The Care Quality Commission
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  • SERVICE PROVIDER

Hertfordshire Community NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

17 February to 06 March 2020

During a routine inspection

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.

17 February to 06 March 2020

During an inspection of Community health inpatient services

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.

18/9/2018 to 20/9/2018

During a routine inspection

  • 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 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.

18/9/2018 to 20/9/2018

During an inspection of Community end of life care

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.

18/9/2018 to 20/9/2018

During an inspection of Community health inpatient services

Our rating of this service went down. We rated it as requires improvement because:

  • The service did not always prescribe, give, record or store medicines in line with best practice. Patients did not always receive the right medication, at the right dose, at the right time.
  • While the service provided mandatory training in key skills to staff not all medical staff had completed all the required mandatory training. Nursing staff across the inpatient units had completed most of their mandatory training.
  • The service generally had suitable premises and equipment and looked after them well. However, some buildings were old and in need of refurbishment or repair, some units had insufficient storage space and some units had broken equipment.
  • The service did not always have enough nursing staff with the right qualifications, skills, training and experience. The service did not report any incidents of harm due to staff shortages.
  • Staff did not always keep appropriate records of patients care and treatment, not all patient records were kept in secured areas. Several staff had difficulties navigating a new electronic notes system, and not all records were completed in line with best practice.
  • Although arrangements to admit, treat and discharge patients were in line with good practice, people could not always access the service when they needed it.
  • Although some managers at all levels had the right skills and abilities to run a service providing high-quality sustainable care, some leaders were very new to their role and were developing their leadership skills.
  • The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected

However, we also found:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Most staff received safeguarding training on how to recognise and report abuse.
  • The service mostly controlled infection risk well. Most staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. During our inspection, we found the environment to be clean and most staff followed the trust policy on infection prevention and control.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Patients’ pain was assessed, we saw evidence that analgesia prescribed was administered.
  • Staff were sufficiently qualified and had the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff continually cared for patients with compassion. Feedback from all patients confirmed that staff treated them well and with kindness.
  • The service took account of patients’ individual needs. Patients were assessed on admission to identify any additional support needs.
  • 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 trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

18/9/2018 to 20/9/2018

During an inspection of Community health services for adults

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.

18 - 19 April 2016

During an inspection of End of life care

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.

18 - 19 April 2016

During an inspection of Community health services for adults

The Care Quality Commission carried out a comprehensive inspection between 17 and 20 February 2015, which found that overall, the trust had a rating of requires improvement.

Community health services for adults were rated as good overall, but required improvement for safety.

We carried out an unannounced, focused inspection on 18 - 19 April 2016 to review the actions that had been taken by the trust to improve this. Overall, we saw progress had been made however; we only reviewed those elements of safety that were of concern in 2015 and did not review the whole of safety. In addition, the focused inspection took place more than six months after the original inspection and therefore this has not led to a change of rating. There were plans in place to continue with improvements.

We found that:

  • During the previous inspection in February 2015, there was a lack of grip by the trust on staffing shortages in almost all disciplines and an effective plan to address this. We saw, in April 2016 that staffing levels had improved and the trust had introduced a variety of measures to attract and retain staff. New policies and working groups had been introduced which involved all levels of staff from departmental heads through to the executive team and the board. Staff vacancies had decreased across the trust.
  • During the previous inspection in February 2015, items of equipment did not have stickers on them to identify their cleanliness and that some examination rooms had cracks in the walls and damaged plaster. We found improvements and that ‘I’m clean stickers’ were placed on equipment that had been cleaned.
  • We also saw that the rooms where patients’ treatment took place were small and did not have sufficient room to use a hoist should a person fall. Since the last inspection the trust had ‘decluttered’ the room and had rearranged the position of furniture; this had been moved back to its original position due to patients’ preference. The trust were limited as to what they could do whilst leasing the current premises, however, plans were in place for the service to move location with more space for patients and equipment.
  • At the previous inspection, the trust had introduced a new electronic system for patient records. A paper light system (a paper light record was at the patient’s home, for visiting professionals to record a brief overview of care provided) was also in place to ensure relevant records were kept at the patient’s home.
  • During the previous inspection, we had identified some issues with accessibility of information; these had now largely been resolved.

18 - 19 April 2016

During an inspection of Community health inpatient services

The Care Quality Commission carried out a comprehensive inspection between 17 and 20 February 2015, which found that overall, the trust had a rating of requires improvement.

We carried out a focused, unannounced inspection on 18 - 19 April 2016 to review the actions that had been taken by the trust. The focused inspection reviewed, within community inpatient services, the main areas that required improvement from the previous inspection; under the domains of safe, effective and well-led. Some of the weaknesses we identified previously were:

  • A lack of learning from incidents.
  • Management of medicines including controlled drugs.
  • Some equipment had been out of date or was faulty.
  • Patient records did not always include relevant information.
  • Cleanliness had been variable between units.
  • Staff had not always completed their mandatory training and had not all received an annual appraisal.
  • Staffing arrangements were not managed effectively.
  • Staff had not been made aware of risks and did not always have the opportunity to attend team meetings.

Overall, we saw progress had been made which had led to improvements and rated the service as good.

  • Staff understood their responsibilities to raise concerns, record and report safety incidents, concerns and near misses. Lessons learned were shared and discussed at team meetings.
  • There were arrangements in place to safeguard adults and children from abuse that reflected relevant legislation and local requirements. Staff understood their responsibilities and followed the trust’s safeguarding policies and procedures.
  • Arrangements for managing medicines including obtaining, prescribing, recording, handling, storage and security, dispensing, safe administration and disposal were mostly in place to keep people safe.
  • Patient records were stored securely and most patients’ individual care records were comprehensive and contained relevant risk assessments which were evaluated.
  • We reviewed a sample of equipment at the Herts and Essex Hospital and found that it was maintained and safe for use.
  • Standards of cleanliness and hygiene at all the inpatient sites we visited were well maintained and there were suitable systems in place to prevent and protect people from healthcare associated infections.
  • Nursing staff numbers, skill mix review and workforce indicators such as sickness and staff turnover were assessed using an electronic rostering tool. The planned and actual staffing numbers were displayed on the wards visited. Staffing levels were assessed as safe to provide patient care.
  • Most patients’ care and treatment was planned and delivered in line with evidence based guidelines, for example falls assessment and infection control guidance.
  • Patient records could be accessed electronically, some other records were paper based, for example National Early Warning System (NEWS) charts and food and fluid charts.
  • In inpatient areas, quality and performance information was displayed on notice boards in public areas of the ward. This included data about the numbers of staff on duty, the numbers of complaints, and the numbers of reported patient incidents such as falls or pressure ulcers. We saw evidence this was regularly updated.
  • There were arrangements in place for supporting and managing staff including supervision and appraisals. Most staff had received an appraisal during the previous 12 months.
  • All relevant clinical staff, including those in different teams and services were involved in assessing, planning and delivering people’s care and treatment.
  • Staff worked together to assess and plan ongoing care and treatment in a timely way, when patients were moved between teams or services.
  • There were computers in each ward area to access patient information. Staff were able to demonstrate how they accessed information on the electronic system. These were mobile and could be moved closer to the patient bedside.
  • Staff understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005, how to make a best interest decision as well as how to seek authorisation for a Deprivation of Liberty.
  • There was a system in place to ensure performance was discussed and monitored through a series of team meetings. Senior managers were aware of the key risk in relation to staffing which was on the trust wide risk register. It was noted that at Danesbury Neurological Centre this had recently been removed from the risk register as new staff had recently been recruited.
  • Leaders understood the challenges of good quality care and supported to staff to ensure this was provided. Leaders were visible and approachable and supported team working.
  • Staff felt valued and appreciated and told us that the culture of the service was to ensure the needs and experiences of patients were met.

However, we found that:

  • Medication for one patient at Queen Victoria Memorial Hospital had not been obtained in line with procedures until four days after admission.
  • Controlled drug checks at the Herts and Essex Hospital were not always routinely done.
  • We saw some inconsistent completion of care records at Danesbury Neurological Centre.
  • A Do Not Attempt Cardiopulmonary Resuscitation for one patient at the Herts and Essex Hospital was not in the patient’s record. We raised this at the time of inspection with a senior nurse and it was rectified promptly.
  • Most staff had completed their mandatory training and were close to achieving the trust’s target of 90% compliance. However, at the Herts and Essex Hospital, 78% of staff had completed all required mandatory training.
  • The National Early Warning Score (NEWS) was used. This is a system whereby the patients’ vital signs are recorded and if they are found to be outside usual parameters the patient’s care is escalated to either a senior nurse or a doctor. This system is used to recognise deteriorating patients. These had not been consistently recorded for all patients.
  • Assessments for patients’ therapy needs were undertaken to determine their baseline, set goals and ensure the patients’ rehabilitation needs were met. At Queen Victoria Memorial Hospital and Midway unit at Langley House, these were not always completed promptly and patients had not always received therapy in accordance with their needs. There was no policy on the frequency with which patients should receive therapy or how soon after admission their assessment should be made.
  • Staffing levels were assessed as safe to provide patient care, although it was the perception of some staff at Danesbury Neurological Centre that on occasions they were short staffed, particularly clinical support workers.
  • We noted that one patient at Danesbury Neurological Centre required turning every four hours, due to them having a pressure ulcer. We saw this had not been recorded consistently and on occasions it appeared the patient had not been turned for up to seven hours.
  • Most staff had received an appraisal during the previous 12 months, although staff at Langley House and Herts and Essex Hospital at a rate of 78%, had not achieved the trust’s target of 90%.
  • Staff worked together to assess and plan ongoing care and treatment in a timely way, when patients were moved between teams or services. However, on occasions, Queen Victoria Memorial Hospital and Herts and Essex Hospital accepted patients who were not suitable for the unit.
  • Patients’ food and fluid charts were not always completed consistently.
  • Leaders were visible and approachable and supported team working, although at Danesbury Neurological Centre, at the time of the inspection, there was, no local team leader on site for physiotherapy or occupational therapy, which was being recruited to.

17-20 February 2015

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We found that the provider, overall, was performing at a level which led to a judgement of Requires Improvement.

The Trust board were a stable team with most board members having been in post for at least 2 years the Chief Executive having been in post since 2012. The Chief Executive was highly respected by all staff we spoke with.

All the executive team told us that recruitment was the biggest risk to the trust, we found there was lack of clarity amongst the executive team relating to the vacancy position and how this was being managed. The vacancy position was addressed through the Trust’s committee structure. However, there was lack of a sufficiently detailed and effective plan in place to address this in a timely manner.

We found the trust safeguarding adult policy to be confusing and ambiguous which meant that staff were not clear on the actions they should take, meaning that there was a risk that patients may not always be protected from the risk of harm. At the time of the inspection the trust did not have a current Children’s Safeguarding policy although there was an awareness this needed to be completed.

The Trust said they had a clear strategy to become a leading light in the provision of innovative programmes of care supported by the creation of a clinical strategy. However, this was not clear as some staff said they were uncertain as to the direction and objectives of the organisation.

The development of a clinical strategy had been led by the executive team and there was evidence of both staff and stakeholder involvement in its development.

Staff were aware of the trust’s values and able to describe them.

There were no clear goals set from the trust for all services that staff could describe. We found that there was some disengagement with the leadership of the trust in one service which had recently been through some significant change.

There were a significant number of change projects taking place at the same time. Some had been extended beyond the original deadlines. The trust told us all projects are assessed for feasibility against suite of criteria including: effectiveness, patient safety, patient feasibility, project feasibility and capacity was increased to support management of individual projects. However there was concern amongst some staff about delivering all at one time whilst also providing the current service.

The quality of patient’s records varied between units. Records of care planning, evaluation of care and essential communication about patients were not always complete and information was not always stored in an organised manner. Nursing assessments and care plans were used but they were not personalised or holistic to enable people to maximise their health and well-being.

Food provision was positively rated by patients. Monitoring of fluid intake was not fully completed or evaluated which meant there was a risk of ineffective nutritional management and lack of fluid intake.

Generally services were provided in clean and hygienic environments, which helped protect patients from the risk of infection. However, hand washing practices were not always consistently practiced when delivering care between patients.

There was evidence care and treatment was provided in line with national guidance. Multidisciplinary teams worked effectively together to provide care for patients. The management of pain relief and use of recognised tools to assist assessment of pain levels varied between wards.

Generally, we found there were effective induction programmes provided including induction for students and agency staff. Staff received annual appraisals. There were opportunities for professional development of staff.

We found some areas of good practice, dental services had implemented a The “Purple Star” strategy. Whilst this is a local initiative within Hertfordshire the skills and knowledge staff acquire, are put into practice across all groups of patients who attend the specialist dental service. The Purple Strategy is a joint health and social care initiative which informs service providers and empowers people with a learning disability and their carers to get fair non-discriminatory health and social care. It has been developed with service users and stakeholders to promote and highlight quality health and community services that have been reasonably adjusted to meet the needs of people with learning disabilities.

The stroke team had been nominated by the trust management for the “life after stroke” award from the Stroke Association.

The introduction of the Home First’s rapid response teams who were able to respond to peoples’ needs within one hour.

The children and young people’s services within the trust were working towards achieving level one of the UNICEF baby-friendly initiative and were implementing a new trust service to be called ‘PALMS’ – Positive Behaviour, Autism, Learning Disability, Mental Health services. It would be an innovation for the trust and was based on a new model dealing with children with complex neurodevelopment disorders in conjunction with the challenging behaviour psychology service at the Hertfordshire Community Trust.

There were specific meetings to discuss end of life care for people with learning disabilities instigated by doctors with an interest in learning disabilities.

17-20th February 2014

During an inspection of Community end of life care

We found that the overall rating for this service was requires improvement.

We spoke to a number of staff working in different areas and they told us that they received information in newsletters and meetings from the trust. We attended multidisciplinary team meetings and saw evidence of wide communication throughout the services we visited.

However we saw that supervision and staff support was not always effective. This was because clinical supervision was provided by hospice clinicians on an informal basis, and the trust had no formal system in place to support managers in their clinical practice. Staff told us that they did not always receive clinical supervision, so people could not be sure that the service was providing an up to date and well-led service.

The service had procedures in place to safeguard people from harm but the policy was difficult for staff to follow and could have led to a misunderstanding of the correct process.

We saw evidence of comprehensive maintenance records for the environment and equipment, and saw that this was implemented in the areas we visited. We saw clean and organised working environments in the areas we visited.

We looked at care planning documentation and saw that the needs of people were documented clearly with their plan of care to ensure that it was safe and effective for people using the service. However we did not see evidence that a new care planning system had been implemented following the Liverpool Care Pathway being discontinued nationally. Staff told us, that new care plans were being developed following the discontinuation of the Liverpool Care Pathway, but had not yet been implemented. Care plans were in place for individual patients to reflect their choices and wishes but they were not specific end of life care plans.

A specific end of life care policy was not in place for staff to follow at the time of our inspection.

People who used the service and their families were complimentary about the way staff cared for them, and we saw interactions between staff and people which was caring and respectful.

Recent changes had been implemented in the trust where the palliative care services had been integrated into the community and based with district nurses to enable more effective communication between the teams. The trust was currently recruiting into these vacant positions. This has resulted in a higher case load for senior nurses and managers.

We saw that changes had been made in the way the service was run in response to problems and changes in legislation that had been identified by the managers. This showed that the service was learning from challenges and improving the service they provided. Staff told us that they had been under pressure from lack of staff and as a result workloads had increased. We saw that the manager at Apsley House had implemented a staffing level action plan for use when staffing levels dropped to five specialist palliative care nurses or below, however this system had not been implemented by the trust or shared at Gregans House at the time of the inspection. However, the trust informed us this had been subsequently implemented.

Staff told us that some GP services in the area did not use the same computerised records system and this caused communication difficulties for staff working with different electronic systems. The trust was working closely with partners to improve communication.

There were no clear goals set for the service that staff could describe to us. There was not a clear written development strategy or vision statement for the service. However, following the inspection, the trust told us this document was being developed. We saw evidence of this document.

Staff felt recent changes imposed on them integrating into the community locations were not fairly consulted with the teams. This had led to staff leaving and increasing the workload for the palliative care teams. However, the trust told us that staff had been consulted with and showed us evidence of the consultation process that took place commencing December 2013.

17 - 20 February 2015

During an inspection of Community health services for children, young people and families

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.

17 - 20 February 2015

During an inspection of Community dental services

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.

17 – 20 February 2015

During an inspection of Community health services for adults

We rated community health services for adults as good overall because:

There was a culture of incident reporting with consistent feedback and learning although this was not cascaded to all staff. The service was taking action to reduce new pressure ulcers and slips, trips and falls. The environments were visibly clean with the exception of the equipment at the Safari therapy clinic. Staff followed the trust policy on infection control. There was a shortage of nursing staff and a high number of vacancies.

Treatment and care was provided in accordance with evidence-based national guidelines. Although staff had access to training, the records showed that not all staff had completed their mandatory training. The managers said there were provisions for staff to receive their annual appraisals. Most staff said they had not received any clinical supervision but said that the managers had an open door policy and were available to discuss any issues or concerns.

Staff had awareness of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). DoLS.

Patients told us that staff treated them in a caring way and were kept informed and involved in the treatment they received. We saw patients being treated with dignity and respect.

The national referral to treatment time (RTT) of 18 weeks was not being met in some specialties. However, services were being developed to improve response to increased demand. We found examples where there were delays in discharging patients, particularly if they were waiting care packages or admission to a care home.

Support was available for people with a learning disabilities and reasonable adjustments had been made to services. An interpreting service was available and used. Patients reported that they were satisfied with how complaints were dealt with.

There was positive awareness among staff of the values of the trust and this included the expectations for patient care delivery across the trust. Some staff felt they received poor support during stressful periods. However, staff were able to speak openly about issues and incidents and this was positive for making improvements to the service.

17th - 20th February 2015

During an inspection of Community health inpatient services

We rated this services overall as requires improvement

Standards in place across community inpatient services were variable and in some areas there was need for improvement.

Systems were in place to keep patients safe and staffs were aware of these however feedback about incidents to staff was inconsistent and dependent on the types of risk reported.

Staff had reported the continued practice of inappropriate referrals but there was little evidence that actions had been taken to minimise the risks these transfers posed for the patients.

Although staffing levels met the needs of the patients at the time of our inspection there was a significant number of vacancies in some areas. Information received from the trust demonstrated that vacancies within the inpatient nursing teams was just below 15% with temporary staff both bank and agency staff being used to address any staffing shortfalls. However such staff were not always available. Information provided by the trust showed only 64% of requested shifts were filled on occasions. There was also a significant level sickness, for the whole trust at 4.28%. This was almost equally divided equally between long term and short term sickness absence.

Nursing assessments and care plans were used but they were not always personalised or holistic to enable people to maximise their health and well-being. Access and response to translation service needs were limited and not always sufficient to meet patient’s needs. Monitoring of fluid intake was not fully completed or evaluated which meant there was a risk of ineffective nutritional management and lack of fluid intake. The quality of patient’s records varied between units.

Appropriate equipment checks of resuscitation equipment were not always carried out consistently across all inpatient areas.

Hand washing practices were inconsistently practiced when delivering care between patients. Staff uptake of some aspects of mandatory training was below the trust’s target.

There was a strong focus on discharge planning which was commenced on admission to the community in-patient wards.

Overall inpatient services at the trust were caring. Patients mostly received compassionate care however patient’s privacy and dignity were not always respected.

Patients were involved in the planning and delivery of their care and were provided with appropriate emotional support. Patients spoke well of the care they received and felt staff were mostly caring and kind.

There was an integrated approach to planning and delivering care in a way that supported people to receive and access care as close to their home as possible. Dementia champions had been introduced to help ensure best practice was used to meet the needs of these vulnerable people. Staff showed an awareness of the need to respect different cultures and religious needs.

Complaints were taken investigated and changes made where appropriate.

In most wards we found medicines were safely managed. Staff were aware of safeguarding procedures and knew how to report safeguarding concerns. Services were provided in clean and hygienic environments, which helped protect patients from the risk of infection.

There was evidence care and treatment was provided in line with national guidance. Multidisciplinary teams worked effectively together to provide care for patients. Food provision was positively rated by patients

The management of pain relief and use of recognised tools to assist assessment of pain levels varied between wards.

Generally, we found there were effective induction programmes provided including induction for students and agency staff. Staff received annual appraisals. There were opportunities for professional development of staff. Staff reported there was good local leadership and that most managers were thought to be approachable and supportive.

Governance processes were in place and there was evidence of effective use of patient feedback to improve services. Leadership training for staff was being provided and innovation amongst teams was encouraged to help develop and improve services.