Hertfordshire Community NHS Trust

Updated 21 May 2020

Hertfordshire Community NHS Trust provides a range of health services for adults and children across Hertfordshire (population over 1.2 million people). Services are diverse and cover the full age spectrum from pre-birth to end of life and ranging from school nursing and health visiting for children and young people, to community nursing, diabetes services, rehabilitation in community hospitals, as well as other specialist services for adults and children. At the time of the inspection, the trust had 48 CQC registered services and employed approximately 2,000 staff in a variety of roles.

Updated 21 May 2020

Our rating of the trust stayed the same. We rated it as good because:

We rated safe as requires improvement, and effective, caring, responsive and well-led as good. We rated well-led for the trust overall as good.

During this inspection we did not inspect community health services for children, young people and families, community health services for adults, community end of life or community health dental services. The ratings we published following the previous inspections are part of the overall ratings awarded to the trust this time.

Updated 24 January 2019

Our rating of this service stayed the same. We rated it as good because:

• Staff understood how to protect patients from abuse and worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff had the appropriate level of safeguarding training for the services they delivered.
• The service controlled infection risk well most of the time. Staff generally kept themselves, equipment and the premises clean. They mostly used control measures to prevent the spread of infection.
• Systems and procedures were mostly in place to assess, monitor and manage risks to patients. Patients in all services were assessed with a range of holistic assessment tools which were in line with national practice. Staff completed risk assessments as part of the electronic patient record.
• The service had established a process for health care assistants to deliver insulin to diabetic patients. This was a unique process and enabled registered nurses to deliver more complex care.
• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
• The service managed patient safety incidents in line with best practice. Staff recognised incidents and reported them appropriately. Managers investigated incidents and sometimes shared lessons learned with the whole team and the wider service.
• The service generally provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Staff in different clinical roles worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Staff worked with referrers and other care providers, such as the local hospital and GP surgeries to ensure patients were seen by the most appropriate service. There were effective communication systems and clear referral processes in place.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The core service planned and provided services in a way that met the needs of local people.
• The service took account of patients’ individual needs.
• Patients could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• The service collected, analysed, managed and used information to support all its activities, using secure electronic systems with security safeguards.
• The service engaged with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
• The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

• The service generally had suitable premises but did not always have equipment that was regularly maintained. When we found out of date equipment during our inspection, we raised this with managers, who took action to address this. Following our inspection, we saw that there were large amounts of equipment on the service equipment maintenance logs that were out of date for annual testing. We were not assured that the service had effective processes for ensuring that all equipment was maintained in line with policy.
• The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. There were high vacancy levels for nursing staff and a dependence on bank and agency staff to cover shifts. However, managers were aware of the issues and had put strategies in place to try and address this problem.
• The service prescribed, gave, recorded and generally stored medicines in accordance with best practice. However, there was lack of knowledge surrounding some key policies and key audits were not undertaken.
• The service generally used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. However, there was not an effective approach for regularly reviewing trust policies or for monitoring compliance with equipment testing requirements.

Updated 6 August 2015

Overall rating for this core service Good l

We found overall that services were safe, effective, responsive, caring and well led. The staff were well trained and competent in their roles.

We visited services for children and young people in a range of environments, including outpatient’s clinics, community settings, a school and vaccination clinics, where staff from Hertfordshire Community NHS worked with other professionals and external organisations. Services for children and young people were developed and delivered in keeping with best practice guidance. All the staff we spoke with told us that the patient was at the centre of everything and this was reflected in the vision and values of the organisation.

Most areas reported staff shortages, but these were being locally monitored, particularly where there were safeguarding issues. However, there had been an influx of newly qualified health visitors and there was some concern how these would be supported, particularly around safeguarding supervision.

All staff received mandatory training and there was a high level of compliance consistently at, or above, 90% which was in line with the trust’s target. Communication between the services dealing with children and young people was described as good. There was evidence of learning from incidents and complaints to improve the quality and safety of services.

Staff were compassionate and respectful in their approach to providing care and treatment; this was reflected in the feedback from parents, young people and children who told us they felt supported.

The service was dealing with a number of changes and restructuring programmes at the same time and these were stretching the capacity of the service in some areas. There was some concern expressed about creating a more generic workforce and blurring of professional roles. However, the leadership was well respected, the strategy was clear and most staff were engaged.

We spoke with 25 staff including health visitors, school nurses, therapists, consultant paediatricians and administration staff. We spoke with 15 parents/carers and 12 young people. We spoke with young people who use the services and their parents. We observed how children and young people were being cared for. We looked at and reviewed eight care and treatment records.

Updated 6 August 2015

Overall rating for this core service Good

Patients and their representatives spoke highly of the care provided. They confirmed they had been given privacy and were treated with dignity and respect whilst receiving treatment.

One person who had been receiving treatment for over four years told us that staff were “Patient and very good with patients”. In all the interactions we saw between staff, patients and their relatives, we observed that staff were friendly, kind and took as much time as was needed. They explained what they were doing, checking they had consent throughout the treatment. Patients were listened to and staff adapted their communication appropriately dependent on the patients age and health need.

The community dental service was responsive to people’s needs. The maintenance of clear, concise and detailed clinical records confirmed that care and treatment was provided in a way that met the diverse needs of their patients. However, there was no commissioned out of hours services for patients who needed to be seen urgently. It was unclear how verbal complaints were recorded and processed.

The community dental service was well-led. Initiatives had been established to improve services, and there were quality assurance processes in place. Staff spoken with confirmed that they felt valued and supported in their roles and that managers, both within the dental service and the Trust, were approachable and visible.

Updated 21 May 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

• Staff did not always administer medicines in line with best practice at Herts and Essex Community Hospital. Staff had not administered or did not record 33 doses of a variety of medicines as being administered. We raised this concern during the inspection and managers took immediate action including a harm review and detailed action plan. The harm review demonstrated that, of the 33 omitted medication doses, 29 resulted in no harm, 3 resulted in potentially low harm and 1 in potentially moderate harm.
• Staff at Queen Victoria Memorial Hospital did not consistently record improvements to patients’ pain levels post analgesia. This had been identified during an audit of the pain tool assessments completed at Queen Victoria Memorial Hospital. Staff were working on improving post analgesia recording. Staff did not effectively communicate whether one patient required barrier nursing. Therefore, staff were unclear how to effectively care for this patient.
• At the Queen Victoria Memorial Hospital and Herts and Essex Community Hospital, staff did not always respond in a timely manner in order to maintain patients’ dignity when requiring assistance with personal needs. Staff did not always respond to call bells in a timely way. Patients and carers at Queen Victoria Memorial Hospital and Herts and Essex Community Hospital gave seven examples of occasions when they had to wait for staff to respond to call bells so they could be supported with their personal needs. Three patients relayed occasions when they had accidentally soiled themselves due to waiting too long for staff to respond to call bells. Patients and carers told us that there was not enough staff to attend to them in a timely way, although when staff did attend to help them with their personal needs, they maintained privacy and dignity.
• The service did not always have enough nursing staff. Staff shortages were a known concern. Over 13 days between 14 and 26 February 2020, there were multiple shifts, across sites, where staffing fell below 80%. The service did not report any incidents of harm due to staff shortages.
• While the service provided mandatory training in key skills to staff, not all allied health professionals and nursing staff at Queen Victoria Memorial Hospital and Herts and Essex Community Hospital had completed all the required mandatory training. Staff did not always record supervision on the electronic database. Local managers kept records for their teams, but were no longer required to report compliance rates. We were therefore unclear how the trust had oversight of the frequency of supervision provided to staff. Not all staff received an appraisal in line with the trust’s target of 90%.
• The environment at Queen Victoria Memorial Hospital required renovation. We observed chipped paintwork, exposed pipes, vermin traps and a staff toilet sink had twist taps which did not allow staff to ensure effective hand hygiene. Historical policies and old patient records were left out in the ward area where staff sat at Queen Victoria Memorial Hospital. We were concerned of the risk to patient confidentiality and the risk of staff unfamiliar with the service referring to out dated polices to guide them with clinical care.
• Staff used standard templates for patient care plans on the electronic system but did not consistently edit care plans to indicate changing individualised needs. All staff did not have knowledge or easy access to the trust’s standard operating procedure for the escalation of care and treatment for the deteriorating patient including sepsis. We were concerned of the risk this posed to patients if staff were not responding to patients’ deteriorating health in line with the trust’s procedure.
• Staff at Danesbury did not regularly check the temperatures of the sample fridge which stored urine, faecal and blood samples. We were not assured of the safety of the samples. Staff could not easily access laboratory tests or x-ray results at Queen Victoria Memorial Hospital or Danesbury. The trust was liaising with local acute hospitals to improve access.
• Leaders did not have sufficient oversight of issues of concern that we identified during the inspection. For example, managers had not ensured effective monitoring of medication administration at the Herts and Essex Hospital. At the Herts and Essex Community Hospital and Queen Victoria Memorial Hospital, call bell audits were not being completed and monitored effectively to ensure patients were not waiting for long periods of time to have their needs attended to. At all locations, managers had not responded to shortfalls in staffing establishments for 13 days in February. At all locations, whilst ward mangers kept lists of staff compliance with supervision, there was no senior oversight of supervision compliance for staff. Managers had not ensured all staff across all locations completed training or received an appraisal.

Updated 24 January 2019

Our rating of this service improved . We rated it as good because:

• The service controlled infection risk in line with best practice. Staff kept themselves, equipment and the premises clean. Staff complied with the infection prevention and control trust policy.
• The service generally had suitable premises and equipment and looked after them well. The equipment was serviced according to the manufacturer’s instructions. Patients admitted for end of life care within the community inpatient wards were cared for in single rooms. This provided the patient and relatives with privacy and ensured a quiet peaceful environment.
• The service prescribed, administered, recorded and stored medicines in accordance with good practice. Patients who were deemed to be at the end of their life, were prescribed a range of medicines that could be administered when required to manage their symptoms, this was referred to as ‘anticipatory medicines’
• The service had systems in place to ensure the safety of patients. Comprehensive risk assessments were carried out for patients, and risk management plans were developed in line with national guidance. These included assessments of patients’ susceptibility to pressure ulcers, dehydration and malnutrition where it was appropriate. In accordance with the end of life care planning, these assessments were adapted according to the patient’s needs.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. During our inspection we saw that patients had personalised advanced care plans (ACP). The care plans included individual’s preferences regarding the type of care they would wish to receive and where they wanted to be cared for. The ACP is a fundamental part of the NHS End of Life Care Programme.
• Staff provided emotional support to patients to minimise their distress. Staff showed awareness of the emotional and social impact of patients care and treatment.
• Patients and relatives that we spoke with were positive about the support they received from the community nurses and SPC team. Patients could access and be given appropriate, timely support and information to cope emotionally and mentally with their care.
• The trust planned and provided services in a way that met the needs of patients and their relatives. End of life services within the inpatient and community localities provided flexibility, choice and continuity of care.
• People could access the service when they needed it. This was provided by either the community trust specialist palliative care team or palliative nurses from local hospices. Staff provided patients with the appropriate telephone numbers to ring if out of hours advice was required.

However:

• The service generally monitored the effectiveness of care and treatment and used the findings to improve them. Monthly data was collected via audits for end of life record keeping compliance, advanced care pathway completion and preferred place of death. This data was disseminated using clinical dashboards and was monitored by the appropriate locality managers, although due to recent changes within the electronic record framework, this information was not easily accessible at the time of the inspection.
• Staff understood their roles and responsibilities regarding the Mental Capacity Act 2005. However, during our inspection we found that consent was not always obtained or recorded in line with relevant guidance and legislation.

Updated 12 October 2016

Overall, we rated the service as requires improvement because:

• The individualised care plan for the dying person, which the service had developed to replace the Liverpool Care Pathway (LCP), was not being used consistently by the community teams at the time of inspection.
• The service was not effectively collating information about the patients preferred place of death.
• The Specialist Palliative Care Team (SPCT) team did not undertake any audits to monitor how well they complied with management of pain relief or with National Institute of Health and Care Excellence (NICE) Guidance on the use of opioids in palliative care (NICE CG140) ‘Opioids in Palliative Care’ (May 2012).
• Whilst the trust had an end of life policy, it was not embedded across the trust. The trust board had ratified the policy in March 2016, and planned to launch it in May 2016.

However, we also found that:

• The service had implemented a system to enable staff to attend clinical supervision. Staff told us and records we saw confirmed staff attended regular supervision.
• The service had a development strategy and delivery plan for end of life care for 2015 to 2018. SPCT staff we spoke with were aware of the strategy.
• The service had an end of life care policy, ratified by the executive board in March 2016. SPCT staff we spoke with were aware of the policy, even though it had not been fully embedded.
• Staff were committed to providing compassionate end of life care.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• Staff demonstrated an understanding of safeguarding and understood the types of abuse that patients might experience and reported their concerns in accordance with trust policy.
• We saw evidence of effective multidisciplinary working across the community team who provided end of life care.
• The service had implemented an audit plan to monitor if they were meeting patients’ wishes and how they could make improvements. Some staff collected information about patients’ wishes, for example, preferred place of death. However, it was not being effectively collated.
• Patient records and do not attempt cardio-pulmonary resuscitation (DNACPR) forms were completed consistently and in accordance with trust policy.
• The SPCT provided services seven days per week.
• An on call consultant in palliative medicine was available out of hours to provide telephone advice to professionals in community and acute settings, across Hertfordshire community NHS trust.
• The service had both an executive director and a non-executive director who provided representation for end of life care at board level.