treatment trajectories. Further refining taking place & to be completed and returned to the commissioner by 11/7/16 as agreed with the commissioner.

4. Action: Initial Assessment and Treatment teams established. Working with Estates to source clinic bases for Treatment. Update: Commissioner wishes to retain outreach appointments and for service to offer outreach/clinic and develop SKYPE options.

6. Action: Advertise for new posts as per additional funding. Update: Recruitment in train.

7. Action: Utilise KOOTH as a new online counselling service commissioned by CAMHS commissioning team. Update: Ongoing

8. Action: Workaround to report on outcome measures. Update: In place.

UPDATE: July 2016

1. No change.

2. Within contract meeting & to raise again/demand management

3. Complete & commissioners appear to accept calculations.

4. Service offering outreach and clinic based services. Exploring Go To meeting as an alternative. Agreed with commissioner that HCT will work with HPFT to explore options to reduce waiting lists working with CAMHS/HCT.

6. Vacant posts out to advert - 8 staff to interview.

7. In place

8. Achieved.

UPDATE: August 2016

1. No change

2. A revised capacity and demand trajectory was provided to commissioners following the improvement notice (August 2016) with revised targets for the service (commissioners have not yet acknowledged the capacity issue). Commissioners want an action plan on managing capacity working in collaboration with CAMHS

3. Document sent on 12th August to manage waiting list with support and partnership

4 Business team completed work and targets for the team agreed and sent to commissioners.

5. Established team using 6 clinic locations from which the team are operating rest of work outreach also go 2 meeting so providing some of services online

6. Recruitment of 2 band 6 in process have had posts offered further advert on line currently for a further 2 band 7 post

7. Service signposting to KOOTH reporting by manual count to commissioners in monthly meetings

8. This is completed and was reported at the contract

9. This is identified as an action team leader scoping how this could happen and costs involved.


Previous Risk

Grade

Current Risk

Grade

Direction of

Change

323 Community Hospitals

West TR Director of

Operations SRC 16 16

Date of Entry onto Risk Register: 19 June 2015 Length of Time on Risk Register: + 12 months

Page 5 of 17

Board 29th September 2016 Attachment D3 Risk Description

Increasing reliance on extra staff for supervision of DOLs resulting in overspends, cancellation of outpatient appointments and unsafe staffing levels impacting on patient care.


Mitigation: Process to reconcile NHSP data and link to patient level data for invoicing and assurance purposes.. UPDATE: June 2016 1. Look at possibility of recruiting HCAs on a peripatetic basis to offset the need to go to NHSP/agency. Finance team undertaking a deep dive of the nursing overspend by 10/6/16. 2. 2nd workshop scheduled for Tuesday 5th July to clarify use of 1:1 Care risk assessment is appropriate for our community hospital 3. Trialled use of tool in 3 community hospitals to date 4. Options paper to be presented to the Exec team on 13th July UPDATE: July 2016 Additional controls:

• Weekly finance meetings with Finance Business partner, Deputy Director of Finance, Clinical Services manager, PA to CSM, Health Roster project specialist and General Manager.

• Daily analysis of e-rosters with close monitoring of spend daily and weekly. UPDATE: August 2016 Weekly finance meetings with Finance Business partner, Deputy Director of Finance, Clinical Services manager, PA to CSM, Health Roster project specialist and General manager. Daily analysis of e-rosters with close monitoring of spend daily and weekly.

Page 6 of 17



Previous Risk

Grade

Current Risk

Grade

Direction of

Change

358 MSK

CROPS (Watford and

Dacorum)

GP Service Manager

Director of Operations Executive 15 15

Date of Entry onto Risk Register: 30 October 2015 Length of Time on Risk Register: 9-12 months

Risk Description

Staff vacancy, maternity leave and long term sick leave resulting in a lack of capacity. May lead to an increased wait of 12 weeks or more.


UPDATE: June 2016

1. Participating in stakeholder events and reviewing with the CCG proposed SLA against which potential providers will be tendered.

2. Longest wait ins 20.3 weeks: equates to 1 patient. Average wait is 6 weeks.

April, average waits were 6.7 weeks.

3. No change to available workforce: 6.94 wte clinical posts, vacancy 1.36 wte, mat leave 0.5 wte. Total reduction in clinical workforce equates to 21%. Posts are in recruitment pipeline.

UPDATE: July 2016

1. HV CCG going out to procurement in Sept 16.CROPS service is within new specification. No response to Business case anticipated.

2. Longest wait 20 weeks (1 patient) Average wait: 6.1 weeks. No progress from June's position. 1.52 wte vacancy in recruitment pipeline.1.0 wte LTS. Operating on 70.56% of established workforce.

UPDATE: August 2016

1-2. Redesign workshop scheduled as part of MSK tender

3. Average waiting time 6.5 weeks. Vacancy 1.75.Operating on 78.7 % of workforce. Out to recruitment.

Page 7 of 17



Previous Risk

Grade

Current Risk

Grade

Direction of

Change

381 Community Nursing & Integrated

Teams West

Sue Simmonds Dennis Enright

Business Unit Performance

Review;

Healthcare Governance Committee;

Safeguarding Committee

15 15

Date of Entry onto Risk Register: 3 February 2016 Length of Time on Risk Register: 6-9 months

Risk Description

High vacancy rate, maternity leave rate and difficulty recruiting within the Dacorum ICT team. 2 staff also on long-term sick.


UPDATE: June 2016

1. To utilise agency cover if needed

2. To implement clinician of the day

3. To offer overtime to staff

4. Establish a working group to look into solutions surrounding staffing issues

UPDATE: July 2016

1. Agency cover procured where available however less availability over summer holidays.

2. Clinician of the day in place to support staff and also undertaking urgent clinical visits where possible.

3. All staff have been offered overtime and a couple of HCAs have had their hours extended on a substantive basis to help support qualified staff (skill mixed from band 5 vacancy).

4. 3 Band 6 RNs have been interviewed and offered posts - awaiting pre-employment checks. Advert out for band 2 phlebotomists to support the team. 1 RN returning from ML in September. 1 community matron starting in August. 1 SPC nurse starting in September.

Currently band 5 and 6 staff are well below safe minimum staffing so concerns continue, may be able to de-escalate in September.

UPDATE: August 2016

1. Agency cover over summer holidays a concern as had an indication from our bank and agency staff that they don’t want to work over the summer and agency cap is having an effect on availability of some nurses who are leaving the trust to work elsewhere.

2. Clinician of the day (CoTD) implemented and working well.

3. Overtime given to staff who are able to do so. Some on short term increased hours. Band 7 team leads are spending increased time in clinical practice supporting the teams,

4. ICT staffing group has been established to look at short, medium and long term solutions to staffing issues .Rapid response has been commissioned and will be rolled out in the Autumn. In mitigation we have increased the working hours of 3 of our HCAs to help support the team and are planning to go out to advert for more band 3's and 4's.

Page 8 of 17



Previous Risk

Grade

Current Risk

Grade

Direction of

Change

400 Skin Health Service LC Director of Operations

BUPR/ Executive 15 15

Date of Entry onto Risk Register: 2 March 2016 Length of Time on Risk Register: 6-9 months

Risk Description

Skin Health Service is now a commissioning risk for HCT due to the new business plan being submitted by ENHT and a separate pilot being undertaken with Royal Free Hospital and LLV.


Mitigation: 1. Raise concerns at the next Task and Finish meeting in April 2016. 2. Raise with HCT contracts manager that there are no contract in place for hire of phototherapy room & Equipment.. 3. Raise with HCT contracts manager that there is no signed SLA with ENHT for the 1 PA Clinical lead. 4. To discuss with Estates Manager the fact that there are no contracts for clinic room rental in GP surgeries. 5. Raise with HCT contracts manager that there are no signed contracts in place for subcontracted clinicians. UPDATE: July 2016 1. No date for next Task and Finish group meeting. 2. Contracts manager aware. 3. Contracts manager aware-Service manager to make contact with Divisional director in ENHT to start the process again of engagement and communicate this to contracts manager to take forward. 4. Kingsway scoping meeting held 18.04.16. Service requirements sent to Transformation team. Awaiting progress with building works to allow the building usage to commence. 5. Meeting held with contracts manager on 21.04.16 to agree content and identify queries. Plan for Service Manager and Contracts manager to meet with clinicians individually to agree and sign contracts through May, has not been achieved in June also, however the contracts were discussed at the Clinical/Operational meeting held on 30.06.2016 and Clinicians asked for comments on the draft contract. UPDATE: August 2016 1. Meeting held with CCG on 15.08.2016. Concerns raised re; ENHT plans and LLV pilot. Meeting to be arranged with ENHT and HCT with CCG present to discuss possible future models and closer working relationships. 2. Additional Clinical lead PA required to maintain current service level and to develop service further, especially if all referrals are sent to Skin Health as a central triaging service. Referrals appear to be increasing already with impact on a depleted admin team. 3. CCG to propose meeting dates to ENHT. 4. Kingsway scoping meeting held 18.04.16. Service requirements sent to Transformation team. Awaiting progress with building works to allow the building usage to commence. 5. No comments received from clinicians re the contracts. Service manager has advised contracts manager to proceed with making arrangements to meet with individual clinicians to agree and sign new contracts.

Page 9 of 17



Previous Risk

Grade

Current Risk

Grade

Direction of

Change

429 Community Hospitals West

Trudy Reynolds

Director of Operations

Board/BUPR/ Executive

12 16

Date of Entry onto Risk Register: 18 May 2016 Length of Time on Risk Register: 3-6 months

Risk Description

Risk that absence of consistent comprehensive SLA in place to secure medical staffing for community hospitals will lead to potential insufficient medical cover for community hospitals which has the potential for adversely affect patient safety.


Mitigation: 1a Review and sign the SLA for consultant cover 1b Negotiate with other providers of medical cover to provide a robust SLA UPDATE: August 2016 1a Held a meeting with WHHT to review the current medical provision and plan provision going forward. Further meeting scheduled for September 2016. 1b General Manager met with another suitable provider to discuss our requirements.


Risk Grade Current


433 Family Nurse Partnership KG

Operations Director

15 15

Date of Entry onto Risk Register: 5 June 2016 Length of Time on Risk Register: 0-3 months

Risk Description

De-commissioning of FNP across Hertfordshire leading to the transfer of over 116 families to the HV service between June and end September 2016.

Resulting in raised operational management risk within the Stevenage, Welwyn & Hatfield, South Oxhey and Hemel Health Visiting Teams to support rapid influx of higher vulnerability families.

Also resulting in a lesser offer to families, fewer intervention contacts as model de-commissioned and no longer funded by PH.


Page 10 of 17

Board 29th September 2016 Attachment D3 UPDATE: July 2016

Actions & (Progress):

1. Each client is risk assessed on an individual basis, handover to HV & care plan agreed with HV, signed off by FN Supervisor. (In train - 23 clients handed over so far with plans signed off.)

2. HV will work with client to introduce to Children's Centre.(Formal part of FN handover to HV pathway) 3. High risk FN client will remain on Safeguarding plan or be escalated in light of removal of service therefore reduced contact with client and baby. Emerging risks will be escalated in line with HSCB policies.( Escalation:- 4 children now going through PLO, 1 child removed and 1 CIN due to lack of FNP involvement and lack of containment due to withdrawal of the service.)

4. 3 antenatal contacts for pregnant young parents (under 21). (LMS to provide assurance that this is happening. Commissioners to confirm if this is expected in every case as routine.)

5. Team risk assessment to be completed by LM/Service Manager (Risk assessment awaited.)

6. HV service prioritisation to be agreed with the commissioner. (Risk assessment in draft for HV changes for agreement 5/8/16.)

7. FNP clients to be offered additional support through Multi-agency assessment panels. Consent required for CAF. (Multi-agency support panels held in East and North only due to FN clients consenting to information sharing and CAF processes.)

8. FNP clients names to be shared with HCT named nurse & Safeguarding supervisors; and HCC - IES system enabling MASH/Social Care and TYS access for prompt action should families be escalated in future.(To be confirmed that this is now complete.)

UPDATE: August 2016

Actions & (Progress):

1. On Track - 63 clients handed over so far with plans signed off.

2. Formal part of FN handover to HV pathway.

3. Escalation: 4 children now going through PLO, 1 child removed and 1 CIN due to lack of FNP involvement and lack of containment due to withdrawal of the service.

4. LMS confirm this is happening if first assessment at AN evidences young person requires follow up.Not insisting on 3 visits if not required. Commissioners asked to confirm if this is expected in every case as routine and to confirm the age of young parents as maybe under 20.

5. Risk assessment available for final sign off before sending to commissioners.

6. Risk assessment in draft for HV CUS changes for agreement 5/8/16.Commissioners have only agreed 2-2 1/2 yr group review pilot but not 6-8 wk MMH proposal.

7. Multi- agency support panels held in East and North only due to FN clients consenting to information sharing and CAF processes.

8. This is now complete August 16. Next FNP board meeting end of September for final completion of action tracker.


Risk Grade Current


436

Community Nursing & Integrated

Teams East & North

Mary Ann

Gregory

Operations Director


Review

12 15


Page 11 of 17

Board 29th September 2016 Attachment D3 Risk Description

Shortfall of therapy staff due to vacancies leading to potential delay in visits, resulting in reduction of quality of patient experience and loss of reputation.


UPDATE: August 2016

Actions:

1.To regularly communicate with Therapy Service manager re rotations into posts

2.To discuss with HR regarding recruitment drives/ advertising

3. To ensure staff resources are used effectively across Stevenage North Herts and Royston considering commissioned work demands.

Progress:

Current vacancy Physio/OT

Band 6 P/T Stevenage 1.6 wte Decision has been made to recruit to TI 1wte as many adverts have been unsuccessful in recruiting physiotherapist. Currently using agency above price cap to ensure commissioned work is carried out in Quantum units. Awaiting exec sign off.

Band 6 P/T R/R 1wte working notice period internal promotion, due to transfer September 16. Recruited to post waiting start date, may be able to start as agency if checks not cleared.

Band 7 P/T R/ R 0. 6 wte on maternity leave since mid-August 2016 (finance have signed off as temp contract for year to cover at band 6 (advertisement out)

Band 5 OT 1WTE rotation not filled ----October next rotation will be covered affects ICT waiting list

Locality Manager working with HR and quality Leads to consider skill mix.

BAND 6 OT 0.5wte Recruitment in process for commissioned work in Woodlands View post offered to applicant in recruitment stage. Using agency to backfill to ensure commissioned work is completed DTA model.


Risk Grade Current


438 Specialist Palliative

Care

Dr Carol Scholes

Operations Director


Review, Healthcare

Governance Committee

16 16


Risk Description

Reduction in medical staffing levels due to recent retirement and numerous unsuccessful recruitment attempts leading to the inability to deliver high quality specialist palliative medical care to patients.


Page 12 of 17


UPDATE: July 2016

Actions & (Progress)

1. Discussions with local specialist providers to ensure shared medical cover, safe patient management and reduction in duplication.(All local providers aware of current situation)

2. Forward thinking workforce plan - including medical recruitment either substantive or locum. (Clinical lead & Interim Service Manager in discussions with Resourcing Team regarding recruitment plans)

3. Robust internal SPC medical management escalation plan (Clinical Lead alongside Clinical Quality Leads have communicated with all SPC CNSs how and where to access medical advice and support if required)

4. Safe and effective support and supervision for medical training placements within SPC (Clinical Lead ensured safe arrangements in place and medical trainee fully aware of how to access advice, assistance and support if required.) UPDATE: August 2016

1. Due to retirement of Associate Specialist doctor within July, capacity to perform

2. Investigating the potential of recruitment of an urgent agency locum Consultant for Palliative Medicine

3. Discussed at SPC Turnaround meeting, HR Business Partner aware

4. Clinical Lead to continue to supervise and provide medical support for training registrar alongside her current secondment into Corporate Medical Team.


Risk Grade Current


443 Child Health & Information

Kay Gilmour

Operations Director


Review 16 16


Risk Description

Lack of P & I functionality to provide GP registrations and deductions as expected to CHIS. This leads to the HV service relying on HV liaison with each GP Practice and each GP Practice providing accurate transfer in data for children.


UPDATE: July 2016

1. P & I - KEN WARREN to work with external company to IUVO/HSCIC to resolve issue ASAP. Partially resolved but work needs to be followed up and completed.

UPDATE: August 2016

1. P & I are requested to prioritise this & escalate barriers to implementation.

Page 13 of 17



Risk Grade Current


447

Positive Behaviour,

Autism, Learning

Disability and Mental Health

Service

Kay Gilmour

Operations Director


Review 16

Date of Entry onto Risk Register: 9 August 2016 Length of Time on Risk Register: New risk

Risk Description

A number of operational issues (high referral rate, impact of staff resignations, difficulty in recruitment and insufficient Estate capacity to see CYP in health settings) are leading to a failure to meet 14 and 28-day targets, increased waiting times, low staff morale and concerns from the commissioners.


Actions:

1a. Recruitment on-going for substantive vacancies to include attendance at recruitment fayres, etc.

1b. Recruitment Lead contacting agencies on a weekly basis to source locum cover

1c. Staff offered additional hours

1d On-going assessment of skill set required to deliver service

2a. Regular meetings taking place to review estate requirement

2b. Estates manager mapping estates availability county wide

2c. Sourcing alternative venues where possible

3a. Service model reviewed

3b. Discussions taking place with commissioners re review of pathways

UPDATE: August 2016

1a Attending Dublin recruitment Fayre Sep 16

1b. No additional locum cover sourced to date

1c. Staff continuing to do additional hours

1d. Included as part of the consultation

2a. Meetings continue

2b. Mapping continues

2c. Bungalow at SACC being used for clinical and admin space on a temporary basis

3a. Consultation currently underway

3b. Regular meetings with commissioners taking place

Page 14 of 17



Risk Grade Current


454 MSK Physio & OT West

Gillian Porter

Operations Director


Review 16

Date of Entry onto Risk Register: 31 August 2016 Length of Time on Risk Register: New risk

Risk Description

HVCCG procurement of MSK services in West Herts may lead to a potential decommissioning of the HCT MSK iCROPS, Chronic Fatigue & Pain Management services in Herts Valley resulting in loss of business, with subsequent impact on HCT finance, business reputation and loss of critical mass of AHP staff potentially impacting on recruitment and retention in other HCT services.


UPDATE: August 2016

No specific actions defined but following controls and assurances:

1. Seeking alliance with other providers to ensure the ability to deliver the specification on its totality with the aim of achieving prime provider status resulting in continuation of business.

2. Project team overseeing tendering process and service redesign in conjunction with Acute, Federation and AQPs to meet requirements of service specification.

3. WHHT, federation Chair & AQPs have agreed in principle to partner HCT rather than compete for business (not fully confirmed).

Page 15 of 17


August 2016 Synopsis Table - Operational Risks de-escalated from High-Level Risk

Register


Previous Risk

Grade

Current Risk

Grade

Direction of

Change

332 HMP The

Mount (H&RTS)

DE Director of Operations BUPR 15 9

Date of Entry onto Risk Register: 7 July 2015 Length of Time on Risk Register: + 12 months

Risk Description

Monetary and reputational impact on HCT delivering health services to HMP The Mount.


UPDATE: August 2016

Long term locum interested in filling post on a permanent basis. Awaiting contract and costing details from GP. Clinic rotas covered until end of Aug 16. Costing proposal forwarded to commercial department for review. Await outcome. Online recruitment through NHS Jobs and BMJ resulted in 0 applicants.

Rationale for de-escalation: likelihood of risk is not of a sufficient level to warrant scoring 5, so has been reduced to a 3.


Risk Grade Current


427 Community Nursing & Integrated

Teams West

Jamie Parsons-Haines

Operations Director


Review 16 12

Date of Entry onto Risk Register: 18 May 2016 Length of Time on Risk Register: 3-6 months

Risk Description

On-going staffing vacancies and service changes i.e. VW decommissioning, Team lead and Service manager changes leading to:

1. Gaps and limited experience at manager and leader level

2. Overspending monthly budget on high proportion of agency staff historically

3. Lack of assurance of the teams following clinical and administration processes


Page 16 of 17

Board 29th September 2016 Attachment D3 UPDATE: June 2016

1. Jamie Parsons-Haines appointed substantive LM.

2. CQL nurse reviewing caseloads.

3. Matrons' interviews booked for 14.7.16.

4. eRosters reviewed 2/12 prospectively.

5. Staffing issues booked for discussion at BUPR on 30.6.16.

6. Ongoing sharing of agency, managers, staff, cross-training - staff being equitably deployed across localities, with daily co-ordination at LM / TM level.

7. RAG raised to 16-High due to worsening staffing at Elstree ICT, despite mitigations

UPDATE: July 2016

1. Hertsmere Plan created, and in action.

2. Fortnightly reporting of Plan's progress, By Deputy General Manager, to Executive.

Further recruitment 'back of bus' campaign now in place in Borehamwood

UPDATE: August 2016

Additional controls:

1. Regular meetings with CCG locality Officer and Chair GP.

2. Monthly meetings with GP Practice managers and monthly meeting with CCG now set up.

Page 17 of 17

Board 29th September 2016 Attachment E1


CHIEF EXECUTIVE’S REPORT

September 2016 1. 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 The Sustainability and Transformation Plan (STP) has become a predominant issue for the Executive team. The work for Hertfordshire and West Essex is being led by Tom Cahill from HPFT. I am leading the workstream on Primary and Community Services for the footprint. The scale of the task is very substantial, with efficiencies of £380m to achieve on a spend of around £2.4 billion and a further £80m gap to bridge on the Hertfordshire budget for social care. The scale of the task, combined with a current absence of money to pump prime change represents the biggest risk to all health and social care organisations. Yet there is a real opportunity to develop the model of health and social care in the community that we have described in our strategy, working closely with other providers.

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 maintaining and improving health and wellbeing include:

• The service model for the Primary and Community Services workstream in the STP closely reflects the HCT strategy. It provides a framework for all organisations to work together to enhance the impact of primary and community services.

• The full formal working arrangements for this workstream have yet to be established but it is likely they will build on existing structures, such as the Accountable Care Partnership in West Essex and the Integrated Care Programme Boards in Hertfordshire.

1


• Within the Trust we are progressing in the implementation of the strategy and have completed the assessment of the maturity matrices for adults and children which relate to the capability of the teams to deliver our strategy.

Risks The risks arising in this work include:

• There are many substantial risks in the STP, including the scale of the task that has to be achieved; the need to have a very effective programme of mobilisation of front line staff and managers and ensuring that we have effective leadership at different levels of delivery.

• The involvement of general practice in the changes is central. To date this has been limited and there need to be effective mechanisms to have the GP voice central in the changes

• The self-assessment of the maturity matrices has identified that there needs to be a deeper appreciation of what the strategy means at a team level

Actions The following actions are being taken to address the areas of risk:

• The approach that will be taken to the implementation of changes to deliver the STP will be agreed in early October, including how GPs will be fully engaged

• In HCT an engagement process will be put in place to talk with teams about how they can effectively implement the Trust’s strategy

Objective 2 The main areas of focus for the delivery of safe and effective care are as follows:

• The CQC has provided a draft report following their re-inspection visit and a response on factual accuracy has been submitted. It is expected that the final report will be received in the first half of October

• There are comparable under and overspends in the integrated community teams and in the bed base. The overspend in beds is very strongly aligned to the use of additional staff to provide 1:1 care for people who are confused. The understaffing of the community teams is a source of concern, in terms of capacity, safety and effectiveness. The Executive team have agreed that this situation needs to be addressed, whilst retaining a close focus on the safety of patients in the bed base

• Negotiations about how we respond appropriately to reductions in staffing in health visiting continue with Herts County Council

Risks The risks in this area include:

2


• The CQC not revising our rating to “good” if we have not fully addressed all of the areas they identified

• The reduction in overspend in the bed base will be achieved by decreasing the additional staffing that have been used. This does create a potential additional risk to safety. The increase in staffing in the community teams will enhance safety and effectiveness

Actions The following actions are being taken to reduce the risks:

• We have responded to the CQC draft report. • The overall impact of the additional staffing in the beds has not had the

impact on falls that might be expected. A mechanism to monitor staffing in the bed base has been put in place, along with tight monitoring of the safety issues. Both will be reported to the Executive team on a regular basis. Staffing levels will be formally reviewed and presented to the Board to determine whether an adjustment should be made to existing ratios to support sound financial management

• Recruitment to the community teams has been difficult for nurses and therapists. Consequently we will seek to recruit other groups of staff who can supplement the teams and take on supervised responsibility for tasks currently performed by qualified staff

Objective 3 The following areas are significant in the development of community services:

• The Trust has gone through the first stage of the bid for integrated children’s services in West Essex

• We were successful in a bid to provide the child health administration function to Hertfordshire, Bedfordshire and Milton Keynes

• MSK will be put out to tender in west Hertfordshire


• The West Essex bid is drawing heavily on management time in children’s services at a time when we need to pursue integration in Hertfordshire

• MSK will be a popular service to bid for and the competition will be very high


• Work on integration of children’s services is being taken forward in the Trust and an area will be selected. We will work closely with Children’s Centres, HPFT and local voluntary organisations to develop a local model

• Preparations for the MSK bid are underway. This will involve working with West Herts Trust and local GPs to create an integrated service

3


Objective 4 The following areas are of note in ensuring the efficient use of resources:

• The Trust is just ahead of plan on delivering its year-end financial position

• Delivering efficiencies is becoming more difficult without some fundamental change in the way in which we work in different services as is demonstrated in the shortfall on efficiencies from service change

• The re-balancing between overspends on the bed base and underspends on community teams is being addressed to ensure appropriate resources are available in both areas


• A number of financial risks to the Trust’s outturn have been identified. Significant amongst these is the withdrawal by HVCCG of funding of £1.6m a year from our bed base that has covered our ability to sustain the number of beds which they commission. There are further risks in relation to achievement of CQUINs; payment of transformation funds linked to performance in our 18 week standard for community paediatrics; under-recovery of non-contract income

• The risks on staffing adjustments are referred to above


• The Trust is seeking to sustain bed capacity at least until March, but requires support from the wider health system to do so. If this is not forthcoming there will be a need to reduce bed capacity

• Delivery on CQUINs is being tightly monitored although there is already some slippage on the diabetes requirements

• We continue to work with the CCG to obtain resources to meet the 18 week standard for community paediatrics in West Hertfordshire. We are also working with the paediatricians to see if alternative solutions can be found

Objective 5 The following are being undertaken in respect of the Trust’s capability and capacity:

• A coherent approach to staff development will be implemented during the course of this year, with a requirement for different staff to ensure they pursue clear personal development plans for their clinical and/or managerial skills

• There is a recognition that we will have a gap in qualified nurses and therapists however effective we are in recruitment so there is a shift towards finding and developing other skills that can be used appropriately

4


• To support the delivery of the strategy, and to use management and clinical skills effectively, we are proposing a strategic alliance with Herts Partnership Foundation Trust (HPFT)


• Releasing time for staff development has been an issue to date and will be one that needs to be overcome to support a wide-ranging development programme

• Recruiting to new posts and developing people’s skills will be demanding of time and resources, although it will enhance capacity in key areas for the future

• Working with HPFT presents many opportunities. The risks appear great if we do not work closely as we would find it increasingly difficult to deliver our strategy


• The approach to staff development will be agreed throughout the Trust • Recruitment has been a major focus for the Trust for some time and we

will build on that work and our learning from it to support the proposed work

• The message about the nature of the partnership needs to be communicated clearly within the Trust so that staff understand how we intend it to work. This will ensure that it can be applied effectively at all levels of the Trust

6. The External Environment

A Partnership with HPFT has been proposed between the organisations. Its primary intention is to make us more able to deliver effective services for the population of Hertfordshire. Combining our resources and expertise, working closely with GP Federations, social care and local hospitals, we will be more able to deliver the substantial changes that are envisaged in the STP. A short paper is attached to identify the key elements of the partnership. (E1i). Sustainability and Transformation Plans (STP) – have to be re-submitted to the central NHS bodies in mid-October. The plan for Hertfordshire and West Essex will reflect the priorities for prevention; primary and community services and acute services. There has been national media attention on the plans and guidance has been issued recently on the approach to engaging local communities in the development of the plans. The STP will continue to remain central to the planning and delivery of services in the coming years. The local financial position – this appears to be tightening with funding being reduced for HCT in west Hertfordshire and ENCCG starting to consider

5


the effectiveness of schemes in which they have invested, such as rapid response. Local acute Trusts have had an uplift in funding and have seen activity rise again but there remains a significant issue for them and for the wider health system about resources not being available to develop alternatives to hospital provision. A Multi-Speciality Community Provider framework – has been produced describing some of the identified success factors in creating integrated service provision in primary and community services. It sets out different organisational models to achieve greater integration. We have drawn on this report in framing the STP approach to Primary and Community Services. The link to the full report is below https://www.england.nhs.uk/wp-content/uploads/2016/07/mcp-care-model-frmwrk.pdf The King’s Fund report on District Nursing identifies the attrition on this service that has occurred over the last, with substantial decreases in workforce whilst activity is increasing. This is compromising the quality of care and impacting adversely on the workforce. Most importantly, this is having an impact on our ability to maintain people in the community. The report makes some recommendations about http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/quality_district_nursing_aug_2016.pdf The King’s Fund Report on Social Care also describes a vital community service being eroded owing to budget cuts in local authorities. It identifies nationally a 26% reduction in provision, pressure on the social care market, workforce shortages, an impact on discharges from acute and community hospitals. The link to the full report is below. http://www.kingsfund.org.uk/publications/social-care-older-people The GP Five Year Forward view was published earlier in the year and describes the plans for general practice, including the investment that will be made in that period. It actually describes much about primary care in the wider sense, including those services provided by HCT. As in other areas the workforce is central to the issues in the document, with a recognised need to broaden the base of the professionals working in general practice. The link to the full report is below. https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

David Law Chief Executive September 2016

6

https://www.england.nhs.uk/wp-content/uploads/2016/07/mcp-care-model-frmwrk.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/07/mcp-care-model-frmwrk.pdf

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/quality_district_nursing_aug_2016.pdf

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/quality_district_nursing_aug_2016.pdf

http://www.kingsfund.org.uk/publications/social-care-older-people

https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

Attachment E1 i

Hertfordshire Community NHS Trust and

Hertfordshire Partnership University NHS Foundation Trust

Proposal for a Strategic Alliance

1. Introduction

This proposal sets out the intention for Hertfordshire Community NHS Trust (HCT) and Hertfordshire Partnership University NHS Foundation Trust (HPFT) to enter into a strategic alliance. This paper sets out initial thinking on: • The scope and principles of the proposed alliance • Priorities and the ambitions for the proposed alliance over the next 18

months. • Governance considerations The paper was developed following a number of meetings by executive representatives of both organisations. These meetings immediately identified synergies and opportunities that are set out in this paper. It was also clear from these initial discussions that the climate has changed and that there is a clear expectation (and urgency) from the wider system that individual providers in general, and HCT and HPFT specifically, start working much more closely together. The paper concludes with recommendations and proposed next steps.

2. The case for a Strategic Alliance between HCT and HPFT

Successful alliances are built on shared understood aims, common values and trust. As a first step we therefore sought to clarify why we believed that an alliance between HCT and HPFT was important, and how it aligns with each organisation’s ambitions as well as wider stakeholder expectations. Shared Organisational Ambitions and Direction On review of each Trust’s visions and strategic objectives there is a strong sense of shared ambition and direction which provides a good platform for an alliance that could be mutually beneficial: • There is strong alignment between HCT’s and HPFT’s stated ambitions

(Vision statement, Strategic Objectives) focused around high quality personalised care close to home.

1

Attachment E1 i

• There is also a shared view on the key enablers and approach that will allow these ambitions to be realised e.g. engaged workforce, use of information, ways of working, integration and partnership working

• The thinking and expected behaviours that sit behind each organisation’s values are very similar o HCT: Care, Respect, Quality, Confidence, Improve o HPFT: Welcoming, Kind, Positive, Respectful, Professional

There is significant overlap between the perceived risks facing each organisation e.g. workforce (recruitment and retention), financial pressures, changing external environment (STP, ambitions of other providers) but together both organisations are key to ensuring that the STP ambitions of reducing acute demand and reducing the financial risks in the footprint are progressed. Benefits of an Alliance There is a shared view about why we are proposing an alliance between HCT and HPFT and the benefits we would hope to achieve through this for patients/service users, the local communities we serve together, our individual organisations as well as commissioners and the wider system. • Service improvement: The opportunity to provide more joined up,

holistic, local care that better meets both people’s physical and mental health needs. Our joint approach to service improvement will be a key deliverable for the STP workstream on primary and community care

• Cost Effectiveness: Reducing duplication both at a front line and back office/ corporate support services level. Our joint approach to back office consolidation will be a key deliverable to the STP

• Capability and Capacity: Leverage complementary skills, shared building of capabilities required by both organisations (Learning Alliance) and increased bandwidth for managing external relationships

• External Positioning & Voice: Stronger unified voice for community physical and mental health services in responding to and driving new models of care

As already noted there is also a strong sense that if we don’t begin to work more closely and effectively together of our own volition and on our own terms then the system will find ways of forcing this to happen in order to deliver on the ambitions of the STP and other pressing national priorities such as back office consolidation. A clear early signal of intent from both organisations quickly followed up by visible action would go a long way towards mitigating this risk.

2

Attachment E1 i

3. Scope and Principles

It is important for us to be clear about what the alliance should include and what it should not include, aligned to the agreed aims. Both organisations would retain their separate identities but agree a set of principles about how we would work together in general, as well as setting out key outcomes for the four proposed aims set out above. There are a large number of potential opportunities for joint working that should be explored in determining the final agreed scope of the proposed alliance which we would expect to evolve over time. These areas include: Service Improvement and Service Delivery Synergies • Single Point of Access • Children & Young People including CAMHS • Older Adults including dementia • Improved physical health for people with a serious mental illness • Mental wellbeing for people with a long term physical condition • Acute liaison and discharge functions Cost Effectiveness and Capacity/Capability Building through Back Office/ Support Service Synergies • HR and OD • Finance • Estates • IM&T • Learning & Development • Procurement External Positioning and Voice • Relationships and collaborative working with GP Federations • Positioning and voice within STP • Engagement with local communities • Building exec and management team capacity though co-

representation Taken together these areas offer huge potential to make significant positive difference to patients, and local communities across Hertfordshire as well as the sustainability of HCT, HPFT and the wider system.

3

Attachment E1 i

Ultimately the expectation is that the scope of the alliance could increase over time to include each of the areas above as appropriate to deliver on the agreed aims. It is envisaged that this would be based on how (as an Alliance) we make use of existing resources across the two organisations, rather than any net investment into the alliance by either party.

4. Governance Considerations

Clear governance arrangements will be critical for the success of the Alliance and in setting a clear framework within which staff at a local level can be empowered to work together to develop and implement new ways of joint working. Whilst further detailed work is required to work up the governance model it is envisage that the Alliance will be overseen by a non-executive led Board with Director level representatives from both organisations.

5. Recommendations and Next Steps

The HCT and HPFT Boards are asked to publically endorse the principle of entering into a strategic alliance as set out above. A communication plan should be urgently developed to support the successful development of the alliance. It is recommended that a Memorandum of Understanding is developed including clarifying scope and governance for sign off in December Board meetings. This may require some third party support and advice. In parallel it is recommended that a delivery plan is developed setting out key objectives and milestones for each of the priority areas over the next 12 -18 months.

Authors of Paper:

Clare Hawkins & Iain Eaves Director of Quality & Governance / Executive Director - Chief Nurse Strategy & Improvement Hertfordshire Community NHS Trust Hertfordshire Partnership University

NHS Foundation Trust September 2016

4



Report from the Director of Finance

29th September 2016 1.0 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.


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. The STP and the changes to the contract round for 2017/18 and 2018/19 are consuming considerable input within the Directorate. Tendering and mobilisation are also increasing demands on a very small number of people.

5.0 Finance 5.1 Update

5.1.1 Month 5 saw the Trust post an in month surplus of £849k which is £871k favourable of plan. The Trust’s year to date surplus is £666k which is £913k ahead of plan. The main reasons for these variances are the receipt of the Sustainability and Transformation Funding ahead of the budget phasing and the release of the Trusts contingent reserve 5.1.2 By the end of Month 5, the Trust had delivered £1,986K of Cost

Improvement Programme (CIP) savings. £1,250k of this being delivered re-currently. Month 5 CIP delivery is £75k behind the in-month plan, with a

year to date shortfall of £39K. 5.1.3 The Trust are forecasting to achieve the NHS Improvement stretch target position of £1,530k.

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5.1.4 The total capital spend at the end of month 5 was £832k, which is £283k underspent against the plan. The Trust is forecasting achieving its Capital Resource Limit. 5.1.5 The Trust has a strong cash position at the end of month 5, being £16,211k against a plan of £14,156k. 5.1.6 The Trust has tendered for its External Audit services and decisions around an appointment will be made during September. 6.0 Estates Estate Development Plan Update

Location Site Status Completion Comments St Albans Sandridge

Business Park Clinical Admin Hub

Main contractor on-site

14/10/16 Staff relocations commence 2/11/16

Abbots Langley

Jacketsfield Surplus estate placed on government surplus register. Negotiations with Scope progressing

2017 Receipt planned for 2017/18 spend

Hemel Hempstead

Health & Wellbeing Centre

Enabling works commenced. Main contractor on-site November 16

July 2017 Design approved. Contractors shortlisted

Bishops Stortford

Herts & Essex Hospital

Proposal to rationalise occupancy to be discussed with CCG

2017 CCG applied for funding for Primary Care development

Cheshunt Cheshunt Community Hospital

Discussions with RFH progressing. LLV project group may also influence site occupancy

2017 Request for Primary Care space received from LLV project group

Harpenden Harpenden Memorial Hospital

Progressing with OBC planned for December 2016

2019 Local engagement events on-going

Borehamwood Elstree Clinic Workshop to agree shortlist of options for future delivery due on 23rd September 2016

2019

Stevenage Health & Wellbeing Centre

Discussions progressing with Stevenage B.C. Danestrete currently being commercially valued

2020 SBC funding health planning exercise

Hoddesdon Hoddesdon Principles for site 2020

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Health Centre

disposal and redevelopment to be discussed by Broxbourne .B.C, Herts Constabulary and HCT on 4/10/16

7.0 Information Governance Information Governance Toolkit 7.1 Information Governance Toolkit

The Information Governance Toolkit currently stands at a baseline of 66%. The target score for final submission in March 2017 is 90%.

7.2 Incident Reporting

During the previous quarter there was concern that the number of incidents had increased from 48 to 53. This figure has now reduced significantly to 39 IG incidents being reported during quarter two. Most incidents continue to be the result of a staff lack of attention to detail and failures to fully follow due process. This continues to be monitored and examined further by the Head of Information Governance in co-operation with the relevant service leads and now forms a key part of induction and refresher Information Governance training. The serious incident that occurred in January 2016 and which was reported to the ICO has now been resolved with no further action being taken against the Trust.

7.3 Freedom of Information Requests The Trusts compliance level is currently at 100% within the statutory 20 working days. 7.4 Requests for Information (Subject Access Requests)

The Trust stands at 64% compliance within statutory timescales. This is a welcome increase from the 58% achieved in the previous quarter. The Head of Information Governance will continue to monitor the process to ensure the trend towards improvement continues.

7.5 Complaints

Three complaints have been received via the Information Commissioner’s Office (ICO) in the year to date relating to the Data Protection Act. In two cases the ICO was satisfied that the Trust had complied correctly and no further action was required. In the third case, the Trust was found to be in partial breach of the Act, but the ICO was satisfied with actions being taken by the Trust to address recommendations. One complaint has been received via the ICO relating to non-disclosure of information as requested under the Freedom of Information Act. The ICO’s investigation concluded that the Trust had correctly applied exemptions under the Act and this outcome is reflected in an ICO “decision notice” which is posted publicly on the ICO’s website.

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Any complaints received via the ICO are reported to the Trust’s Information Governance Group for consideration and agreement on any actions necessary.

8.0 Performance and Information 8.1 IT

• HBL Business Change TUPE in progress • System C CHIS pre contract/due diligence • Telecoms future state preparation – Unified Comms • Updated IT strategy draft November 2016 SRC

8.2 Business Intelligence

• Team manager packs intelligence gathering complete • Mandatory training email reminders to staff one month before training expires • Caseload Dashboard deployed

8.3 Performance

• See M5 August IBPR (Agenda Item D2) • Outcomes measures (joint working with Jill Callander, Allied Health

Professional Lead) 9.0 Commercial Opportunities 9.1 The level of activity continues to provide resourcing challenges for HCT

particularly as the annual 2017/18 contract negotiations have been brought forward thus consuming some of the same resources that are needed for effective tender responses.

9.2 Notwithstanding this challenge it is pleasing to note that that NHS England

(London and Central Midlands) has made the decision to provisionally select HCT as the provider for the provision of Child Health Information Services (CHIS) Lot 5, Central Midlands. This opportunity will now enter into a mobilisation phase with a view to implementing this service across Hertfordshire, Bedfordshire, Luton and Milton Keynes commencing 1st April 2017 for five years plus a possible two year extension. This represents the successful defence of existing Hertfordshire CHIS business plus new CHIS business in adjoining geographies.

9.3 This successful tender represents the first positive open competitive tender

response for HCT since the award of the HMP Mount health service in 2014 and along with the news that HCT have been shortlisted in the Essex County Council Children’s Services tender (West Essex Lot) vindicates the Board decision to reinforce the Business Development function.

The Essex opportunity will be discussed as a separate Board Agenda item

however it is sufficient to say here that HCT are the only potential solo provider in the West Essex lot whereas the other three competitors (Virgin

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Healthcare, Provide CIC and North East London FT) are bidding for all four geographic lots (West, Central, East and North Essex). The PQQ feedback from commissioners was positive and it seems that all potential providers are evenly matched although the West Essex opportunity uniquely includes the CCG health element thus providing HCT with a potential incumbent provider advantage.

In addition HCT are actively involved in pursuing a number of further

opportunities. We are in the process of evaluating two other potential opportunities. The HCT business development tender evaluation process introduced in

January 2016 has to date evaluated 18 business development opportunities with five evaluated as a positive bid, four requiring further internal discussion (with subsequent agreement to proceed), two rejected as a no bid and five opportunities not considered for evaluation with two awaiting evaluation. We have also received a small number of unsolicited requests from neighbouring geographies in order to gauge our interest in service provision and we are in active discussion to gauge the prospects before entering into internal evaluation. This represents a healthy and balanced appetite for growth with a comparable success rate to date.

10.0 Business Planning & Contracting

• An updated version of the Sustainability & Transformation Plan (STP) for Herts and West Essex was submitted to the national team on 16 September; the final version is due at the end of October.

• The national guidance received so far on planning and contracting for the coming period, states that two year Operating Plans and two year contracts need to be finalised by the end of December 2016. These are expected to set out how individual organisations will play their part in delivering their locally agreed STP objectives. Further national guidance is expected during September.

• HCT’s proposed approach, timeline and resourcing for planning and contracting for 2017/18 and 2018/19 has been reviewed at the Senior Management Team meeting and has been submitted to the Strategy and Resources Committee September meeting for approval.

• One of the first deliverables in the timeline is a briefing event on the afternoon of the September Board meeting for HCT’s Senior Management Team, Service and Locality Managers and supporting Corporate Business Partners, to enable them to hear from Commissioners about their priorities and commissioning intentions for the coming two years, and to understand HCT’s approach to planning and contracting.

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• On 14 June, HCT received a letter from HVCCG giving 6 months’ notice that they intend to withdraw CIP reimbursement on HCT Beds (£1.6m p.a.). This represents a significant risk to HCT. We are now considering options, in conjunction with HVCCG, to manage this reduction in funding.

• Other key risks and issues associated with planning and contracting have been discussed at Strategy and Resources Committee and mitigating actions have been put in place.

11.0 Control Totals & the STP There has been much recent press speculation about the size of the

2016/17 NHS Provider deficit (c£550m deficit has been quoted) and NHSI’s requirement to bring it down to c£250m. Of concern was whether this now means that even where a control total has been agreed, that this will be stretched even further.

Coupled to this is the additional requirement that STP footprints have been

asked to respond to by the end of July:

• Sharing Back office functions, (for information HCT currently utilises shared services for; finance, procurement, IM&T, payroll and Occupational Health),

• Merging Pathology services (not applicable for HCT), and • Reviewing those specialties / services that are heavily reliant on locums

/ agency staff and seeing whether a neighbouring organisation is better placed to run this service leading to a better quality and cheaper service.

From the information known at the time of writing this report, NHSI will not

be coming back to those organisations, like ourselves, who have already signed up to a stretching control total. However if new savings opportunities appear nationally then this position may change.

From previous experience the move to a shared service / outsourced

approach is not something that could be achieved in the short term (i.e. this financial year) and needs to be properly planned and resourced if the service and financial benefits are to be achieved, experience shows they are often not. The STP CEO Group are looking at opportunities in this area and HCT are exploring potential opportunities with HPFT.

As for those services heavily reliant on non-permanent staff we are currently

reviewing and will update the Board as this work progresses. 12.0 PMO 12.1 Planning Services and locality teams have completed the self-assessment against the

Adult & Children’s delivery model. Findings were presented to the SMT in 6


the meeting on 14th September followed by a discussion on next steps and priorities in light of the findings. Our response to the findings will be explored further in a session on ‘Health & Wellbeing Strategy - bringing it to life’ at the Senior Leaders Forum on 27th September.

We are close to finalising the scope and delivery plans for the agreed

transformation programmes. The PID for User Self Management and Care Coordination has been completed and is awaiting PMOSG approval. Proposals on Locality Working, Population Health & Wellbeing will be presented to the Health and Wellbeing Transformation Steering group, chaired by David Law, on 28th September.

12.2 Monthly reporting There are 28 programmes and projects that are expected to report into PMO

each month. 20 Highlight Reports were submitted to the PMO in August and 24 in July. Additional effort is required to achieve the shift in culture required to increase this number further.

The PMO has completed work to align projects and programmes with the

Trust strategy and the ‘Train’. This is due to be approved at the next meeting of the Health & Wellbeing Transformation Steering Group on 28th September. The reporting Dashboard and new cover sheet will be amended to suit and for future months reporting will be in line with the new Dashboard.

The PMO now has access to Sharepoint and this will be used to facilitate

sharing of information and future project reporting. It is hoped that this will significantly reduce the amount of effort required to compile the monthly report of progress.

12.3 Approvals and assurance There are a significant number of existing projects without approved PIDs or

with out of date PIDs which creates a risk in terms of potential scope creep and the delivery of planned outcomes and benefits. A ‘STAR Chamber’ review process has now been put in place to review progress with project managers and increase the level of check and challenge.

So far, four “Star Chamber” meetings have been held and the process is

providing an improved picture of project issues and risks to delivery. The plan is to continue with the arrangement and for all projects to go through the process at periodic intervals.

Projects are also being prioritised as part of the “Star Chamber” process.

Small refinements have been made to the prioritisation model as a result of the meetings held so far and the expectation is that the outcome will prove useful in future discussions regarding portfolio priorities.

12.4 Audit A recent audit was carried out of HCT financial planning and CIPs. PMO

actions to address recommendations contained within the report have been

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agreed and changes to PMO guidance will be implemented by end October 2016.

12.5 Communications

The next Project Managers Network Meeting is scheduled for the 12th October and will cover the following items: • HCT approach to change including the NHS Change Model and PDSA • How to write a good quality PID • Business Case Development • Communication and Stakeholder Engagement Toolkit

13.0 Risk Commentary 13.1 The following are the main risks within the Directorate;

• Impact of the reduced timescale for 2017/18 & 2018/19 contracting, • Tendering & mobilisation pressures on a small number of staff, • STP timescales

Phil Bradley Director of Finance September 2016

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Board: 29th September 2016 Attachment E3


Report from the Director of HR and Organisational Development

September 2016

1.0 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 3.1 Workforce KPIs: In month sickness is just above the stretch target at

3.8% but continues to benchmark positively vs aspirant Community Trusts. Staff turnover has increased and focused retention work is underway. Current vacancy rate is 10%.

3.2 Trust Mandatory training performance remains above 90% target at 92%. 3.3 Trust appraisal rate for August shows much improved performance at

91% against a 90% target 3.4 Compliance with the national Agency price caps and framework use

continues to progress with only 2.9% breaches. Wage cap compliance has also improved further. Total spend is within plan. The proportion of nursing shifts filled by bank rather than agency increased in August.

3.5 An enhanced work programme is underway on Staff Health & Wellbeing in support of the new national CQUIN.

3.6 The Trust submitted its 2015/16 WRES performance data to NHS England on 31 July, showing some slightly increased performance, and re-accreditation to use the ‘Two Ticks’ disability symbol for a further year has been achieved.

4.0 Recommendations

The Board is asked to note the content of this paper.

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SECTION 1: WORKFORCE KPIs & OPERATIONAL ACTIVITY 5.0 Workforce Key Performance Indicators 5.1 Sickness, Turnover and Vacancy Rates

In-month sickness absence for August was 3.82% - above the 16/17 stretch target of 3.6%. Staff turnover rates have decreased to 13.42% for underlying turnover and 18.57% for total turnover; the lowest total turnover rate of the last 12 months. A retention ‘deep dive’ is underway, with the development of a new retention monitoring report and Trust retention action plan. The Trust vacancy rate currently stands at 10.16%, a reduction in this rate is actively being worked on through planned recruitment activity in line with the Resourcing Plan, alongside the focus on retention.

5.2 Temporary Staffing KPIs There has been ongoing improvement in compliance with the April agency price caps and the new wage caps introduced in July. Work continues on this at both Trust and a system wide level.

KEY : XXXX predicted leavers based on average of last 3 years.

- - - trajectory to achieve 8.5% vacancy rate by end March 2017

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Temporary staffing shift fill for August stood at 93% for nursing (qualified and unqualified) and 82% for non-nursing (down from 88% prior to the school holidays). The proportion of nursing shifts filled by bank rather than agency increased from 38% in April 2016 to 45% in August 2016, suggesting that the controls are having an impact in making agency working less attractive.

5.3 Mandatory Training Trust Mandatory Training Compliance remains above target at 92% with 80% of staff now being compliant at 90% and above. HR teams in Operational Business Units report reduced performance management of staff against this requirement.

5.4 Appraisals Trust appraisal rate 91% against 90% target for August. This reflects increased completion in both Adult Service Business Units.

SECTION 2: WF&OD STRATEGY DELIVERY 6.0 Staff Engagement (WF&OD Strategic Objective #1) 6.1 Pulse Survey

The Q2 pulse survey was run in 25th July to 12th August 2016, with 663 staff (22% of the workforce) participating. Of the 16 core questions, 7 showed a further improvement in positive responses, 5 showed a small deterioration and 4 remained the same.

6.2 Annual Staff Survey Preparations for the 2016 survey re complete and the survey launches on 26th September.

7.0 Workforce Planning & Resourcing (WF&OD Strategic Objective #2) 7.1 Resourcing

A comprehensive new Recruitment Handbook has been developed to support recruiting managers in fair and effective recruitment and selection practices.

7.2 Recruitment Pipeline The number of posts going through the recruitment process has increased through June and July. Of the 370 posts in the pipeline at July 2016, 177 have been offered and are going through pre-employment checks.

7.3 Workforce Plan The HEE 5 year workforce plan continues to be delayed due to need to link to the STP. A new integrated planning tool is being piloted in HomeFirst as part of the Integrated Care Programme Board work.

8.0 Learning & Development (WF&OD Strategic Objective #3)

Following a successful recruitment campaign, a further 6 apprentices joined the Trust in September. All are working in administrative positions in Operational and Corporate Services. A further 2 apprentices are waiting to start with 2 of the

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original apprentices transferring to higher level apprenticeship positions in the Trust.

9.0 Employment Practices (WF&OD Strategic Objective #4)

9.1 Staff Health and Wellbeing CQUIN – Flu Target The Trust annual flu campaign is being given additional impetus this year as the result of a national CQUIN target to increase the uptake of frontline clinical staff flu vaccinations to 75%. Planning is well advanced and communications are underway, including a September pay slip attachment. New incentives and reporting mechanisms are being introduced, with a statement for all staff to complete on their vaccination compliance.

9.2 Staff Health and Wellbeing Strategy A new strategy has been developed for the next 3 years, incorporating the national CQUIN requirements.

9.3 Widening Access Scheme Tax Rebate

A process has been introduced to address HMRC requirements for providing tax rebates to those undertaking full time education (e.g. Health Visitor training) whilst employed by the Trust.

9.4 Equality & Diversity

The national NHS Workforce Race Equality Standard (WRES) came into effect in 2015. It is designed to improve the representation and experience of BME staff at all levels of the organisation – particularly senior management. There are a total of nine indicators that make up the WRES split across workforce data, the national NHS Staff Survey and Trust Board composition. The Trust submitted its 2015/16 performance data to NHS England on 31 July. The data and an action plan to improve performance have been published on our public website in line with the national guidance.

Re-accreditation to use the ‘Two Ticks’ disability symbol for a further year has been achieved. This allows the Trust to continue encouraging applications from disabled people through the ‘Two Ticks’ scheme.

An external trainer specialising in disability matters has been secured for a session on managing staff with a disability at the next Leaders Forum on 20 October. Improving the experience of disabled staff is one of our corporate equality objectives for 2016/17.

The next Equality & Community Engagement Forum, an important new element of our engagement and governance for our equality & diversity work, is planned for 9 October.

10.0 Leadership (WF&OD Strategic Objective #6)

In order to progress the enhanced leadership agenda for 2016/17, the post of Education Lead - leadership and management development has been successfully recruited to. The post will support the current leadership agenda

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and drive forwards the new leadership element of the Effective Teams work stream. A franchised and locally delivered model of The Leadership Academy Mary Seacole programme for bands 6/7 is being developed in partnership with other local provider Trusts.

11.0 Risks & Challenges 11.1 CQUIN

The Staff Health and Wellbeing has been identified as an emergent financial risk for the Trust, particularly in relation to the Flu vaccination uptake target of 75%. £230k is attached to this one element across Herts (West Essex being an additional amount). A mitigation plan has been developed and the risk is being added to the risk register.

11.2 Medical Staffing Support An interim medical staffing lead has been recruited to provide support to the Associate Medical Director/RO particularly with respect to revalidation requirements. This remains a risk regarding ongoing resource for this area and the Executive Team will be considering options for longer term resource provision.

11.3 Agency Spend

Despite flexed criteria into our beds, total spend on Agency is within plan year to date and the Trust remains on target to achieve its year end Agency spend control target. Actions associated with reducing reliance on, and cost of, Agency staff are having positive impact but the ongoing risk is noted.

Alison Shelley Director of HR & OD September 2016

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Board September 2016 Attachment E4

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Report from the Director of Service Development and Partnerships

September 2016 1.0 Introduction

This paper provides an introduction to the role of the Director of Service Development and Partnerships.

2.0 Link to Trust Strategic Objectives This paper relates to all Strategic Objectives:

3.0 Recommendations

The Board is asked to note the areas of progress in service development and partnership working.

4.0 Introduction

The work of this role is very varied and rapidly developing, particularly with the opportunities the STP brings and the rapidly developing commitment to working together across the system.

5.0 Health and wellbeing strategy

Work has progressed with refreshing the HCT health and wellbeing strategy. Attention is being given to develop “patient” outcomes that when monitored can demonstrate our contribution to the health of the population. This includes work to explore patient centered outcome measures, where an individual scores their own improvements. This work links very closely with system outcomes and the outcomes already monitored within individual services.

6.0 Sustainability and Transformation Plan (STP)

HCT is a key stakeholder in driving and developing the Hertfordshire and West Essex STP. I have been working in partnership with colleagues from HPFT and SEPT to drive the work of the Primary and Community Care work stream. Linking with both the acute and prevention work streams – so all the knowledge, expertise, local and national best practice can all be used to inform how we deliver services across the health and social care system in the future, within the resources available. This work builds on the existing work of the Integrated Care Programme boards e.g. the roll out of rapid response, case management and children’s services – integrated service delivery between health visiting and children’s centres.


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As a system we have been accepted onto the system change through transformation NHSI programme. Two GP’s , a Herts Valley federation lead, a member of the LMC, leaders from HPFT, HCS, E&NHT, WHHT and myself will work together to support the system to move towards a place based population health approach.

7.0 HCT service transformation and development The transformation team has developed a competency approach to the skills and knowledge required to change services, and the team are making themselves available to support services and individuals in the change they are driving. A HCT resource pack for an organizational approach to change has been developed for all to use, as well as accessing details of successful activities that can be learnt from.

8.0 Delivery Model Self-assessment

Services and locality teams have completed the self-assessment against the HCT Adult & Children’s delivery model matrices. This provided a baseline of how services deliver services now, and how they for see the future development of their service. It covered providing a flexible service that includes: A comprehensive needs assessment, a single plan of care, optimizing peoples independence, coordinated care for those with most complex needs and effective communication The operational leads are working with each service to determine where services need support to develop their service offer, e.g. different systems and processes, training and development. A significant component of the development required will be addressed by the transformation programme internal to HCT and by the interagency working e.g. single plan of care, care coordination. The transformation programme is now in place and each work stream is utilizing the knowledge and skills of our skilled teams to drive the developments. Key components of the delivery plans are: To pilot a locality working approach in three localities initially, Stort Valley & Villages, Dacorum and St Albans for adult services, in addition in Hertsmere for children’s services.

9.0 User Self-management & Care Co-ordination In addition to the HCT programme for training and skilling up staff in self-management, HCT has been asked to lead the Organisation Development Workstream reporting into the system wide Self-management Steering Group chaired by Public Health. The aim is to develop self-management training programmes for front line staff, with the aim of rolling out the training programme across the STP footprint. As a first step the plan is to


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arrange a multi-agency task and finish group working with partners to support this work. There are different levels of training from awareness through to full health coaching. Skills development is being aimed at teams who can optimise applying their knowledge and skills with the greatest of impact. Plans are in development for health coaching resources including a toolkit and video to be shared with staff via the HCT Facebook Group and Noticeboard. There are a number of services that provide effective care coordination already within adults and children’s services, there are also good opportunities to develop this approach in integrated teams e.g. stroke services, rapid response, virtual ward. There has been recent development through primary care of “My plan” which is for people to hold their own plan, as well as a more clinical plan “professionals plan”. These developments are being shared across all agencies with a view to develop one joined up approach across the system that will support more personalised service delivery.

. 10.0 Health and Wellbeing – Population Approach to Health and Wellbeing

and Locality Working Developing an approach for organizing services to meet the needs of local populations is a goal of the whole system. HCT is working to involve and engage our teams to be involved in this and actively drive the development of their own practice. This approach is being piloted in a few localities- for adult services in St Albans and Dacorum and in Hertsmere for children’s services. A wide selection of staff have been involved in developing a locality approach and will continue to be involved in this area of work. A particularly successful locality is Stort valley, where the work through the Integrated Care Programme Board which joined the work of physical, mental health and social care services has been joined up with primary care to drive a “place based” approach. Work is also progressing well in each of the enabling work streams- examples are clinical effectiveness – piloting a wider range of staff to administer insulin in the community, developing leadership competencies, working to “ release time to care” by removing time wasting activities that take up the time of clinical teams and add no value to service users. Examples of using technology more creatively include – using “ go to” meetings ( face to face meetings over computer) reducing the need and time taken to travel to meetings, piloting using Apps to support the cardiology service. Business management team members with the estates team have developed a tool to plot where people live who use services and plot the need for estate for local service delivery in line with that volume of people to be served. This has been applied very effectively with the podiatry service.


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Finally a wide range of services have been supported to analyse how the team use their time and identify opportunities to increase their time for care delivery.

11.0 HCT Working in partnership

The health and social care system are increasingly working in partnership, across health and social care services, acute and community, providers with commissioners. Some of this is described above, in addition I attended the first Child and Young People Mental Wellbeing Transformation Programme Board – which is the first all agency children’s provider and commissioner meeting. I am working with HCT colleagues, HPFT, HCS and the Dacorum Federation to plan a partnership approach to implementing a final Rapid Response locality service. We are starting to work more closely with primary care and I have been invited to join a locality with looking at how they use their primary care funding over coming years. Finally we are aware that our rapid response services has greater potential to impact on supporting people in the community and avoiding hospital admission. I have developed and colleagues from HCT and HPFT have implemented an audit at E&NHT. Asking people attending over 65years, how they came to be in A&E and what could have been provided in the community that could have helped them avoid that happening. The results are being collated and this will inform how we develop our locality services to have greater impact. Work is also underway to explore how we build on existing work with stakeholders to support delivering the HCT vision.

12.0 Keeping in touch with services I had an excellent visit with a Hertsmere matron. I visited a number of patients with her, and saw the challenges that people with very complex needs face, and how far our staff go to meet their needs. She was very committed to improving services further and spoke highly of the work of our recently appointed deputy general manager Jane Lawson in supporting her and her colleagues to explore improvements they can make. I attended a listening session at Herts and Essex Hospital and was stuck by how the local staff wanted to work together and drive a recruitment campaign and tackle things they think they can make a difference with. They spoke of how proud they were of the service they provide and how passionately they cared about their services. I was hugely impressed.

Julie Hoare Director of Service Development and Partnerships September 2016


TRUST BOARD Title: EMERGENCY PLANNING CORE STANDARDS Meeting Date: 29th September 2016 Executive Lead: MARION DUNSTONE, DIRECTOR OF

OPERATIONS Author(s): JUDITH CANNON, EMERGENCY PLANNING &

RESILIENCE MANAGER For: APPROVAL Risk Rating: Amber/Green


1.1 To advise the Board regarding the Emergency Planning Core Standards submission

1.2 To ask the Board to:

(1) Approve the submission


2.1 Hertfordshire Community NHS Trust considers its overall level of compliance with the core standards to be substantially compliant.

2.2 There are no categories where HCT is not compliant, all

categories were rates as partially compliant or above

2.3 A rectification plan has been put in place and progress will be monitored by the Emergency planning Strategic Group


3.1 6 Impacts on all Strategic Objectives

4.0 References, Appendices & Attachments Appendices & Attachments

(1) Core Standards Submission letter

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(2) Core Standards response matrix (3) Rectification plan

Author(s) of paper: Judith Cannon Emergency Planning and Resilience Manager September 2016 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): Issues arising from committee consideration




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Up To Date


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Clearly Defined


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Marion Dunstone Dir. of Operations

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26th August 2016 Kevin Robotham Head of EPRR NHS England – Midlands & East (Central Midlands) Fosse House 6 Smith Way Grove Park Enderby Leicestershire LE19 1SX Dear Kevin Emergency Planning Response and Resilience Core Standards – statement of compliance Hertfordshire Community NHS Trust considers its overall level of compliance with the core standards to be substantially compliant. Governance Standard – against this standard HCT rates itself as fully compliant, HCT has an identified Accountable Officer and the organisation has a policy and response plans in place. A work plan is produced annually that is agreed and monitored by the Emergency Planning committee, processes are also in place to produce a lessons learnt report from exercise participation and incidents. An Emergency Planning report is presented annually to the Executive Team and Board and minutes of emergency planning meetings are presented to the Executive Team meeting providing the organisation with reassurance that EPRR work is being undertaken appropriately within the organisation. Duty to assess the risk – against this standard HCT rates itself as fully compliant. The organisation has processes in place to assess at least annually risks at national, regional and local level, risk is also a standard agenda item at all HCT Emergency Planning meetings. Maintain plans – against this standard HCT rates itself as fully compliant. The organisation has a number of key response plans in place and a review process that ensures these are updated. Command and Control – against this standard HCT rates itself as fully compliant. The organisation has on-call arrangements in place and an on-call training programme for staff on the rota is in place. Both the Major Incident plan and on-call information contain details of the Incident Command Centre that can be activated to support an incident response. HCT has arrangements to ensure decisions are appropriately logged during an incident response and a process has been identified to provide situation reports where required.

Unit 1A, Howard Court 14 Tewin Road

Welwyn Garden City Hertfordshire

AL7 1BW

01707 388000

Chair: Declan O’Farrell Chief Executive: David Law

Board 29th September 2016 Attachment E5 Duty to communicate with the public - against this standard HCT rates itself as fully compliant. HCT has arrangements in place to manage communications as part of its incident response. Information sharing – against this standard HCT rates itself as fully compliant. The organisation is signed up to the Health and Social Care Information Sharing Agreement and Protocol for Hertfordshire. Cooperation – against this standard HCT rates itself as fully compliant. HCT participates in LRF and LHRP meetings and training and minutes from this meeting are received by the HCT Emergency Planning committee. Training and exercise – against this standard HCT rates itself as fully compliant. A programme of training and exercising plan is agreed by the HCT Emergency Planning committee annually and HCT also participates where invited in multi-agency training and exercising events. Business Continuity – against this standard HCT rates itself as substantially compliant. HCT has business continuity plans in place for all its services that include a business impact assessment and detail critical functions. Work is still being undertaken to ensure that providers we commission services from and any sub-contractors have robust business continuity planning arrangements in place which are aligned to ISO 22301 or subsequent guidance, this work is due to be completed by March 2017. Fuel Demand – the figures submitted have been based on an average usage for April 2016, these figures have also been used to provide the average litres required from the petrol forecourts. CBRN – against this standard HCT rates itself as substantially compliant. HCT has a plan in place that details how the organisation will respond to an incident. A training and awareness raising plan has been developed to support this plan and training is currently being delivered to those identified as key responders. This training is planned to be completed by February 2017. Yours faithfully

David Law Chief Executive, Hertfordshire Community Trust

Chair: Declan O’Farrell Chief Executive: David Law

Core standard Clarifying information

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Evidence of assurance

Self assessment RAG

Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months.

Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months.

Green = fully compliant with core standard.

Governance

1Organisations have a director level accountable emergency officer who is responsible for EPRR (including business continuity management) Y

GREEN

2

Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to EPRR (including details of training and exercises and past incidents) and improve response.

Lessons identified from your organisation and other partner organisations. NHS organisations and providers of NHS funded care treat EPRR (including business continuity) as a systematic and continuous process and have procedures and processes in place for updating and maintaining plans to ensure that they reflect: - the undertaking of risk assessments and any changes in that risk assessment(s)- lessons identified from exercises, emergencies and business continuity incidents- restructuring and changes in the organisations- changes in key personnel- changes in guidance and policy

Y

GREEN

3

Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response.

Arrangements are put in place for emergency preparedness, resilience and response which: • Have a change control process and version control• Take account of changing business objectives and processes• Take account of any changes in the organisations functions and/ or organisational and structural and staff changes• Take account of change in key suppliers and contractual arrangements• Take account of any updates to risk assessment(s)• Have a review schedule• Use consistent unambiguous terminology, • Identify who is responsible for making sure the policies and arrangements are updated, distributed and regularly tested;• Key staff must know where to find policies and plans on the intranet or shared drive.• Have an expectation that a lessons identified report should be produced following exercises, emergencies and /or business continuity incidents and share for each exercise or incident and a corrective action plan put in place. • Include references to other sources of information and supporting documentation

Y

GREEN

4

The accountable emergency officer ensures that the Board and/or Governing Body receive as appropriate reports, no less frequently than annually, regarding EPRR, including reports on exercises undertaken by the organisation, significant incidents, and that adequate resources are made available to enable the organisation to meet the requirements of these core standards.

After every significant incident a report should go to the Board/ Governing Body (or appropriate delegated governing group) .Must include information about the organisation's position in relation to the NHS England EPRR core standards self assessment.

Y

GREEN

Duty to assess risk

5Assess the risk, no less frequently than annually, of emergencies or business continuityincidents occurring which affect or may affect the ability of the organisation to deliver it'sfunctions.

YGREEN

6

There is a process to ensure that the risk assessment(s) is in line with the organisational, LocalHealth Resilience Partnership, other relevant parties, community (Local Resilience Forum/Borough Resilience Forum), and national risk registers.

Y

GREEN

7 There is a process to ensure that the risk assessment(s) is informed by, and consulted andshared with your organisation and relevant partners.

Other relevant parties could include COMAH site partners, PHE etc. Y GREEN

Duty to maintain plans – emergency plans and business continuity plans Incidents and emergencies (Incident Response Plan (IRP) (Major Incident Plan)) Y GREEN

corporate and service level Business Continuity (aligned to current nationally recognised BC standards) Y GREEN HAZMAT/ CBRN - see separate checklist on tab overleaf Y GREEN

Severe Weather (heatwave, flooding, snow and cold weather) Y GREENPandemic Influenza (see pandemic influenza tab for deep dive 2015-16 questions) Y GREEN

Mass Countermeasures (eg mass prophylaxis, or mass vaccination) Y GREENMass Casualties Y GREEN

Fuel Disruption Y GREENSurge and Escalation Management (inc. links to appropriate clinical networks e.g. Burns, Trauma and Critical Care) Y GREEN

Infectious Disease Outbreak Y GREENEvacuation Y GREENLockdown Y GREEN

Utilities, IT and Telecommunications Failure Y GREENExcess Deaths/ Mass Fatalities N/A

having a Hazardous Area Response Team (HART) (in line with the current national service specification, including a vehicles and equipment replacement programme) - see HART core standard tab

N/A

firearms incidents in line with National Joint Operating Procedures; - see MTFA core standard tab N/A

• Ensuring accountable emergency officer's commitment to the plans and giving a member of the executive management board and/or governing body overall responsibility for the Emergency Preparedness Resilience and Response, and Business Continuity Management agendas• Having a documented process for capturing and taking forward the lessons identified from exercises and emergencies, including who is responsible.• Appointing an emergency preparedness, resilience and response (EPRR) professional(s) who can demonstrate an understanding of EPRR principles.• Appointing a business continuity management (BCM) professional(s) who can demonstrate an understanding of BCM principles.• Being able to provide evidence of a documented and agreed corporate policy or framework for building resilience across the organisation so that EPRR and Business continuity issues are mainstreamed in processes, strategies and action plans across the organisation. • That there is an appropriate budget and staff resources in place to enable the organisation to meet the requirements of these core standards. This budget and resource should be proportionate to the size and scope of the organisation.

Risk assessments should take into account community risk registers and at the very least include reasonable worst-case scenarios for:• severe weather (including snow, heatwave, prolonged periods of cold weather and flooding);• staff absence (including industrial action);• the working environment, buildings and equipment (including denial of access);• fuel shortages;• surges and escalation of activity;

• Being able to provide documentary evidence of a regular process for monitoring, reviewing and updating and approving risk assessments• Version control• Consulting widely with relevant internal and external stakeholders during risk evaluation and analysis stages• Assurances from suppliers which could include, statements of commitment to BC, accreditation, business continuity plans.• Sharing appropriately once risk assessment(s) completed

8

Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity.

Have arrangements for (but not necessarily have a separate plan for) some or all of the following (organisation dependent) (NB, this list is not exhaustive):

Relevant plans:• demonstrate appropriate and sufficient equipment (inc. vehicles if relevant) to deliver the required responses• identify locations which patients can be transferred to if there is an incident that requires an evacuation; • outline how, when required (for mental health services), Ministry of Justice approval will be gained for an evacuation; • take into account how vulnerable adults and children can be managed to avoid admissions, and include appropriate focus on providing healthcare to displaced populations in rest centres;• include arrangements to co-ordinate and provide mental health support to patients and relatives, in collaboration with Social Care if necessary, during and after an incident as required;• make sure the mental health needs of patients involved in a significant incident or emergency are met and that they are discharged home with suitable support• ensure that the needs of self-presenters from a hazardous materials or chemical, biological, nuclear or radiation incident are met.• for each of the types of emergency listed evidence can be either within existing response plans or as stand alone arrangements, as appropriate.


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9

Ensure that plans are prepared in line with current guidance and good practice which includes: • Aim of the plan, including links with plans of other responders• Information about the specific hazard or contingency or site for which the plan has been prepared and realistic assumptions• Trigger for activation of the plan, including alert and standby procedures• Activation procedures• Identification, roles and actions (including action cards) of incident response team• Identification, roles and actions (including action cards) of support staff including communications• Location of incident co-ordination centre (ICC) from which emergency or business continuity incident will be managed• Generic roles of all parts of the organisation in relation to responding to emergencies or business continuity incidents• Complementary generic arrangements of other responders (including acknowledgement of multi-agency working)• Stand-down procedures, including debriefing and the process of recovery and returning to (new) normal processes• Contact details of key personnel and relevant partner agencies• Plan maintenance procedures(Based on Cabinet Office publication Emergency Preparedness, Emergency Planning, Annexes 5B and 5C (2006))

Y

• Being able to provide documentary evidence that plans are regularly monitored, reviewed and systematically updated, based on sound assumptions:• Being able to provide evidence of an approval process for EPRR plans and documents• Asking peers to review and comment on your plans via consultation• Using identified good practice examples to develop emergency plans• Adopting plans which are flexible, allowing for the unexpected and can be scaled up or down• Version control and change process controls • List of contributors • References and list of sources• Explain how to support patients, staff and relatives before, during and after an incident (including counselling and mental health services).

GREEN

10

Arrangements include a procedure for determining whether an emergency or business continuity incident has occurred. And if an emergency or business continuity incident has occurred, whether this requires changing the deployment of resources or acquiring additional resources.

Enable an identified person to determine whether an emergency has occurred- Specify the procedure that person should adopt in making the decision- Specify who should be consulted before making the decision- Specify who should be informed once the decision has been made (including clinical staff) Y

• Oncall Standards and expectations are set out• Include 24-hour arrangements for alerting managers and other key staff.

GREEN

11

Arrangements include how to continue your organisation’s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical.

Decide: - Which activities and functions are critical- What is an acceptable level of service in the event of different types of emergency for all your services- Identifying in your risk assessments in what way emergencies and business continuity incidents threaten the performance of your organisation’s functions, especially critical activities

Y

GREEN

12Arrangements explain how VIP and/or high profile patients will be managed. This refers to both clinical (including HAZMAT incidents) management and media / communications management of VIPs

and / or high profile management YGREEN

13Preparedness is undertaken with the full engagement and co-operation of interested parties and key stakeholders (internal and external) who have a role in the plan and securing agreement to its content

Y• Specify who has been consulted on the relevant documents/ plans etc. GREEN

14 Arrangements include a debrief process so as to identify learning and inform future arrangements

Explain the de-briefing process (hot, local and multi-agency, cold)at the end of an incident. Y GREEN

Command and Control (C2)

15

Arrangements demonstrate that there is a resilient single point of contact within the organisation, capable of receiving notification at all times of an emergency or business continuity incident; and with an ability to respond or escalate this notification to strategic and/or executive level, as necessary.

Organisation to have a 24/7 on call rota in place with access to strategic and/or executive level personnel

Y

Explain how the emergency on-call rota will be set up and managed over the short and longer term.

GREEN

16

Those on-call must meet identified competencies and key knowledge and skills for staff. NHS England published competencies are based upon National Occupation Standards .

Y

Training is delivered at the level for which the individual is expected to operate (ie operational/ bronze, tactical/ silver and strategic/gold). for example strategic/gold level leadership is delivered via the 'Strategic Leadership in a Crisis' course and other similar courses.

GREEN

17

Documents identify where and how the emergency or business continuity incident will be managed from, ie the Incident Co-ordination Centre (ICC), how the ICC will operate (including information management) and the key roles required within it, including the role of the loggist .

This should be proportionate to the size and scope of the organisation.

Y

Arrangements detail operating procedures to help manage the ICC (for example, set-up, contact lists etc.), contact details for all key stakeholders and flexible IT and staff arrangements so that they can operate more than one control/co0ordination centre and manage any events required.

GREEN

18Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business continuity incident. Y

GREEN

19

Arrangements detail the process for completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response. Y

GREEN

20 Arrangements to have access to 24-hour specialist adviser available for incidents involving firearms or chemical, biological, radiological, nuclear, explosive or hazardous materials, and support strategic/gold and tactical/silver command in managing these events.

Both acute and ambulance providers are expected to have in place arrangements for accessing specialist advice in the event of incidents chemical, biological, radiological, nuclear, explosive or hazardous materials

N/A


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21 Arrangements to have access to 24-hour radiation protection supervisor available in line with local and national mutual aid arrangements;

Both acute and ambulance providers are expected to have arrangements in place for accessing specialist advice in the event of a radiation incident

N/A

Duty to communicate with the public22 Arrangements demonstrate warning and informing processes for emergencies and business

continuity incidents.Arrangements include a process to inform and advise the public by providing relevant timely information about the nature of the unfolding event and about: - Any immediate actions to be taken by responders- Actions the public can take- How further information can be obtained- The end of an emergency and the return to normal arrangementsCommunications arrangements/ protocols: - have regard to managing the media (including both on and off site implications)- include the process of communication with internal staff - consider what should be published on intranet/internet sites- have regard for the warning and informing arrangements of other Category 1 and 2 responders and other organisations. Y

• Have emergency communications response arrangements in place • Be able to demonstrate that you have considered which target audience you are aiming at or addressing in publishing materials (including staff, public and other agencies)• Communicating with the public to encourage and empower the community to help themselves in an emergency in a way which compliments the response of responders• Using lessons identified from previous information campaigns to inform the development of future campaigns• Setting up protocols with the media for warning and informing• Having an agreed media strategy which identifies and trains key staff in dealing with the media including nominating spokespeople and 'talking heads'.• Having a systematic process for tracking information flows and logging information requests and being able to deal with multiple requests for information as part of normal business processes.• Being able to demonstrate that publication of plans and assessments is part of a joined-up communications strategy and part of your organisation's warning and informing work.

GREEN

23

Arrangements ensure the ability to communicate internally and externally during communication equipment failures

Y

• Have arrangements in place for resilient communications, as far as reasonably practicable, based on risk.

GREEN

Information Sharing – mandatory requirements

24

Arrangements contain information sharing protocols to ensure appropriate communication with partners.

These must take into account and include DH (2007) Data Protection and Sharing – Guidance for Emergency Planners and Responders or any guidance which supercedes this, the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 ‘duty to communicate with the public’, or subsequent / additional legislation and/or guidance.

Y

• Where possible channelling formal information requests through assmall as possible a number of known routes. • Sharing information via the Local Resilience Forum(s) / BoroughResilience Forum(s) and other groups.• Collectively developing an information sharing protocol with the LocalResilience Forum(s) / Borough Resilience Forum(s). • Social networking tools may be of use here.

GREEN

Co-operation

25

Organisations actively participate in or are represented at the Local Resilience Forum (or Borough Resilience Forum in London if appropriate)

Y

GREEN

26Demonstrate active engagement and co-operation with other category 1 and 2 responders in accordance with the CCA Y

GREEN

27Arrangements include how mutual aid agreements will be requested, co-ordinated and maintained NB: mutual aid agreements are wider than staff and should include equipment, services and supplies.

YGREEN

28Arrangements outline the procedure for responding to incidents which affect two or more Local Health Resilience Partnership (LHRP) areas or Local Resilience Forum (LRF) areas.

N/A

29Arrangements outline the procedure for responding to incidents which affect two or more regions. N/A

30 Arrangements demonstrate how organisations support NHS England locally in discharging its EPRR functions and duties

Examples include completing of SITREPs, cascading of information, supporting mutual aid discussions, prioritising activities and/or services etc.

Y GREEN

31Plans define how links will be made between NHS England, the Department of Health and PHE. Including how information relating to national emergencies will be co-ordinated and shared

N/A

32 Arrangements are in place to ensure an Local Health Resilience Partnership (LHRP) (and/or Patch LHRP for the London region) meets at least once every 6 months

N/A

33Arrangements are in place to ensure attendance at all Local Health Resilience Partnership meetings at a director level Y

GREEN

Training And Exercising

• Attendance at or receipt of minutes from relevant Local Resilience Forum(s) / Borough Resilience Forum(s) meetings, that meetings take place and membership is quorat.• Treating the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership as strategic level groups• Taking lessons learned from all resilience activities• Using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to consider policy initiatives• Establish mutual aid agreements• Identifying useful lessons from your own practice and those learned from collaboration with other responders and strategic thinking and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to share them with colleagues• Having a list of contacts among both Cat. 1 and Cat 2. responders with in the Local Resilience Forum(s) / Borough Resilience Forum(s) area


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34

Arrangements include a training plan with a training needs analysis and ongoing training of staff required to deliver the response to emergencies and business continuity incidents

• Staff are clear about their roles in a plan • Training is linked to the National Occupational Standards and is relevant and proportionate to the organisation type. • Training is linked to Joint Emergency Response Interoperability Programme (JESIP) where appropriate• Arrangements demonstrate the provision to train an appropriate number of staff and anyone else for whom training would be appropriate for the purpose of ensuring that the plan(s) is effective• Arrangements include providing training to an appropriate number of staff to ensure that warning and informing arrangements are effective

Y

GREEN

35

Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work.

• Exercises consider the need to validate plans and capabilities• Arrangements must identify exercises which are relevant to local risks and meet the needs of the organisation type and of other interested parties.• Arrangements are in line with NHS England requirements which include a six-monthly communications test, annual table-top exercise and live exercise at least once every three years.• If possible, these exercises should involve relevant interested parties. • Lessons identified must be acted on as part of continuous improvement.• Arrangements include provision for carrying out exercises for the purpose of ensuring warning and informing arrangements are effective

Y

GREEN

36 Demonstrate organisation wide (including oncall personnel) appropriate participation in multi-agency exercises

Y GREEN

37Preparedness ensures all incident commanders (oncall directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation.

YGREEN

• Taking lessons from all resilience activities and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership and network meetings to share good practice• Being able to demonstrate that people responsible for carrying out function in the plan are aware of their roles• Through direct and bilateral collaboration, requesting that other Cat 1. and Cat 2 responders take part in your exercises• Refer to the NHS England guidance and National Occupational Standards For Civil Contingencies when identifying training needs.• Developing and documenting a training and briefing programme for staff and key stakeholders• Being able to demonstrate lessons identified in exercises and emergencies and business continuity incidents have been taken forward• Programme and schedule for future updates of training and exercising (with links to multi-agency exercising where appropriate)• Communications exercise every 6 months, table top exercise annually and live exercise at least every three years

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s Self assessment RAGRed = Not compliant with core standard and not in the EPRR work plan within the next 12 months. Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months.Green = fully compliant with core standard.

Q Core standard Clarifying information Evidence of assurancePreparedness

38 There is an organisation specific HAZMAT/ CBRN plan (or dedicated annex) Arrangements include:• command and control interfaces • tried and tested process for activating the staff and equipment (inc. Step 1-2-3 Plus)• pre-determined decontamination locations and access to facilities• management and decontamination processes for contaminated patients and fatalities in line with the latest guidance• communications planning for public and other agencies• interoperability with other relevant agencies access to national reserves / Pods

Y • Being able to provide documentary evidence of a regular process for monitoring, reviewing and updating and approving arrangements• Version control

GREEN

39 Staff are able to access the organisation HAZMAT/ CBRN management plans.

Decontamination trained staff can access the plan Y • Site inspection• IT system screen dump

GREEN

40 HAZMAT/ CBRN decontamination risk assessments are in place which are appropriate to the organisation.

• Documented systems of work• List of required competencies• Impact assessment of CBRN decontamination on other key facilities• Arrangements for the management of hazardous waste

Y • Appropriate HAZMAT/ CBRN risk assessments are incorporated into EPRR risk assessments (see core standards 5-7)

GREEN

41 Rotas are planned to ensure that there is adequate and appropriate decontamination capability available 24/7.

• Resource provision / % staff trained and available• Rota / rostering arrangements

N/A

42 Staff on-duty know who to contact to obtain specialist advice in relation to a HAZMAT/ CBRN incident and this specialist advice is available 24/7.

• For example PHE, emergency services. Y • Provision documented in plan / procedures• Staff awareness

GREEN

Decontamination Equipment43 There is an accurate inventory of equipment required for decontaminating

patients in place and the organisation holds appropriate equipment to ensure safe decontamination of patients and protection of staff.

• Acute and Ambulance service providers - see Equipment checklist overleaf on separate tab• Community, Mental Health and Specialist service providers - see Response Box in 'Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and Community Care Facilities' (NHS London, 2011) (found at: http://www.londonccn.nhs.uk/_store/documents/hazardous-material-incident-guidance-for-primary-and-community-care.pdf)• Initial Operating Response (IOR) DVD and other material: http://www.jesip.org.uk/what-will-jesip-do/training/

Y • completed inventory list (see overleaf) or Response Box (see Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and Community Care Facilities (NHS London, 2011))

GREEN

44 The organisation has the expected number of PRPS suits (sealed and in date) available for immediate deployment should they be required (NHS England published guidance (May 2014) or subsequent later guidance when applicable)

There is a plan and finance in place to revalidate (extend) or replace suits that are reaching the end of shelf life until full capability of the current model is reached in 2017

N/A

45 There are routine checks carried out on the decontamination equipment including: A) SuitsB) TentsC) PumpD) RAM GENE (radiation monitor)E) Other decontamination equipment

There is a named role responsible for ensuring these checks take place N/A

46 There is a preventative programme of maintenance (PPM) in place for the maintenance, repair, calibration and replacement of out of date Decontamination equipment for: A) SuitsB) TentsC) PumpD) RAM GENE (radiation monitor)E) Other equipment

N/A

47 There are effective disposal arrangements in place for PPE no longer required.

(NHS England published guidance (May 2014) or subsequent later guidance when applicable)

N/A

Training

Hazardous materials (HAZMAT) and chemical, biological, radiological and nuclear (CBRN) response core standards (NB this is designed as a stand alone sheet)

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s Self assessment RAGRed = Not compliant with core standard and not in the EPRR work plan within the next 12 months. Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months.Green = fully compliant with core standard.

Q Core standard Clarifying information Evidence of assurance

Hazardous materials (HAZMAT) and chemical, biological, radiological and nuclear (CBRN) response core standards (NB this is designed as a stand alone sheet)

48 The current HAZMAT/ CBRN Decontamination training lead is appropriately trained to deliver HAZMAT/ CBRN training

N/A

49 Internal training is based upon current good practice and uses material that has been supplied as appropriate.

• Documented training programme• Primary Care HAZMAT/ CBRN guidance• Lead identified for training• Established system for refresher training so that staff that are HAZMAT/ CBRN decontamination trained receive refresher training within a reasonable time frame (annually). • A range of staff roles are trained in decontamination techniques• Include HAZMAT/ CBRN command and control training• Include ongoing fit testing programme in place for FFP3 masks to provide a 24/7 capacity and capability when caring for patients with a suspected or confirmed infectious respiratory virus• Including, where appropriate, Initial Operating Response (IOR) and other material: http://www.jesip.org.uk/what-will-jesip-do/training/

Y • Show evidence that achievement records are kept of staff trained and refresher training attended• Incorporation of HAZMAT/ CBRN issues into exercising programme

AMBERtraining is currently being delivered to staffLEAD EP & Resilience Manager

50 The organisation has sufficient number of trained decontamination trainers to fully support it's staff HAZMAT/ CBRN training programme.

Feb-17

51 Staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant.

• Including, where appropriate, Initial Operating Response (IOR) and other material: http://www.jesip.org.uk/what-will-jesip-do/training/ • Community, Mental Health and Specialist service providers - see Response Box in 'Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and Community Care Facilities' (NHS London, 2011) (found at: http://www.londonccn.nhs.uk/_store/documents/hazardous-material-incident-guidance-for-primary-and-community-care.pdf)

Y AMBERtraining is currently being delivered to staffLEAD EP & Resilience Manager


HCT Core Standards Rectification plan Detailed below are the identified gaps and the proposed work that HCT has added to its Emergency Planning annual work plan and the timescales within which this work is expected to be completed.

Core standard

Core standard description Current position and intended resolution

Date for completion

Business Continuity Deep Dive DD5 The Accountable Emergency

Officers has ensured that their organisation, any providers they commission and any sub-contractors have robust business continuity planning arrangements in place which are aligned to ISO 22301 or subsequent guidance which may supersede this.

Work is currently being undertaken to ensure that the providers we commission services from and any sub-contractors have robust business continuity planning arrangements in place which are aligned to ISO 22301 or subsequent guidance

March 2017

Hazardous materials (HAZMAT) and chemical, biological, radiological and nuclear (CBRN) response core standards

Core standard

Core standard description Current position and intended resolution

Date for completion

Hazardous materials (HAZMAT) and chemical, biological, radiological and nuclear (CBRN) response core standards Training

49 Internal training is based upon current good practice and uses material that has been supplied as appropriate.

Training plan has been developed and is currently being delivered to staff

February 2017

51 Staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant.

Training plan has been developed and is currently being delivered to staff

February 2017



Community Engagement Committee Date of Board Meeting: 29 September 2016 Committee Chair: Brenda Griffiths Date of Committee Meeting: 18 August 2016 Date of Report: 18 August 2016 Dates of Committee Meetings Held Since Last Board Meeting: None Date of Next meeting: 17 November 2016

Item Ref



Committee Assurance



Risks Arising From Minutes / Tracker Updates: Tr1 None N/A All items were either

completed, elsewhere on the agenda or agreed to return to a future meeting.

Communication and Engagement:

6.1 • Communication and

Membership Engagement Priorities 2016/17

The Communications Priority Matrix is an excellent tool but requires some revision. Timelines would be helpful and it will return to the Committee as an update when the Executive has considered some of the fine detail.

6.2 • Becoming an Engaging Trust

This was an excellent paper that formalised the proposal to adopt an enhanced approach to communications and engagement with our patients, service and the public. It was agreed that SMT should be asked to

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consider that all change programmes and project PIDs should include a stakeholder assessment and communications and engagement plan.

6.3 • Partnership Work For information

Succinct presentation on partnership organisations and contacts. The Committee discussed the value of the Director of Service Development and Partnerships attending our meetings and the CEO undertook to explore if this would be feasible.

6.4 • Staff Engagement update For

consideration at SRC

This paper was a follow up from previous discussion. Responsibility for Staff issues is within the remit of SRC. However, the extensive feedback from the Leading Lights event was very informative and will be incorporated in to the planning of future events.

6.5 • Patient and Public

communication and engagement update

The summary of HCT inclusion in press and media was mixed. Overall, there was more positive exposure than negative in the previous 3 months but this organisation remains at reputational risk at all times.

6.6 • Equality & Community

Engagement Forum Update

For Information

The Committee was asked to note the progress of the newly formed Equality an Engagement Forum. This was agreed as an excellent way forward. There were concerns around the work streams being extensive but we were assured that the Forum had undertaken to agree four items to take forward as priorities. Tricia Wren and Monika Kalyan were congratulated and thanked for their efforts with this initiative.

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Further Coming Business

7.00 • Future Business

Other Urgent Business: (List Below):

8.00 None

Summary of Committee governance issues and any other points for the Board’s Attention The Committee took the opportunity to discuss how it could best provide assurance to the Board that HCT engagement with the wider community is appropriate and effective. The distinction between working with colleagues, stakeholders and partners, and engaging with others was considered. There are various options for ensuring that resources are used to best effect and the CEO and the Head of Communications and Engagement undertook to report back to the Committee at the next meeting to try to ensure that we have consistency of understanding and approach. The Equality and Engagement Forum is developing well to give a voice to communities with protected characteristics and to promote co-operation and understanding between the Trust and this local population. It was suggested that such a model could also be considered for specific service users to gain the benefit. The Diabetes Service was suggested as an example that may benefit from such a people-centred approach. Brenda Griffiths 19/08/2016

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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 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

Board 29th September 2016 Attachment F1


Audit Committee Date of Board Meeting: 29 September 2016 Committee Chair: Jeff Phillips Date of Committee Meeting: 12 September 2016 Date of Report: 12th September 2016 Dates of Committee Meetings Held Since Last Board Meeting: none Date of Next meeting: 13 December 2016

Item Ref



Committee Assurance



Risks Arising From Minutes / Tracker Updates: Tr1 B Internal Audit

B1 • Internal Audit Plan changes Green

B2 • Internal Audit Progress

Report

Amber/Red

Updated IT strategy to be presented at SRC in November. Plans are in place for a re-build of the data centre at Charter House, especially focussed on disaster recovery. However, delay to this plan is ongoing due to the difficulty in accessing capital funding

Internal Audit final reports

B3 Fire Safety

The quality of the estate acquired by HCT is a material factor involved in

1


achieving full Fire Safety compliance, though much has been done. A report on patient safety and statutory compliance will be on the part 2 agenda for the September HCT board meeting

C External Audit

C1 • External Audit update Green

Planning for this year’s audit will be discussed in October, with a view to taking as much work as possible out of the peak period (to be done at the interim audit stage)

D Quality, Clinical Governance, Risk & Assurances

D1 • High Level Risk Register Amber/Red

Of the 20 risks on the HLRR, 17 have not changed since the last submission. 10 risks have been in place for over 12 months. Managers have been contacted to establish why these risks have not been actioned. It was agreed that selected managers with long standing risks will be asked to attend the HCT board to give an appreciation of the difficulties involved in managing such risks

D2 • Risk Strategy

Implementation Plan

Amber/Red

A risk SWOT analysis will be presented to the Audit Committee at the December meeting. There have been delays to the e-learning programme due to staff capacity issues, and options are currently under consideration, and additional risk surgeries are being developed

2


The objective is for the board to be assured that risk is ‘buttoned up’

E Financial

E1 • Tender Waivers

One tender approved in the period in relation to children’s health websites procured from Leicester Partnership NHS Trust

F Counter Fraud

F1 • Local Counter Fraud progress report

Amber/Green

Counter fraud is now part of staff induction Four referrals have been made since the start of the year, and the outcomes were discussed by the committee. RSM will share benchmark data on the level of fraud referrals at other trusts HCT was considered to be a low risk fraud environment

F3 • Local Counter Fraud Stop

Amber/Green

The newsletter tabled was discussed and positively received – an electronic copy has been submitted and will be disseminated to all staff

G Trust Governance

G1 • Any other urgent Business

PB raised an issue which was discussed by Committee members, PB and CA alone

Summary of Committee governance issues and any other points for the Board’s Attention The Fire Audit was comprehensive and whilst significant progress has been made in achieving compliance across the estate, the Committee was concerned that there was still some more work to be done and this was accepted by management. A full report on patient safety and statutory compliance will be on the Part 2 agenda for the September HCT board meeting.

3

Board 29th September 2016 Attachment F1 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

4

Board 29th September 2016 Attachment F1 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.

5


Remuneration Committee Meeting

Main Item of Discussion

28th July 2016

Focolore Centre, Parkway, Welwyn Garden City

Present: Anne McPherson (AMcP) Chair of Remuneration Committee

Declan O’Farrell (DO’F) Board Chair Jeff Phillips (JP) Chair of Audit Committee

In attendance: Alison Shelley (AS) Director Human Resources & OD

Item

Introductions & Apologies The Chair welcomed everyone to the extra-ordinary meeting.

Minutes of 28th June 2016 The Minutes were approved as a correct record, having already been Chair approved for presentation of the main items of discussion at the July Board meeting in public.

Annual Performance Reviews for Chief Executives in NHS Trusts and Pay Awards for VSM Staff AS shared with the Committee the content of the letter dated 15 July to NHS trust Chairs from Jim Mackey, Chief Executive NHSI. The Committee noted the actions required and agreed to implement the government guidance i.e. application of a 1% pay award budget via a consolidated cash payment, calculated per the NHSI formula and backdated to 1 April 2016. In terms of performance related pay (PRP) the Committee noted that the Trust did not have such a scheme in operation.

1


TRUST BOARD Title: BOARD AND BOARD COMMITTEE MEETING DATES

(April 2017 – March 2018) Meeting Date: 29th September 2016 Executive Lead: David Law Chief Executive Author(s): Clive Appleby Company Secretary Marina Sweatman Board Support Officer For: APPROVAL


1.1 To set a schedule of Board and Board Committee meetings for the period April 2017 to March 2018

1.2 To ask the Board to Approve the schedule.

2.0 Key Points for the Attention of the Board

2.1 Board and Board Committee meeting dates until March 2017 have already been agreed in November 2015, but dates from January to March have been included in this schedule for completeness.

2.2 Dates of Board and Committee meetings follow the same

frequency pattern as for 2015/16 and have been programmed as far as reasonably possible to avoid public holidays, school holidays and religious festival holidays. However, some meeting dates will inevitably clash with school holiday periods. (Half Term holiday clashes are identified on the schedule).

2.3 The Annual General Meeting will be held on Thursday, 28th

September 2017. (Venue to be advised).

2.4 The meeting dates are aimed at providing as timely a flow of business as possible, from data collection through to committee(s) and on to the Board.

2.5 Board meetings will continue to rotate in a cycle between venues

in the West, “Centre” (*) and East & North of the County. Meetings in public in each area will also rotate between

1


mornings and afternoons. (“Centre” for this purpose is “central” to Trust HQ, ie the A1 corridor). Venues for Board meetings in public for the whole year will be confirmed in January 2017.

2.6 Chairs may agree with lead directors that any given programmed

meeting may be cancelled on account of not being necessary or to recognise other organisational priorities, eg preparation for regulatory inspections. However, when dates are fixed, Chairs are requested to avoid altering the dates unless absolutely necessary, as altering dates can impact detrimentally on reporting cycles.

2.7 Board briefing / development sessions will primarily be on days

identified in months when there are not Board meetings in public. However, time has been provisionally programmed in for some briefing / development time on days when there are Board meetings in public.

2.8 Subject to agreement to the meeting dates, business cycles for

each committee will be as agreed with Chairs between December 2016 and January 2017 and ratified by the relevant committee.

3.0 Relevant Strategic Objective(s) / Strategies 3.1 6 Impacts on all Strategic Objectives

4.0 References, Appendices & Attachments Appendices & Attachments

(1) Schedule of Board and Board Committee Meeting Dates Dec

2016 – March 2018 Author(s) of paper: Clive Appleby Marina Sweatman Company Secretary & Board Support Officer September 2016

2


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): None Issues arising from committee consideration


Description Comments / Exceptions √


√


√


√

Up To Date


√


√

Clearly Defined


√



David Law Chief Executive

√


3

Board 29th September 2016 EASY READ BOARD AND BOARD COMMITTEE SCHEDULE FOR 2017/18

Attachment F3

\\nebula.xherts.nhs.uk\Data\PCTs\Secure\HCT\HCT Shared Secure\Corporate\Board and Board Committee Meetings\Board - 1 & 2 Papers\Board 2016\5 September 2016\z F3i 2017-18 Board and Committee easyview datesv1.xlsx

Month Date Part 2 Part 1 Venue Month Date Time Venue Month Date Time VenueDec-16 Dec-16 TBA Central Dec-16 13.12.16 9.30 -11.30 Boardroom Howard CourtJan-17 26-01-2017 1.45-3.00 10.00-1.00 West Jan-17 26-01-2017 3.15-5.00 St Albans Jan-17Feb-17 Feb-17 23-02-2017 9.30-4.30 Central Feb-17Mar-17 30-03-2017 4.15-5.30 1.30-4.00 Central Mar-17 30-03-2017 10.00-12.45 Central Mar-17 14-03-2017 9.30 -11.30 Boardroom Howard CourtApr-17 Apr-17 27-04-2017 9.30-4.30 Central Apr-17May-17 25-05-2017 1.15-3.00 10.00-1.00 East & North May-17 25-05-2017 3.15-5.00 East & North May-17 25-05-2017 EX ORD To review AccountsJun-17 TBA EGM To approve Accounts Jun-17 22-06-2017 Jun-17 13-06-2017 9.30 -11.30 Boardroom Howard CourtJul-17 27-07-2017* 4.15-5.30 1.30-4.00 West Jul-17 27-07-2017 10.00-12.45 West Jul-17

Aug-17 Aug-17 TBA Aug-17Sep-17 28-09-2017 TBA Central Sep-17 28-09-2017 TBA AGM Engagement Central Sep-17 12-09-2017 9.30 -11.30 Boardroom Howard CourtOct-17 Oct-17 26-10-2017 9.30-4.30 Central (school Holidays) Oct-17Nov-17 30-11-2017 4.15-5.30 1.30-4.00 East & North Nov-17 30-11-2017 10.00-12.45 East & North Nov-17Dec-17 Dec-17 21-12-2017 9.30-4.30 Central Dec-17 12-12-2017 9.30 -11.30 Boardroom Howard CourtJan-18 25-01-2018 1.45-3.00 10.00-1.00 West Jan-18 25-01-2018 3.15-5.00 West Jan-18Feb-18 Feb-18 22-02-2018 9.30-4.30 Central Feb-18Mar-18 29-03-2018 4.15-5.00 1.30-4.00 Central Mar-18 29-03-2018 10.00-12.45 Central Mar-18 13-03-2018 9.30 -11.30 Boardroom Howard Court

Month Date Time Venue Month Date Time Venue Month Date Time VenueDec-16 Dec-16 20-12-2016 9.00-12.00 Dec-16 07-12-2016 2.00-4.00 cancelledJan-17 17.1.2017 2.00-5.00 Jan-17 24-01-2017 9.00-12.00 Boardroom Jan-17 11-01-2017 2.00-4.00 cancelledFeb-17 Feb-17 28-02-2017 9.00-12.00 Boardroom Feb-17 01-02-2017 2.00-4.00 holdMar-17 21-03-2017 2.00-5.00 Boardroom Howard Court Mar-17 28-03-2017 9.00-12.00 Boardroom Mar-17 01-03-2017 2.00-4.00 tbaApr-17 Proposed Operational Review Apr-17 25-04-2017 9.00-12.00 Boardroom Apr-17 05-04-2017 2.00-4.00 tba (school holidays)May-17 16-05-2017 2.00.-5.00 Boardroom Howard Court May-17 23-05-2017 9.00-12.00 Boardroom May-17 03-05-2017 2.00-4.00 tbaJun-17 Jun-17 27-06-2017 9.00-12.00 Boardroom Jun-17 07-06-2017 2.00-4.00 tbaJul-17 18-07-2017 2.00.-5.00 Boardroom Howard Court Jul-17 25-07-2017 9.00-12.00 Boardroom Jul-17 05-07-2017 2.00-4.00 tba

Aug-17 Aug-17 22-08-2017 9.00-12.00 Boardroom Aug-17 02-08-2017 2.00-4.00 tbaSep-17 19-09-2017 2.00-5.00 Boardroom Howard Court Sep-17 26-09-2017 9.00-12.00 Boardroom Sep-17 06-09-2017 2.00-4.00 tbaOct-17 Operational Review Oct-17 24-10-2017 9.00-12.00 Boardroom (school holidays) Oct-17 04-10-2017 2.00-4.00 tbaNov-17 21-11-2017 2.00-5.00 Nov-17 28-11-2017 9.00-12.00 Boardroom Nov-17 01-11-2017 2.00-4.00 tbaDec-17 Dec-17 19-12-2017 9.00-12.00 Boardroom (3rd week) Dec-17 06-12-2017 2.00-4.00 tbaJan-18 16-01-2018 2.00-5.00 Jan-18 23-01-2018 9.00-12.00 Boardroom Jan-18 03-01-2018 2.00-4.00 tbaFeb-18 Feb-18 27-02-2018 9.00-12.00 Boardroom Feb-18 07-02-2018 2.00-4.00 tbaMar-18 20-03-2018 2.00-5.00 Boardroom Howard Court Mar-18 27-03-2018 9.00-12.00 Boardroom Mar-18 07-03-2018 2.00-4.00 tba

Q1 reports Q3 ReportsQ2 reports Q4 Reports

No Meeting

Proposed Assurance/ Ops review

No meeting

No Meeting

Operational Review

Healthcare Governance Committee Strategy & Resource Committee Foundation Trust Committee

No meeting

No meeting

No meeting

No meeting

No meeting

Board Meeting Audit CommitteeBoard Briefing

No meetingNo meetingNo meeting

No meeting

Postponed until ??

Board 29th September 2016 EASY READ BOARD AND BOARD COMMITTEE SCHEDULE FOR 2017/18

Attachment F3

\\nebula.xherts.nhs.uk\Data\PCTs\Secure\HCT\HCT Shared Secure\Corporate\Board and Board Committee Meetings\Board - 1 & 2 Papers\Board 2016\5 September 2016\z F3i 2017-18 Board and Committee easyview datesv1.xlsx

Month Date Time Venue Month Date TimeDec-16 Dec-16Jan-17 Jan-17Feb-17 Feb-17 9.02.2017 10.00-12.30Mar-17 Mar-17Apr-17 Apr-17May-17 May-17 17-05-2017 10.00-12.30Jun-17 Jun-17Jul-17 Jul-17

Aug-17 Aug-17 16-08-2017 10.00-12.30Sep-17 Sep-17Oct-17 Oct-17Nov-17 30-11-2017 Integrated into part 1 Board Agenda Nov-17 15-11-2017 10.00-12.30Dec-17 Dec-17Jan-18 Jan-18Feb-18 Feb-18 *Mar-18 Mar-18

Month Date Time Venue Month Date TimeDec-16 Dec-16 27-12-2016 12.00-12.30Jan-17 Jan-17 24-01-2017 12.00-12.30 Boardroom Feb-17 28-02-2017 12.30-1.30 Flex start Boardroom Feb-17 28-02-2017 12.00-12.30 Boardroom Mar-17 Mar-17 28-03-2017 12.00-12.30 Boardroom Apr-17 Apr-17 25-04-2017 12.00-12.30 Boardroom May-17 23-05-2017 12.30-1.30 Flex start Boardroom May-17 23-05-2017 12.00-12.30 Boardroom Jun-17 Jun-17 27-06-2017 12.00-12.30 Boardroom Jul-17 25-07-2017 12.30-1.30 Flex start Boardroom Jul-17 25-07-2017 12.00-12.30 Boardroom

Aug-17 Aug-17 22-08-2017 12.00-12.30 Boardroom Sep-17 Sep-17 26-09-2017 12.00-12.30 Boardroom Oct-17 Oct-17 24-10-2017 12.00-12.30 Boardroom (school holidays)Nov-17 28-11-2017 12.30-1.30 Flex start Boardroom Nov-17 28-11-2017 12.00-12.30 Boardroom Dec-17 Dec-17 19-12-2016 12.00-12.30 Boardroom (3rd week)Jan-18 Jan-18 23-01-2018 12.00-12.30 Boardroom Feb-18 27-02-2018 12.30-1.30 Flex start Boardroom Feb-18 27-02-2018 12.00-12.30 Boardroom Mar-18 Mar-18 27-03-2018 12.00-12.30 Boardroom

No meetingNo meeting


No meetingNo meetingNo meetingNo meeting


No meeting

No meeting

Community Engagement Committee

VenueNo meetingNo meeting

Charitable Funds Trustees

No Meeting

No meeting

Remuneration Committee(If required)

Postponed until ??No meeting

Charitable Funds CommitteeFlexible start if Rem Comm required

Venue

No meeting

No meeting

No meeting

No meeting

No meeting

No meeting

No meeting

No meeting

No meeting

No meeting

No meeting

Boardroom No meetingNo meeting

No meeting

Boardroom No meetingNo meeting

Boardroom (16 is SH )

No meetingBoardroom No meetingNo meeting

No meeting