Hertfordshire Community NHS Trust Board Meeting in Public

3rd August 2021 9.00 to 12.00

Via Microsoft Video Conferencing AGENDA

Allocated Approx. For Att. Lead Time Timing Welcomes, Introductions and Apologies for 9.00 LS Absence To note Patient Experience/ Story 20 mins 9.02 YR/RT Supported Early Hospital Discharge To note /RF Enhanced Neuro Services https://youtu.be/il4QxBrG6uw

(A) HealthWatch 5 mins 9.25 A verbal report from Alan Bellinger, To note for HealthWatch observer, on HealthWatch (verbal) information news and issues pertinent to the Trust. (B) Opening Administration 10 mins 9.30 1. Welcomes, Introductions and Apologies LS for Absence To note

LS 2. Chair’s Announcements / Notice of Urgent Business (to include confirmation To note of Board appointments and leavers):

Two new Non-Executive Director – Rukshana Kapasi Rohan Sivanandan

Director of Strategy Sarah Brierley - full time secondment from 1 August 2021

LS 3. Declarations of Interest (Members to To note declare any interest’s material to items on the agenda)

Board 4. Ratification of items of Chair’s and Chief Executive’s Action taken since the last None meeting under Standing Order 5.2 LS 5. To approve the minutes of the meeting To approve (B1) held on 1st June 2021

LS 6. Matters arising from the Minutes of the To note (B2) meeting held on 1st June 2021

(C) Strategy, Planning and Engagement 40 mins 9.40

(C1) CEO 1. Chief Executive’s Report To note for assurance

2. Finance report Month 3 To note for DB (C2) assurance

3 . ICS/ ICP and Collaboration update To note for SBY (C3) assurance

4. Patient Engagement and Experience To approve (C4) SBY Strategy 2021-2024

(D) Clinical Services and Quality 40 mins 10.20

MSa/ 1. Joint Medical Director & Director of To note for SBE/ Nursing Report assurance (D1)

To note for SBE 2. Infection Prevention and Control (IPC) assurance Update re COVID-19 including Board (D2) Assurance Framework To note for SBE 3. Update on the Delivery of the Trust Mass assurance (D3) Vaccination programme To note for SBE 4. Community Hospital Safe staffing assurance (D4)

5. Learning from Deaths Q1 2021/22 (D5) MSa To note for 6. COVID Deaths Review 2020/21 assurance (D6)

7. Chair of Quality Committee’s Assurance SW To note for Report for the meeting held on 20 July assurance (D7) 2021

(E) Performance and Operations 15 mins 11.30 To note for ARob 1. Service Recovery and Performance (E1) Report assurance 2. Workforce Race Equality Standard (WRES) and Workforce Disability Equality (E2) ARy Standard (WDES) reports To approve

3. People Performance and Finance To note for Committee Chair’s Assurance report assurance JP covering meeting on 22nd June 2021 and (E3) 27th July 2020

(F) Board Governance and Leadership 20 mins 11.45

1. Audit Committee Chair’s Assurance RR th Report from held on 8 June 2021 verbal

To approve DB 2. Governance Manual (F1 (G) Urgent Business 5 mins 12.05

(As notified under Item (C) 2 above)

(H) Risks Arising / Observations 5 mins 12.10

ARob 1. Board Assurance Framework To review (H1)

LS 2. Summary of Risks Arising To discuss (verbal)

(J) Supporting Papers / Items for Receipt and Noting Only 5 mins 12.15 Quality Committee Annual Reports D6 a) Complaints (J1) b) Infection Control (J2) c) Looked after Children (LAC) (J3) d) Safeguarding Children (J4) e) Adult Safeguarding. (J5)

E2 Workforce Race Equality Standard (WRES) (J6)

E2 Workforce Disability Equality Standard (J7) (WDES)

(K) Date, Time & Venue of Next Meeting(s) 2 mins 12.20

5th October 2021 9.30-12.30 MS Teams LS

(L) Questions from the Public 3 mins 12.22 The Chair will respond to questions from LS members of the public provided in advance.

(M) Informal Review of Meeting 12.25

Please note that Board papers and Trust papers referenced in Reports are available on the Trust’s Website at: https://www.hct.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 Assistant Board Secretary Hertfordshire Community NHS Trust Unit 1A Howard Court, 14 Tewin Road, Welwyn Garden City, Hertfordshire, AL7 1BW

a LIST OF COMMON TRUST AND NHS ABBREVIATIONS Abbr'ns In Full Abbr'ns In Full A&E Accident & Emergency ACS Adult Care Services GM General Manager ACSC Ambulatory Care Sensitive Conditions GMC General Medical Council AD Assistant Director GP General Practitioner ADD Attention Deficit Disorder GPN General Practice Nursing Adm Admission GUM Genito Urinary Medicine AfC Agenda for Change AGM Annual General Meeting H&SCA Health & Social Care Act 2012 AHP Allied Healthcare Professional H&WBB Health & Wellbeing Board ALOS Average Length of Stay HBL Hertfordshire, Bedfordshire & Luton ASD Autism Spectrum Disorder HCA's Health Care Assistants HCAI Healthcare Associated Infection BAF Board Assurance Framework HCC Hertfordshire County Council BAME Black Asian and Minority Ethnic HCPA Hertfordshire Care providers Association BC Borough Council HCS Health and Community Services BLMK Bedfordshire, Luton, Milton Keynes HCT Hertfordshire Community NHS Trust BMJ British Medical Journal HDD Historic Due Diligence BRE British Research Establishment HEE Health Education England BI Business Information HILS Hertfordshire Independent Living Service BU Business Unit HLRR High Level Risk Register HMRC Her Majesty's Revenue & Customs C.dif Clostridium difficile CAMHS Child & Adolescent Mental Health Service HPFT Hertfordshire Partnerships Foundation Trust CCG Clinical Commissioning Group HPMA Healthcare People Management Association CDOP Child Death Overview Panel HPV Human Papilloma Virus CEO Chief Executive Officer HR Human Resources CHD Coronary Heart Disease HSAB Hertfordshire Safeguarding Adults Board CHPPD Care Hours per Patient Day HSCB Hertfordshire Safeguarding Childrens Board CHIS Children's Health Information Services HSCIC Health and Social Care Information Centre

CIP Cost Improvement Programme HSJ Health Service Journal COO Chief Operating Officer HUC Herts Urgent Care (Out of hours GP service) COPD Chronic Obstructive Pulmonary HV Health Visitor CoS Continuity of Service HVCCG Herts Valleys CCG CPD Continuous Professional Development HWE Herts & West Essex CPN Community Psychiatric Nurse CQC Care Quality Commission I&E Income and expenditure CQUIN Commissioning for Quality & Innovation I/P or IP Inpatient CRM Contract Review Meeting IBP Integrated Business Plan CRN Clinical Research Network IBPR Integrated Business Performance Review CYP Children and Young People ICA Integrated Care Alliance ICAG Integrated Clinical Advisory group DHSC Department of Health and Social Care ICP Integrated Care Partnership DH2A Discharge Home to Assess ICPB Integrated Care Programme Board DIPC Director of Infection Prevention and Control ICO Information Commisioners Office DNACPR Do Not Attempt Cardiopulmonary Resuscitation ICS Intermediate Care Strategy DoF Director of Finance ICS Integrated Care System DOLS Deprivation of Liberty Safeguards ICT Integrated Community Team DoN Director of Nursing IDAT Integrated Discharge and Transfer team DoS Directory of Strategy IG Information Governance DToC Delayed Transfers of Care IM&T Information, Management & Technology DVT Deep Vein Thrombosis IMC Intermediate Care IPC Infection prevention and control ECHP Educational Health and Care Plan IT Information Technology ED&I Equality Divsity and Inclusion IV Intravenous E&N East and North E&NHCCG East & North Herts CCG JCN Journal of Community Nursing EBITDA Earnings Before Interest, Taxes, Depreciation and Amortisation JNC Joint Negotiating Committee

ECC Essex County Council JSNA Joint Strategic Needs Assessments ECIP Emergency Care Improvement Programme JVCI Joint Committee on Vaccination and Immunisation. EEAST East of England Ambulance Trust EPMA Electronic Prescribing and Medicines Administration KPI Key Performance Indicator

ENHT East & North Hertfordshire NHS Trust LAC Looked After Children EoE East of England L&D Learning & Development EPUT Essex Partnership University NHS Foundation Trust LeDeR Learning Disability Mortality Review EPR Executive Performance Review LETB Local Education & Training Board EPR Electronic Patient Record LGBT Lesbian Gay Bisexual & Transgender ERS Electronic Referal Service LIFT Local Improvement Finance Trust ESD Early Supported Discharge LLV Lower Lea Valley ESR Electronic Staff Record LMC Local Medical Committee ESD Early Supported Discharge LoS Length of stay EWTD European Working Time Directive LTC Long Term Conditions LTFM Long Term Financial Model FPPT Fit and Proper Person test FNP Family Nurse Partnership MCVP Mass COVID Vaccination Programme FoI Freedom of Information M&E Midlands & East (Cluster of SHAs) FTSU Freedon to Speak Up MD Medical Director FYE Full Year Effect MDS Minimum Data Set MDT Multi-Disciplinary Team MIND Mental Health Charity MIU Minor Injuries Unit MRSA Methicillin-Resistant Staphylococcus Aureus MSK Musculoskeletal MST Multisystemic Therapy LIST OF COMMON TRUST AND NHS ABBREVIATIONS

Abbr'ns In Full Abbr'ns In Full NCMP National Child Health Measurement R&D Research and Development NED Non-Executive Director RAF Risk Assessment Framework NHS National Health Service RAG Red, Amber, Green (“Traffic Light” rating) NHSE/I NHS England/Improvement RCA Root Cause Analysis RCN Royal College of Nursing NHSR NHS Resolution RFH Royal Free Hospital NHSP NHS Professionals RPIR Routine Provider Information Request NI National Insurance RN Registered Nurse NIB National Information Board RO Responsible Officer NICE National Institute for Health and Care Excellence RPA Remote Process Automation NIHR National Institute for Health Research RR Rapid Response NMC Nursing & Midwifery Council RTT Referral to Treatment Time (18 weeks)

NMP Non Medical Prescriber NPSA National Patient Safety Agency SEND Special Educational Needs and Disability NQB National Quality Board SI Serious Incident NTDA NHS Trust Development Authority SI(RI) Serious Incident (Requiring investigation) NWB Non Weight Bearing SIMs SIMs Information Management System SIP Staff In Post OBC Outline Business Case SIP System Integrated Plan OH Occupational Health O/P or OP Outpatient SIRO Senior Information Risk Owner OD Organisational Development SLA Service Level Agreement OT Occupational Therapy SLR/M Service Line Reporting/Mgt SLT Speech & Language Therapy PAH The Princess Alexandra Hospital SMART Specific, Measurable, Agreed, Realistic, Timely PALMS Positive behaviour, Autism, Learning disability, Mental Health Service PALS Patient Advice & Liaison Service SOC Stratgeic Outline Case PCN Primary Care Networks SOF Single Oversight Framework PNHS Public Health Nursing Service SOP Standard Opertaing Procedure PESTEL Political Economic Social Technological Environmental SPA Single point of Access PCOM Person-centred outcome measures SOM Single Operating Model PHE Public Health England SPC Statistical Process Control PID Project Initiation Documentation SPEC Strategy Planning & Engagement Committee PIES Productivity Efficiency Improvement Schemes SRIG System Resilience Implementation Group PIR Provider Information request STF Sustainability and Transformation Funding PLACE Patient Led Assessments of the Care Environment STP Sustainability and Transformation Partnerships PMO Project / Programme Management Office SWOT Strengths Weaknesses Opportunities Threats PMR Provider Management Regime Systm1 HCT’s Clinical IT System POA Prevention of Admission PPE Personal Protective Equipment PPFC People Performance and Finance Committee PQQ Pre-Qualifying Questionnaire PREP Professional Registration Education Preparation PROMS Patient Related Outcome Measures PSED Public Sector Equality Duty TFA Tri-partite Formal Agreement PSHE Personal, Social and Health Education TOF Target Operating Framework PSPP Public Sector Payment Policy TUPE Transfer of Undertakings (protection of employment) PSF Provider Suistainability Funding PT Physiotherapy Welhat Welwyn Hatfield PYE Part Year Effect WECCG West Essex CCG WHHT West Hertfordshire Hospitals NHS Trust QC Quality Committee WLF Well led Framework QIA Quality Impact Assessment WDES Workforce Disability Equality Standard QIP Quality Improvement Plan WRES Workforce Race Equality Standard QIPP Quality Innovation Productivity and Prevention WTE Whole Time Equivalent QOF Quality Outcome Framework QRP Quality Risk Profile YCYF Your Care Your Future QSIR Quality Service Improvement & Redesign YTD Year to Date QVM Queen Victoria Memorial Hospital Board 3rd August 2021 Attachment B1

HERTFORDSHIRE COMMUNITY NHS TRUST

Minutes of the Hertfordshire Community NHS Trust Board Meeting Held by video conference on 1st June 2021

The Board approved:

(i) The minutes of the Board meeting in Public held on 25th March 2021 (ii) The People Strategy (iii) The Freedom to Speak Up Policy (iv) The Public Sector Equality Duty (v) Delegated authority for the Audit Committee on 8th June to approve the audited Annual Accounts for 2020/21 (vi) The Annual Report and Governance Statement 2020/21 (minus audited reports) (vii) The Quality Account 2020/21 (viii) The Board Committee self-assessment report (ix) The NHS Provider Licence self-certification for General Condition 6 and FT4

The following were noted:

(i) The content of the Chief Executive’s report (ii) The content of the updated 2021/22 Financial Plan and Month 1 report (iii) The content of the ICS/ICP Collaboration update (iv) The Organisational Strategy (v) The content of the Strategy Planning and Engagement Committee Chair’s Assurance report for the meeting held on 25th May 2021 (vi) The content of the Joint Medical Director and Director of Nursing Report (vii) The content of the Infection Prevention and Control and Board Assurance Framework re COVID-19 (viii) The content of the update on the delivery of the Trust Mass Vaccination Programme (ix) The Community Hospital safe staffing report (x) The Learning from Deaths Q4 2020/21 report (xi) The Freedom to Speak up Q3/4 report (xii) The content of the Quality Committee Chair’s Assurance Report for the meeting held on 18th May 2021 (xiii) The content of the Service Recovery and Performance Report (xiv) The content of the People Performance and Finance Committee Chair’s Assurance report for meetings held on 27th April and 25th May 2021 (xv) The verbal update form Audit Committee chair from the meeting held on 1 May 2021 (xvi) The Head of Internal Audit Opinion (xvii) The content of the Board Assurance Framework

PRESENT (*) denotes Voting Member of the Board Dr Linda Sheridan (LS) Trust Chair * Jeff Phillips (JP) Non-Executive Director* Richard Rolt (RR) Non-Executive Director* Sarah Wren (SW) Non-Executive Director*

Elliot Howard Jones (EHJ) Chief Executive Officer* David Bacon (DB) Director of Finance, Systems and Estates* Sarah Browne (SBE) Director of Nursing and Quality* Sarah Brierley (SBY) Director of Strategy for HCT & ENHT Mark Sanderson (MSa) Deputy Medical Director * Deputy Director of Ops Children and Young Naomi Mason (NM) People

IN ATTENDANCE Alan Bellinger (AB) HealthWatch Observer Alison Ryder (ARy) Associate Director of People (Acting) Mary Heffernan (MH) Clinical Quality Lead (left during item D6) Development Director Sam Tappenden (ST) East and North Hertfordshire Integrated Care Partnership (left during item C2) Marina Sweatman (MS) Assistant Trust Board Secretary (minutes) Donna Lesmond (DL) EA to CEO and Office of the Board

APOLOGIES Luke Edwards (LE) Non-Executive Director (Associate) Dr Elizabeth (EK) Medical Director* Kendrick Marion Dunstone (MD) Chief Operating Officer

OBSERVERS also in attendance Ellen Schroder (ES) Chair of East and North Herts NHS Trust (Left during item 77/21)

53/21 Welcomes and Introductions The Chair welcomed those present 54/21 End of Life Care for Children and Young People Mary Heffernan, Clinical Quality Lead, with the permission of the family gave a very informative and emotive presentation on the end of life planning and care provided to a 15 old young lady diagnosed with a terminal brain tumour. This included a full description of the teenager, her character, her personality and interests, and her full and frank involvement in the advanced planning undertaken to ensure that her wishes were carried out and she was able to live a quality life for her last few months.

MH highlighted the extensive multi-disciplinary approach required to facilitate the patient’s final wishes, whilst making sure that family and friends were supporting pre and post the patient’s passing. In this case the family’s GP provided significant support to the parents

at the time and continues to do so.

MH commented that the teenager had taught her a great deal with her mature approach to her end of life planning and care, her openness and honesty will help to improve multi-disciplinary services for children and young people in the future.

MH explained the extensive governance involved, outlined the challenges and opportunities that are present when dealing with end of life care for children and young people and explained the transition process from Children and Young People’s services into Adult services if appropriate.

Observations (O) Questions (Q) and Response (R) to the End of

Life Care for Children and Young People O LS thanked MH for the presentation and asked that the Board’s thanks be passed onto the whole team involved in supporting children and young people and their families with premature death. LS commented that it is amazing what young people can teach us which could lead to improvements in care for the future.

O SBE commented that the team should be proud of the care that they provide in such difficult circumstances. SBE asked what ongoing support is provided to the family and how are the team supported after each case.

R MH advised that the multidisciplinary team hold debriefing sessions, in this case it was online but worked well and there is significant signposting to other areas of support for staff. The GP continues to support the parents in this case and there is other bereavement support in place.

O SBY commented that this story clearly illustrates the benefits of joined up care which successfully supported the patient to deliver her wishes.

O SBY agreed that the emotional wellbeing of staff is important and commented that the introduction of Schwartz rounds would be beneficial as these would provide a structured forum where all staff could come together to discuss the emotional and social aspects of their work. The rounds can help staff feel more supported in their jobs, allowing them the time and space to reflect on their roles.

O JP asked what care was provided for the parents.

R MH advised that the parents were fully engaged throughout the whole time and the team facilitated the parents’ needs wherever possible, this included interaction from other partners such as the hospices, Child Bereavement Trust and the GP who was and remains exceptionally supportive. MH acknowledged that support needs to be tailored to the individuals involved as one size does not fit all.

R MSa confirmed that GP support to bereaved families can be extensive and long-term.

O LS thanked MH again and asked that the Board’s condolences and thanks are conveyed to the family.

Decision(s), Outcome(s) and Action(s) Action

1. The Board noted the Children and Young People End of Life

patient story.

(A) HealthWatch 55/21 HealthWatch Hertfordshire (HWH) update AB provided an update on recent HealthWatch initiatives which

included:

i) COVID-19 Vaccine Study into motivation and experience; the final report is being drafted. ii) An audit of Hertfordshire Dentists’ websites especially in relation to NHSE “Expectations” letter of Jan 21; due for publication in late June or July. iii) A study into the “Impact of COVID-19 on Young People with Learning Difficulties” which is due for publication in July. iv) COVID-19 Vaccine Survey – Attitudes/ Motivations among ethnically diverse patients which is currently underway v) Testing is underway on the “Hear Me Now App” especially looking at digital inclusion. vi) Work continues with the Mount Vernon Cancer Centre network development.

Observations (O) Questions (Q) and Response (R) to the HealthWatch update

O LS congratulated HWH on the amount of work undertaken and commented that the vaccination study and the survey with ethnically diverse patients will be of a particular interest to the Trust.

(B) Opening administration 56/21 Apologies

Apologies were noted and Deputies were acknowledged.

57/21 Chair’s Announcements / Notice of Urgent Business

The Chair announced that there were no items of urgent business notified.

Declarations of Interest 58/21 (Members to declare any interest’s material to items on the agenda)

• SB (DoS) declared her joint post as Director of Strategy at East & North Herts NHS Trust and Hertfordshire Community NHS Trust.

Ratification of items of Chair’s and Chief Executive’s Action 59/21 taken since the last meeting under Standing Order 5.2

There were no Chair’s and Chief Executive’s actions taken since the Board meeting held on 25th March 2021

60/21 Minutes of the meeting held in Public on 25th March 2021 The minutes of the Board meeting in public held on 25th March 2021were agreed as a correct record.

Matters arising from the Minutes of the meeting held on 25th 61/21 March 2021

The completed (blue) and in progress actions (green) were noted.

(C) Strategy, Resources and Engagement 62/21 Chief Executive’s Report Chief Executive’s Report 3.0 The COVID-19 Pandemic response

The Chief Executive provided highlights from his report within the context of COVID-19 prevalence, which is reducing, but the Trust, the NHS and the country are remaining vigilant as the future and the likelihood of further spikes remain unclear. The Trust is endeavouring to return to normal function but recognises that trying to engage in long term planning is difficult during this period of uncertainty.

3.1 Overview of HCT’s response

3.2 Service Recovery • Work over the winter has resulted in less lost activity which has enabled a much quicker recovery across the service delivery areas. The pressure on teams and the hard work involved to reach this position was acknowledged.

3.3 Delivering the vaccination programme – • 17 COVID-19 vaccination centres are now open across Herts and West Essex (HWE) and Bedfordshire, Luton and Milton Keynes (BLMK) • The centres are now offering a mixture of vaccines: Moderna, Pfizer and AstraZeneca, each requiring different protocols

• 100,000 vaccines have been provided from our Robertson House, Stevenage site and a total of 500,000 vaccines have been provided across both systems since 11 January 2021 • The roving vaccination programme has delivered vaccines to housebound and care home residents in smaller number but in more challenging circumstances on behalf of the Primary Care Networks • To date 92% of staff have received their first vaccination and 74% of staff have received their second vaccination; reporting on the second vaccine uptake is slightly delayed.

3.4 Winter and COVID-19 surge plan activation –the winter and COVID-19 surge escalation plans have been stepped down and services have now returned to normal operation.

3.5 COVID-19 testing is also included in the report.

Future Chief Executive reports will focus on the four main areas to achieve the Trust’s long-term strategic aims:

• Outstanding Quality and Performance with a view to progressing from CQC Good to Outstanding • Joined up local care including the development of the Integrated Care System (ICS) and Integrated Care Partnerships (ICPs) • Great place to work • Best Value through innovation

Chief Executive’s Report 4.0 Supporting Our People The CEO highlights related to:

4.1 Workforce key performance indicators (KPIs) - the workforce KPIs have remained consistently within target for some months demonstrating significant engagement over this difficult time.

4.2 Staff Health and Wellbeing • A focus on staff health and wellbeing resulting in a very successful staff Wellbeing Week at the end of April. The feedback from staff was extremely positive

• A highly valued menopause workshop was held during Wellbeing Week, further sessions are being planned along with the launch of a menopause support app with system partners • Work is underway for the introduction Schwartz Rounds (a well-regarded reflection and mental wellbeing tool) in July.

4.3 Disciplinary Process Review update resulting in the updating of HCT’s Disciplinary Policy was included in the report.

4.4 Workforce Planning was included in the report.

4.5 Equality and Diversity and Inclusion • The Talent 3-5 Programme is up and running. Staff from under-represented groups were prioritised for this programme and were consequently overrepresented, providing opportunities to progress.

4.6 Staff Recognition the process for nomination of the 2021 Leading lights Awards has commenced.

Chief Executive’s Report 5.0 National and Local System updates

5.1 The Queens Speech, May 2021

5.2 National priorities and operational planning guidance for 2021/22

5.3 Consultation on reforming the Mental Health Act

5.4 NHS Oversight Framework for 2021/22

5.5 Hertfordshire and West Essex Integrated Care System (ICS) Update

5.6 Developments in the Integrated Care Partnerships (ICP) within Hertfordshire and West Essex • HCT is working with East & North Herts Trust (ENHT) to support an ambitious plan to decant wards into the community to enable a hospital refurbishment and to

develop a future model of care to allow this care to continue in the future • Several pathways are being developed with ENHT to expand care at home • Work continues to involve other partners within the ICP, taking forward the tone set by the enhanced relationship developing between HCT and ENHT.

Chief Executive Report 6.0 Trust Update

The Trust update included:

6.1 Changes to key Corporate services personnel – thanks were extended to Anne McPherson who stepped down from her Board Advisor role after 60 years dedicated service to nursing and healthcare.

Welcomes were extended to Allan Morley the new Associate Director of Estates and Facilities, a joint role with

Hertfordshire Partnership University NHS Foundation Trust and to Tina Batchelor who joins the Trust in early June as our new Head of Communications.

6.2 Awards The Trust has been awarded a Purple Star by Hertfordshire County Council (HCC) in recognition for HCT’s COVID-19 immunisation programme in “bridging the health inequality gap” for people with learning disabilities.

Observations (O) Questions (Q) and Response (R) to Chief

Executive’s Report

O SW acknowledged the excellent work underway with ENHT and asked if other health partners are helping with service recovery and tackling health inequalities.

R EHJ confirmed that work is underway with Hertfordshire

County Council (HCC) on an integrated approach to dealing with health inequalities in line with the Children and Young People’s Strategy. Discussions are underway with HCC Adult social care to scope how data sets can be merged to pick up different perspectives on inequality to ultimately delivery better results.

O JP asked if decanting of patients from ENHT wards into the community is successful, will this translate into a model of care for the future and thereby release some capacity for ENHT to enable them to focus on reducing waiting lists and other priorities.

R EHJ confirmed that a future model of providing patient care in the community is the joint intention whilst ensuring that services and funding are in place. There is evidence to support that caring for patients at home has a positive effect on recovery and their longer-term prospects and ultimately will help to reduce pressure in the acute trust.

O LS asked if the additional £325 million new investment for diagnostics equipment to improve clinical outcomes announced in the Queen’s speech could be accessed to support this new model of care.

R EHJ advised that discussions are underway with the ICS and ENHT to scope where community diagnostics could be sited. However, it is not yet clear if funding can be accessed for community use.

Decision(s), Outcome(s) and Action(s) Action

1. The Chief Executive’s Report was received with no actions

and was noted

Update on the Financial Plan for 2021/22 and Month 1 Report 63/21

The update on the Financial Plan for 2021/22 and Month 1 Report was received and taken as read:

DB provided highlights; the Board noted: i) The initial draft plan was presented to the March Board acknowledging that an update would be required following discussions within the system in respect of the months 1-6 position and the continuation of national ‘emergency’ funding arrangements. ii) The Trust is planning to achieve a breakeven position for H1 2021-22

iii) The Trust has increased the level of Productivity Efficiency Improvement Schemes (PIES) required above the 0.28% (£140k) mandated value for the period to include recurrent delivery of ‘arrears’ from previous years and to achieve breakeven. iv) The mass vaccination programme income and expenses have been recorded separately. The pace at which the programme is delivered fluctuates resulting in changes to both costs and income, the service continues to be funded on a cost reimbursement basis. v) The PIES achievement 2020/21 and the plan for PIES of £3m in 2021/22 and beyond was explained, including the potential risk that the efficiency requirement over the next 18 months could be higher. vi) The risks to achieving the breakeven position were discussed, included the impact on Adult services, Children and Young People’s services, Corporate services, the Capital Plan, and overall system flow. vii) Formal reporting to NHSEI on the month 1 financial position is not required. The headlines were: • A slight operating deficit of £36k was reported, • The deficit is partly due to non-delivery of PIES profiled in the first month.

Observations (O) Questions (Q) and Response (R) to Update on the Financial Plan for 2021/22 and Month 1 Report

O LS commented that the financial position for the coming year looks exceptionally challenging and expressed that it is essential that the Clinical Commissioning Groups (CCG) fund the Trust’s ambitions to move more care into the community to support the system. This situation is worrying especially taking into consideration the potential increase in the efficiency savings required.

Q JP asked what plans are in place to recover the deficit recorded in month 1 before this becomes a month on month trend.

R DB commented that it is good that the Board is sighted on the position. He does not feel that the month1 deficit reflects any underlying trend as it is due in part to some short-term delays which are not unduly worrying currently.

Q JP acknowledged that the CCG and HCC are reported to understand the need to get services back on track, however he asked if there is any appreciation or understanding in these organisations of the impact this will have on HCT staff, and is there any recognition that recovery from COVID-19 is a systemic problem?

R DB commented that there is a recognition of HCT’s achievements during the pandemic, however the CCG are currently evaluating some of the enhanced services and there is no clear steer in respect of funding for future provision at present.

R EHJ commented that discussions are underway with the CCG but the framework and finances are uncertain. EHJ agreed that the additional developments will need to be funded and plans put in place to enable these services to continue. The Board may need to discuss and decide whether to demonstrate the value of the developments prior to securing funding.

O RR commented that the ambition and strategy aspiration for the future will need to be balanced with a realistic approach to being able to achieve the PIES during this very challenging time.

Decision(s), Outcome(s) and Action(s)

The Board noted the Update on the Financial Plan for 2021/22 and

Month 1 Report, no actions were recorded

Integrated Care System (ICS) and Integrated Care Partnership 64/21 (ICP) and Collaboration update

The Integrated Care System (ICS) and Integrated Care Partnership (ICP) and Collaboration update was taken as read.

The Board noted: i) HCT is continually working to improve the understanding of the changing environment, working to improve relationships with key partners, which in turn will result in improved outcomes.

ii) West & South Hertfordshire Healthcare Partnership (WSHCP)

• The end of year report was shared with all partnership organisations for noting

• HCT’s relationship with WSHCP is predominantly in respect of Children and Young People’s Services and the recovery of these services

• WSHCP’s next steps are to revise and refresh their governance arrangements in alignment with the transition of the Integrated Care System (ICS) as it becomes a statutory organisation. ii) East & North Herts ICP (ENHICP) • Strengthening and building relationships continues

• From a clinical transformation point of view the focus is on developing a virtual hospital in the community to help the system through the winter and reduce the waiting lists. Bilateral work is underway to develop a financial framework to progress this further

• Governance is being review within the ICP and a memorandum of understand is being developed to ensure all parties are sighted on and signed up to the principles of the ICP. iii) Mental Health & Learning Disabilities ICP

• The main interaction with the MH&LD ICP is in connection with Children & Young People’s services, Child & Adolescent Mental Health Services (CAMHS). iv) Hertfordshire County Council (HCC) • Collaborative work continues with HCC to build understanding of each other’s needs to develop and deliver services that support both Adults and Children and Young People in the communities that we serve. v) Vaccination Programme • This programme has demonstrated the extensive collaboration across a variety of partners and geographies which has enhanced and strengthen relationships with several different partners.

vi) Primary Care • The Deputy Medical Director is leading work to improve the communication flow with Primary Care to build a better understanding of each other and to deal with and discuss potential changes. vii) The governance and priority setting process for ICP engagement was explained and shared as requested by the Strategy Planning and Engagement Committee (SPEC).

Observations (O) Questions (Q) and Response (R) to O SW commented that she is concerned that the joint work with MH&LD ICP locally and systemwide is dealing with mental health issues separately from physical health issues. This could lead to further significant delays, especially with the undiagnosed mental health impact as a result of the pandemic for both patients and staff. SW asked how HCT can proactively ensure that this risk is dealt with and how can HCT ensure that there is enough support with mental health as soon as possible.

R The modelling for the MH&LD partnership has tried to forecast the impact of the pandemic and the impact on future demand. HCT has been anticipating at a strategic level how services can evolve and adapt in the future by strengthening the holistic approach to patient care. There are opportunities for future hybrid models of care which will be developed in the clinical

strategy.

R SBE commented that the impact of the pandemic on community services will not be fully known for some time. Issues are emerging within Children’s and Young People’s services with school referrals increased massively. How this will be supported going forward needs to be reviewed.

R NM advised that additional initiatives have been introduced to support schools to identify issues sooner. There has been an increase in referrals and a significant number of interventions are being introduced to tackle issues jointly across the system.

O EHJ commented that strategically the ICS needs to ensure that the interaction with MH&ICP works to ensure that both physical and mental health issues are dealt with together and

not in isolation. Recently Amanda Pritchard, Chief Operating Officer for NHS England visited HCT and acknowledged that it is not just Mental Health Trusts that that deal with mental health issues and that there are a range of other services that are needed to maintain children’s ongoing health and wellbeing. Amanda recognised that the hidden demand coupled with delays in treatment time and the length of treatment involved could have a long-term effect on children’s health and wellbeing, she planned to take steps to understand the impact of the waiting times on the children’s health and wellbeing across the country.

O JP highlighted that special educational needs budgets in schools had been reduced along with the increase in demand which is making the situation much worse.

O LS provided some anecdotal information gathered from a School Health Nurse who expressed that most of her current workload involves mental health issues.

Decision(s), Outcome(s) and Action(s)

1. The Board noted the Integrated Care System (ICS) and Integrated Care Partnership (ICP) and Collaboration update,

no actions were recorded.

65/21 Organisational Strategy The Organisational Strategy was received.

The Board noted: i) The Organisational Strategy was presented for noting at the Board, it was reviewed and approved at the May Board meeting in private.

ii) The Organisational Strategy has been published on the Trust’s website. iii) Good progress is being made on the People, Patient Engagement and Experience, and Clinical enabling and supporting strategies.

Observations (O) Questions (Q) and Response (R) to the

Organisational Strategy

O LS commented that the strategy is deliberately pitched at a high level, the detail will be contained within the enabling and

supporting strategies.

Decision(s), Outcome(s) and Action(s)

1. The Organisational Strategy was noted.

66/21 The People Strategy for 2021-2025 The People Strategy 2021-2025 was received, it sets out the workforce objectives for the Trust for the coming four years (to align with the Trust Organisational Strategy). The strategy sets out how the Trust plans to meet its Great Place to Work strategic objective.

The Board noted: i) The strategy includes feedback provided by71% of staff who completed the NHS staff survey and direct feedback from several other groups who reviewed the written document prior to completion, including the People Performance and Finance Committee (PPFC).

ii) The Strategy incorporates four strategic workforce objectives, which are: • Looking after our people • Shaping our workforce • Developing our people • Releasing capacity through technology.

Observations (O) Questions (Q) and Response (R) to the People

Strategy

O LS commented that this is an excellently presented document

and it is good to see the challenging targets.

Decision(s), Outcome(s) and Action(s)

1. The People Strategy was accepted and approved.

Strategy Planning & Engagement Committee Chair’s Assurance 67/21 report

The Chair’s assurance report for the Strategy Planning and Engagement Committee meeting held on 25th May 2021 was taken as read.

The Board noted that: i) The committee self-assessment was completed. ii) The Board Assurance Framework and High-Level Risk Register were reviewed and discussed. iii) Other areas considered at the Committee have already been discussed during the Board meeting which included the ICS ICP collaborative report, the Organisational Strategy, and the People Strategy.

Decision(s), Outcome(s) and Action(s)

1. The Strategy Planning & Engagement Committee Chair’s

Assurance report was noted.

(D) Clinical Services and Quality (D)

68/21 Medical Director and Director of Nursing Report

The Medical Director and Director of Nursing Report was taken as read.

The main area highlighted to the Board included: i) An update on the vital safeguarding work underway, especially in respect of the pandemic. Referrals in both Adults and Children’s services have significantly increased. The Rapid Response Team have been exceptionally busy with very complex cases. Dealing with unexpected deaths ultimately impacts on the team, despite their skills and experience. Work is underway to review the support provided to staff to identify any areas where further support is required to ensure staff health and wellbeing. Observations (O) Questions (Q) and Response (R) to the Medical

Director and Director of Nursing Report O JP asked for further clarification on the what “increased acuity” in the community beds and in other services means.

R SBE advised that patients that would previously have been looked after in the acute hospitals with a large multidisciplinary team in situ, are now being looked after in the community with

a smaller co-ordinated team with nursing, GP and other specialist service support. Patients are living much longer with more complex co morbidities which makes the care required much more complex.

O JP asked if the acute hospitals are supporting the complex care issues.

R SBE confirmed that joint care pathways are being developed but some patients are on several pathways which adds to the complexity.

O MSa confirmed that over time there have been more complex patients being treated in the community, this has also increased as a result of the pandemic but collaboration with other health care providers in secondary, primary and community care is central to treating patients in the community. COVID-19 has improved the cross-boundary working but further work is required to continue to build on this.

O LS complimented the report for its excellent and informative content.

Decision(s), Outcome(s) and Action(s)

1. The Medical Director and Director of Nursing Report was noted.

Infection Prevention and Control and Board Assurance 69/21 Framework re COVID-19 The Board received the Infection Prevention and Control (IPC) and Board Assurance Framework (BAF) re COVID-19 and it was taken as read.

The Board noted that: i) This report is discussed in detail at the Quality Committee

monthly. ii) No other infections have been reported which is indicative of the excellent IPC work across the Trust. iii) No further outbreaks have been reported. The last outbreak was dealt with very swiftly. iv) The BAF had been updated.

v) Further guidance is awaited from Public Health England (PHE) on the use of personal protective equipment (PPE) in respect of the proposed relaxation of restrictions in June.

Observations (O) Questions (Q) and Response (R) to the Infection Prevention and Control (IPC) and Board Assurance Framework re COVID-19 O EHJ explained that the Howard Court meeting room has been fitted with a clean air filtration system which is why masks are not required.

Decision(s), Outcome(s) and Action(s) Action

1. The Board noted the Infection Prevention and Control (IPC)

and Board Assurance Framework re COVID-19

Update on the Delivery of the Trust Mass Vaccination 70/21 Programme The report as at 16th May 2021 provided an update on HCT’s role as lead provider for the Herts and West Essex (HWE), and Bedfordshire Luton and Milton Keynes (BLMK) area mass vaccination programme. As the position changes rapidly, a verbal update was also provided.

The Board noted: i) The Chief Executive report included a brief update. ii) All 17 vaccination centre sites are open and flexing operational hours according to the national programme of vaccine allocation. iii) Each centre is now offering a choice of two vaccines which has added to the complexity, alongside the fluctuating vaccine supply. iv) In line with short notice guidance second doses have been brought forward to 8 weeks between vaccines for cohorts 1-9. v) Several walk-in sessions have been established, these were well received and working to the capacity originally envisioned. vi) The Delta variant has been identified in Bedford, focussed work is underway with PHE to increase the delivery of both first and second vaccines in this area as quickly as possible. vii) Planning has now commenced for phase 3 from September 2021 onwards. Observations (O) Questions (Q) and Response (R) to the Trust

Mass Vaccination Programme

Q JP asked how the walk-in sessions were communicated.

R SBE advised that the main flow of communication is via the media and system communication, information via the CCG and HCT websites. The publicity has been limited to take into account capacity and vaccine availability. Feedback has been very positive. Where second vaccines have been brought forward patients have received text messages to access walk in sessions locally.

Q LS asked if the Moderna vaccine would be reintroduced at the Stevenage centre for the second doses?

R SBE advised that alternative system solutions are being investigated, as currently sites are not permitted to administer three different vaccines.

Q LS asked if people over the ages of 18 are being offered the vaccine in areas known for the Delta variant.

R SBE advised that multi-generational household vaccines can be given but any flexibility must remain within the Joint Committee on Vaccination and Immunisation (JCVI) cohorts.

O LS commended and congratulated the programme and the teams involved on the positive feedback received, the achievement of 100,000 vaccines at the Stevenage site, 500,000 vaccines across both systems and the Purple Star award from Hertfordshire County Council in recognition of the COVID-19 immunisation programme in “bridging the health inequality gap” for people with learning disabilities.

Decision(s), Outcome(s) and Action(s) 1. The update on the delivery of the Mass Vaccination Programme was noted.

71/21 Community Hospital Safe Staffing report The Board received the Community Hospital Safe Staffing report which was taken as read.

The Board noted:

i) The report was reviewed, discussed in detail and approved by the Quality Committee. ii) The community hospitals have now resumed their pre COVID- 19 bed numbers and staffing ratios.

Decision(s), Outcome(s) and Action(s) 1. The Board noted the Community Hospital Safe Staffing report.

72/21 Learning from Deaths Q4 report

The Board received the Learning from Deaths Q4 and end of year report which was taken as read.

The Board noted: i) There were 35 deaths in 2021 of which 27 were linked to COVID-19. All COVID-19 related deaths were reported as incidents and have been fully investigated and lessons have been learned. ii) A process is being developed to ensure that learning from deaths reviews elsewhere in the system for Child deaths and death of patients with Learning Disabilities are shared. iii) Structured judgement reviews are carried out for all deaths to allow clinicians to review care given and assess whether the death was avoidable. All deaths in 2021 were assessed to be between not very likely to be avoidable or definitely not avoidable. iv) Detail in relation to two cases were shared and how the lessons learned would inform future care.

Observations (O) Questions (Q) and Response (R) to Learning from Deaths Q4 report O LS commented that it was good to see the shared learning in practice from other areas, this demonstrates system wide learning.

Decision(s), Outcome(s) and Action(s) 1. The Board noted Learning from Deaths Q4 report.

73/21 Freedom to Speak Up Q3/Q4 report

The Board received the Freedom to Speak Up Q3/Q4 report, it was taken as read.

The Board noted: i) Normally Christine Stock the FTSU Guardian would present this to the Board but she retired on Friday, the Interim Guardian will be Paul Brown whilst the role is reviewed in line with latest guidance. ii) The Q3/4 and end of year report showed 18 FTSU reports were received which is slightly lower than last year, of these 14 have now been closed and four remain under investigation. iii) The FTSU index report was received recently. HCT ranks 7th which the highest ranking for any of the organisations in Herts & West Essex ICS. iv) The FSTU index report will be reviewed, and a future update will be provided to the Board.

Observations (O) Questions (Q) and Response (R) to Freedom to Speak Up Q3/Q4 O RR congratulated the Guardian and the Ambassadors on a good year and thanked them for the support that they have provided to the organisation. RR advised that he had been involved in the interim guardian appointment as the Non- Executive lead for FTSU.

O LS commended the report and expressed that the Board would like to convey they thanks to Christine Stock and wish her well in her retirement.

Decision(s), Outcome(s) and Action(s) 1. The Board noted the Freedom to Speak Up Q3/Q4 report.

74/21 Freedom to Speak Up Policy

The Board received the updated Freedom to Speak Up Policy for approval.

The Board noted: i) The that there are no major changes and the policy has been reviewed and approved by the Quality Committee.

Decision(s), Outcome(s) and Action(s) 1. The Board approved the updated Freedom to Speak Up Policy.

Quality Committee Chair’s Assurance Report for the meeting 75/21 held on 18th May 2021

The Board received the Quality Committee Chair’s assurance report for the meeting held on 18th May 2021.

It was acknowledged that several of topics have already been discussed within the meeting.

It was noted that: i) Seven reports had been reviewed and considered in detail and recommended to the Board. ii) The impact of COVID-19 was considered in several reports including the increase in patient deaths, the increase in patient frailty and acuity and the impact on safer staffing which identified the need to undertake a deep dive into falls. iii) Mandatory training is improving but has also been affected by COVID-19. iv) The Clinical Audit Annual Report 2020/21 showed several clinical audits had been postponed due to the pandemic. Action has been taken in the Clinical Audit plan for 2021/22 to prioritise and oversee outstanding issues from 2020/21. v) The Clinical Governance Sub-committee assurance report and minutes were received, they demonstrated cross-specialism and cross-organisational working. vi) A separate meeting is being arranged to focus on other annual reports, this will allow time to review and acknowledge the excellent work undertaken over the last year and share any lessons learned.

Observations (O) Questions (Q) and Response (R) to Quality Committee Chair’s Assurance report.

O JP acknowledged that the Quality Committee reviews and oversees complaints but asked if there is a requirement for the

Board to have direct visibility of complaints.

R SBE advised that the Quality Committee has been given delegated authority to review complaints on behalf of the Board and provide assurance to the Board. A complaints annual report will be shared with the Board and will be available on the website. SBE advised that the Quality Committee recently discussed in depth some complex ongoing investigations and the impact that these are having on teams.

R SW confirmed that the complaints discussion looked at the holistic impact and considered the support that staff have received and will continue to receive.

O LS asked for confirmation the complaints annual report will be provided to the Board.

R SBE confirmed that the complaints annual report will be one of the reports included for the Board to note.

Decision(s), Outcome(s) and Action(s) Action

1. The Board noted the Quality Committee Chair’s Assurance

report.

(E) Performance and Operations

76/21 Service Recovery and Performance Report The Service Recovery and Performance report of Trust-wide data for April 2021 was received and taken as read.

Key highlighted areas were noted including:

i) The report was discussed in detail at the People Performance and Finance Committee (PPFC). ii) Activity reporting for 2021/22 is now being compared to activity in 2019/20 to avoid the impact of the pandemic and to ensure a useful comparator. iii) Activity in April in both Adults and Children’s services contacts are almost identical to 2019. iv) The waiting time position is improving, the performance against the 18-week waiting time for non-consultant led services is on track and on target at 92%.

v) The performance in Consultant-led Referral to Treatment (RTT) services remained below target with 78% recorded in April, this is an improvement upon March performance by 2%. vi) At the end of April there were 66 patients waiting over 40 weeks for treatment, this is an improvement compared to the April 19 baseline position. vii) For our services with shorter waiting time targets, the number of patients waiting over the commissioned waiting time is 1669 (with a reduction of 322 since March) - this is a 40% improvement over the April 2019 position.

Observations (O) Questions (Q) and Response (R) to Service Recovery and Performance report.

Q LS asked if diabetes patients are stable and are being well managed by the specialist nursing team do they need consultant care.

R NM advised that according to NICE guidance and when a patient has certain conditions, they are expected to be overseen by a consultant. The nursing staff are highly qualified and skilled and would escalate any issues to a consultant if required therefore patients are safe however these patients need to remain under the care of a consultant.

Q JP asked for further clarification on steps to being taken to address the backlog and increased demand for Autistic Spectrum disorder (ASD) assessments.

R NM advised that the business as usual capacity is 16 per month but this has been increased to 50-60 assessments per month, however this needs to be further increased to 100 per month which cannot be achieved without some external outsourcing support. A joint tender is currently underway with ENHT to procure some additional resource. Some significant work is being undertaken on the pathways as not all referrals will require a full assessment. A mixed model of virtual video assessments and face to face assessments are being offered.

Decision(s), Outcome(s) and Action(s)

1. The Board noted the content of the Service Recovery and

Performance Report.

77/21 Public Sector Equality Duty

The Public Sector Equality Duty was received and taken as read.

It was noted that:

i) The report was discussed in detail at the People Performance and Finance Committee (PPFC). ii) The Trust is required to publish a PSED Report each year, this year the publication was deferred due to the pandemic. iii) The PSED report analyses the workforce against the nine protected characteristics set out in the Equality Act 2010.

iv) It was noted that there cannot be a direct comparison between this PSED report and the previous report, as the workforce has changed due to the TUPE transfer out of Herts Valleys’ staff. v) The key points were noted. vi) Overall, the Trust’s PSED report shows a mixed picture and that further work is required. An action plan was included at the end of the report. vii) This report is support by other workforce reports which will be presented later in the year.

Observations (O) Questions (Q) and Response (R) to Public Sector Equality Duty

O LS commented that this was a very good report.

Q JP asked for further clarification on the actions being taken to ensure that there is equality in career progression and promotion across all the protected characteristics in the workforce. R ARy advised that as per the action plan, initiatives are being introduced to support the recruitment and promotion of people in under-represented groups resulting in the Trust’s workforce

being representative of the local population at all levels. This work is already underway but further work is required. ARy provided an update on how existing staff from all groups are being encouraged to be involved in the talent management programmes. Further work is underway in this area at system level. O SW congratulated ARy and the People team for the excellent report. SW expressed that she was pleased to see an increase in staff willingness to declare information in respect of

disabilities and ethnicity which demonstrates that HCT is a safe and inclusive organisation.

Decision(s), Outcome(s) and Action(s)

1. The Public Sector Equality Duty was approved.

People Performance and Finance Committee (PPFC) Chair’s 78/21 Assurance for the meeting held on 27th April 2021 and 25th May 2021 The PPFC Chair’s assurance report from 25th May 2021 was taken as read.

The key item for the Board’s attention: i) Due to a technical oversight only the May Chair’s assurance

report was included in the papers. As the PPFC meetings are monthly it was felt a report covering matters discussed since the last Board meeting would enable full assurance reporting to the Board in the future.

Observations (O) Questions (Q) and Response (R) to PPFC Chair’s Assurance report

O JP commented that this is likely to be a challenging year financially due to the uncertainty, there is less confidence in the delivery of the financial position this year.

R DB agreed that the next 12 months is likely to be challenging but this is the case for the whole NHS not just specifically for HCT.

Decision(s), Outcome(s) and Action(s)

1. Director of Finance and PPFC Chair to review joint assurance DB/JP reporting. 2. The Board noted the content of the May 2021 People Performance and Finance Committee Chair’s assurance report.

(F) Board Governance and Leadership

79/21 Audit Committee Chair’s Assurance report The verbal Audit Committee Chair’s assurance report from the

Extraordinary meeting held on 1st June 2021 was received.

It was noted that: i) The Extraordinary meeting received updates on the progress to finalise the accounts for the year. Good progress is being made however further work is still required before these are completed. ii) The usual timetable for preparation, completion and submission of the audited annual accounts would be by the last week of May. However, due to the pandemic the timetable has been extended with submission by 29th June. HCT’s Audit Committee agreed to actively reduce the audit period and continue to aim for the normal timelines. Whilst the external auditors acknowledged that HCT is well ahead of the rest of the NHS, the audit process is not fully completed. iii) The draft annual accounts provided will be amended slightly however the auditors have no issues of concern to raise to the Audit Committee and the accounts are 95-99% complete. iv) The Board was asked to delegate authority to the Audit Committee on 8th June to approve the final audited accounts and the remuneration report. v) The Audit Committee recommended that the Governance statements, the Quality Account and the rest of the annual report are approved today. vi) The current draft accounts show a surplus of £284k, the initial draft accounts showed a surplus of £15k but the internal team recommended adjustments to increase this surplus. vii) The Capital Resource Limit was underspent by £20k, which is an excellent achievement. viii) The hard work undertaken to get to this position in a very challenging year was recognised by RR and DB. Thanks, were extended to the James Thirgood, Christine Baker and Farhana Bhatti for the account’s preparation and for their input to improve processes over the last few months.

Decision(s), Outcome(s) and Action(s) th 1. The Board delegated authority to the 8 June Audit Committee to approve the final audited accounts and the remuneration report.

2. The Board noted the verbal Audit Committee Chair’s assurance report from 1 June 2021.

Annual Report and Governance statement 2021/21 Quality Account 80/21 2020/21 and Head of Internal Audit Opinion

As per the recommendation from the Extraordinary Audit Committee held on 1 June 2021 the Annual Report and Governance statement

2021/21, Quality Account 2020/21 and Head of Internal Audit Opinion were received and approved.

Decision(s), Outcome(s) and Action(s)

1. The Governance Statements, the Quality Account and the Annual Report minus the audited reports were approved.

81/21 Board Committee self-assessment report 80/21

The Board received the Board committee self-assessment of effectiveness report for 2020/21.

It was noted that: i) Each committee is required to undertake an annual self- assessment process. ii) The evaluation process was conducted in an open and constructive manner and focussed on the effectiveness of the committees. iii) The high-level results were shared along with the list of key lessons learned which will inform future improvements.

Observations (O) Questions (Q) and Response (R) to Board Committee self-assessment report

O JP endorsed the key themes identified for consideration and improvement, whilst acknowledging it will take time and resource to achieve the improvements recommended.

O LS agreed with the comments above.

O EHJ expressed that the framework of delegating work to the Board committees works well and allows dedicated discussion however the timetable does impact on the availability of the complete Board papers. Further discussion will be undertaken with the Executive team to review the potential and feasibility of sharing interim papers.

Decision(s), Outcome(s) and Action(s)

1. Review the potential and feasibility of providing interim papers. EHJ

2. Board Committee self-assessment report was noted.

82/21 NHS Provider Licence: Self certification for General Condition 6 and FT4 NHS Provider Licence: Self certification for General Condition 6 and FT4 were received.

It was noted that:

i) Under the NHS Oversight Framework, the Board is required to self-certify compliance with Conditions G6 and FT4 of the NHS Provider Licence although as an NHS Trust HCT does not need to hold a provider licence. ii) The 2019/20 declaration was reviewed, and minor alterations were made to update committee terminology, the outcome was discussed at the PPFC. iii) The Board, on the advice and recommendation of the People Performance and Finance Committee, were asked to consider and approve certification of compliance with Licence Conditions G6 and FT4.

Decision(s), Outcome(s) and Action(s)

1. NHS Provider Licence: Self certification for General Condition 6 and FT4 was approved.

(G) Urgent Business

83/21 None

(H) Risks Arising / Observations Action 84/21 Board Assurance Framework

The summary Board Assurance Framework (BAF) was taken as read. The Board was asked to consider whether the BAF fully reflects the strategic risks currently faced by the Trust and whether the risk scores are appropriate.

It was noted that: i) There are 11 open risks on the BAF. Two of the BAF risks have been downgraded and two risks have reached their target score:

• BAF-06 has reached its target score of 8 • BAF-07 risk score has reduced from 15 to12 • BAF-10 risk score has reduced from 12 to 8 and has reached its target score. ii) All Board committees have reviewed their aligned risks in detail. This process was deemed to be working well.

Observations (O) Questions (Q) and Response (R) to the

summary BAF

O EHJ provided further reassurance to the Board that the Executive team have discussed whether target dates should be applied to the risks. Not all risks were suitable for a target date and these would be left on the BAF for visibility as they are potentially genuine on-going risks. It is not possible to eliminate all risk but the review process in Board committees is working well.

Decision(s), Outcome(s) and Action(s)

1. The summary BAF was approved.

85/21 Summary of Risks Arising The main risks arising included:

• The financial uncertainty and risk to break even especially in month 7-12. It was acknowledged this is an NHS-wide problem although HCT may have some difficult decisions to make linked to finance and service delivery • The ongoing challenge in relation to the development of the ICS and ICPs. The developments, transformation and finances will need to focus on the best outcomes for patients • The challenges to the ongoing service recovery, also there is an additional risk in Children and Young People’s services in meeting the increase in demand within existing capacity due to the impact of the COVID-19 pandemic • The constant challenges and uncertainty around the vaccination programme.

(J) Supporting Papers / Items for Receipt and Noting Only

86/21 The following supporting papers were noted: • Disciplinary Policy • Board Governance and Leadership

• Annual Accounts • Annual Report & Governance Statements • Quality Account

(K) Date, Time and Venue of the Next Meeting

87/21 The next is meeting is 3 August 2021 time to be confirmed. The meeting will be held virtually.

(L) Questions from the Public

88/21 • No questions were received.

(M) Informal Review of the meeting i) LS commented that the meeting ran to time and the members confirmed that there was sufficient time for challenge where required.

ii) AB suggested that it would be useful to understand the standards in relation to the Discharge Home to Assess assessment process and consider if these are viable.

89/21 iii) SW commented that with HCT attending system partners meetings there is a risk that distractions will take away time that could focus on patients. LS suggested that this needs further consideration.

Meeting closed 12.55.

Board 3rd August 2021 Attachment B2

HERTFORDSHIRE COMMUNITY NHS TRUST BOARD –TRACKER

RAG Traffic Light Key:

Action in progress but Action not yet initiated Action in progress and Action in progress and not on target or target Action Complete Action Deferred but within target on target likely to miss target has expired

Minute Meeting Board Target / Item / Action Required Progress R/A/G Ref No. Date Lead Finish Date

Board Meeting 1 June 2021 Executive team reviewing Executive team to review the potential and Action in 81/21 1.6.21 EHJ/MS Sept 21 technology to facilitate earlier progress and feasibility of interim papers access to papers on target The Board delegated authority to the 8th June Delegated action taken on 8th Action 79/21 1.6.21 Audit Committee to approve the final audited DB/RR June 21 June complete accounts and the remuneration report. Chair’s Assurance reports to be reviewed to Action in 78/21 1.6.21 DB/JP Sept 21 progress and record items discussed since last Board on target Board Meeting 1 December 2020

Commitment to review and include the Engagement Strategy to August Board. Committee Action in 153/20 01.12.20 patient voice on subcommittees in line with ALL Sept 21 progress and membership will be reviewed on target Engagement Strategy once the strategy approved

Board 3rd August 2021 Attachment C1

Chief Executive’s Report

1 EXECUTIVE SUMMARY

1.1 This report provides the Board with an update on the work of our Executive Team and Trust since the last board meeting in June 2021.

1.2 The report updates on our response to the COVID-19 pandemic, our recovery of services impacted by the pandemic and our support to our people.

1.3 The report also includes updates on other key issues, including developments both nationally and locally within the Hertfordshire and West Essex Integrated Care System.

2 RECOMMENDATIONS

2.1 Board members are asked to note the contents of this report.

3 COVID-19 PANDEMIC RESPONSE AND RECOVERY

3.1 Latest position

3.1.1 HCT continues to balance its response to the pandemic – including delivery of enhanced services and the COVID-19 vaccination programme – with the delivery and recovery of our usual services.

3.1.2 Our July 2021 infographic highlighting some key areas of delivery is shown below.

3.2 Evaluation of enhanced services

3.2.1 In response to the anticipated increase of people requiring hospital beds due to the COVID-19 pandemic, and in line with national guidance and to support the East & North Hertfordshire health and social care system, HCT made significant changes to mobilise three enhanced services:

• Prevention of admission (POA) • Discharge home to assess (DH2A) • COVID-19 rehabilitation (Long COVID)

An evaluation of the impact of these services of 2020/21 has now been completed and their continuation has been supported by the East and North System Resilience Group.

3.2.2 Within DH2A, 2,899 patients have been supported at home (263% increase from 2019/20) of which only 14% had to return to hospital while on the pathway (compared to 19% in 2019/20). Flexing of the criteria for the pathway has also

enabled more complex patients (including palliative care patients) to be successfully discharged from hospital. Other key metrics include: 87% of comprehensive assessments completed within 72 hours and 87% of patients discharged from the DH2A service within the threshold set, with 60% needing no further care.

3.2.3 The POA service has diverted pressure away from hospital during the pandemic with a minimum annual cost saving opportunity of £1.56m (assuming a 30% admission rate). The service treated 4,192 patients and prevented 3554 attendances / admissions in 2020/21. 87% of accepted referrals avoided acute attendance or admission.

3.2.4 The integrated Long COVID pathway has been very well received by patients as well as secondary and primary care teams. The service has been flexible and agile in order to meet system needs and NICE guidance. 65% of patients have had more than one onward referral following initial triage with the breakdown of these shown below:

300 242 250 Number of referrals on from the Long Covid-19 200 clinic (2020/21) 131 150 100 52 35 26 24 23 22 50 15 12 12 10 7 2 1 1 1 0

3.3 Surge response and readiness for future surge

3.3.1 As well as evaluating our enhanced services, we have recently conducted surveys to encourage all staff to take some time to reflect on their experiences during the winter COVID-surge and to use their feedback to inform our future response to surges and other incidents.

3.3.2 Findings indicate that the learning from the first wave has been successfully utilised and that our approach to surge planning and activation for the winter surge has been better for our staff and enabled us to continue the recovery of our services. Nonetheless, there are still areas where further improvements can be made and we are in the process of developing an action plan to address these and to update our Surge and Activation Plans.

3.4 Service Recovery

3.4.1 Recovery of our usual services continues to progress well alongside delivery of our COVID-19 response and is the subject of the separate ‘Service Recovery and Performance Report’ paper to Board.

4 STRATEGY DEVELOPMENT

4.1 Clinical Strategy

4.1.1 HCT is currently developing its Clinical Strategy which will explain how we want to develop our services and the way we deliver care to patients and the wider population to improve their outcomes, their experiences and to contribute to the reduction of health inequalities within the wider population. Whilst the strategy is still in development, we have worked with our staff, stakeholders and patient representative groups to develop cross-cutting clinical priorities which will influence how we think about our services and how we can improve them. At a high level, these cross-cutting priorities are:

• Integrated care • Improving physical and mental health outcomes • Personalised care closer to home • Reducing health inequalities • Supporting and growing our people

4.1.2 In developing this strategy, we have engaged early and meaningfully with our system partners to ensure that wherever possible we reduce duplication, align our strategic aims and work together to improve care for the people we serve. This engagement has included other NHS Trusts, hospices, commissioners, Hertfordshire County Council, Primary Care Networks and stakeholders from our Integrated Care System and Integrated Care Partnerships.

4.1.3 We have engaged heavily with our staff to develop the priorities for each of our service areas to ensure a ‘bottom up’ approach, so that we are using the skills, experience and expertise of our staff to tell us what changes we need to make. Formal sign off by Trust Board is expected in October 2021.

4.2 Patient Engagement and Experience Strategy

4.2.1 We have developed a new Patient Engagement & Experience Strategy which reflects HCT’s commitment to working in partnership with patients, the public and local communities. The strategy is the subject of a separate paper to the Board.

5 SUPPORTING OUR PEOPLE

5.1 Workforce KPIs

5.1.1 Our workforce KPIs targets for 2021/2 have been reviewed and new targets agreed and shared with PPFC. The Trust vacancy rate went up between April and May, but this was due to an additional 70 funded posts being added to the budgeted establishment. The number of staff in post has remained stable at 2150 over the last few months, but worth noting that this is 110 more people than we employed this time last year (these figures exclude mass vaccination centre workers). Sickness is fractionally up, but of more concern is the increase in staff not actually sick, but having to self-isolate (up to 90 staff in the week commencing 19th July 2021). This continues to be monitored daily.

2020/21 2021/22 May KPI April 2021 June 2021 Target Target 2021 Vacancy % 11% 10% 8.1% 10.9% 10.4% Turnover - Underlying % 14% 12% 11.0% 11.0% 11.7% Sickness Absence % 3.7% 3.5% 2.7% 3.0% 3.2% Mandatory Training % 90.0% 90.0% 95.6% 94.4% 94.4%

5.2 People Plan

5.2.1 The Trust People Plan 2021/2 has been finalised and shared with PPFC. This is the annual delivery plan for implementation of the People Strategy 2021-25, and progress against this will be monitored regularly via the People and OD Strategy Steering Group. Key priorities for this year include: completing the cultural and leadership diagnostic programme, developing our workforce planning processes, implementing a range of new staff health and wellbeing initiatives and improving representation of disadvantaged groups at all levels of the organisation.

5.3 Staff Health and Wellbeing

5.3.1 We ran our first Schwartz round on the 14th July, with the theme ‘in at the deep end’. The feedback from those involved was that they found this very powerful and moving. Participants reflected that the stories shared at the session resonated with them and they were reassured to find they were not alone. Rounds will now be run regularly, with the next one taking place on the 15th September, with the theme ‘meaning of hero’.

5.3.2 We have now filled all 70 of the available licences for the Peppy Menopause app (with excellent feedback) and have submitted a bid with ICS partners for further work to support our staff on menopause. We have also been successful in our ICS bid for national funding to support staff with Long COVID and have trained the first cohort of Mental Health First Aiders. In addition, we are working with our Staff Side partners to

review what more we can do to support our staff, recognising our shared concern about current low levels of resilience.

5.4 Equality, Diversity and Inclusion

5.4.1 Following advert and interview , we are pleased to have appointed Tinu Fakoya into the role of Head of Equality, Diversity and Inclusion (ED&I) on a 6 month secondment. Tinu, who is also our BAME Network Chair, has already been covering parts of this role on a part time basis, but we are delighted that she will now be joining the People Team full time. Trialling this new full time role reflects our increased focus on inclusion and will support delivery of our ambitious plans going forward. The main focus for ED&I in recent weeks has been on gathering data for our Workforce Race Equality Standard (WRES), Workforce Disability Equality Standard (WDES) and Gender Pay Gap reports and the WRES and WDES Reports 2021/21 are included in the papers for Board approval.

5.5 Cultural and Leadership Diagnostic programme

5.5.1 We are now re-starting the programme to analyse our organisational culture using the NHSI cultural diagnostic tool after pausing during the pandemic. We have added to our cohort of ‘Change Makers’ (promoting this as a development opportunity for those who have recently undertaken our Talent 6-7 Realising Your Potential programme) and are running a series of focus groups for staff during July and August. We will also be encouraging staff to complete a leadership survey. The outputs from these will be added to analysis of our Annual Staff and new Pulse Survey results and other feedback mechanisms. The full outcome of the diagnostic programme will be shared with staff in the Autumn in order to co-design the next steps.

5.6 Staff Recognition

5.6.1 Over 160 nominations were received for our 2021 Leading Lights awards and the judging panel had a difficult time choosing between all the fantastic entries. Our Leading Lights celebration event will take place on the 14th September 2021 and plans are proceeding for holding this back at Tewinbury Farm again (pandemic permitting). In recognition of the fact that we may need to control numbers, we are investigating the possibility of also live-streaming the event.

6 DELIVERY PLAN & PRIORITIES FOR THE YEAR

6.1 The Trust Delivery Plan for 2021/22 has been developed and is due for discussion and approval by the Strategy Planning and Engagement Committee in July. The Delivery Plan includes three main transformation programmes, three key enabling programmes; plus ongoing work with system partners on a range of ICS priorities. Priorities for the Delivery Plan include:

• continuing service recovery and reducing the backlog • planning for winter/COVID-19 demand surge(s) • continuing delivery of the COVID-19 vaccination programme • clinical transformation with a focus on Hospital at Home, services for the frail and roll-out of the Target Operating Framework (TOF) • customer service transformation • digital transformation • system transformation and pathway redesign • quality improvement • delivery of our people & OD and estates programmes • partnership and growth

7 NATIONAL AND LOCAL SYSTEM UPDATES

7.1 Integrated Care Systems Design Framework

7.1.1 NHS England and NHS Improvement (NHSE/I) published the Integrated Care System (ICS) Design Framework on 16th June 2021 which sets out the operating model for ICSs from April 2022 following the enactment of the Health and Care Bill. ICS NHS bodies will be statutory organisations that bring together all organisations involved in planning and providing NHS services within their footprint to take a collaborative approach to agreeing and delivering ambitions for the health of their population. Once an ICS NHS body has been established, NHSE/I expects that all CCG functions and duties will transfer over, including CCG assets and liabilities, commissioning responsibilities and contracts.

7.2 New CQC Five Year Strategy

7.2.1 The Care Quality Commission (CQC) has launched its new five-year strategy which combines its learning and experience over the past five years with contributions from its stakeholders and partners. The new strategy builds on the four thematic areas of focus: people and communities; smarter regulation; safety through learning; and collaborating for improvement. It restates CQC’s commitment to ensuring health and care services provide people with safe, effective, compassionate, high-quality care, and to encourage those services to improve. Running through each of the four areas of focus within the new strategy are two core ambitions, which are to assess local systems and tackle inequalities in health and care.

7.3 Green Plan

7.3.1 In June 2021 NHS England produced updated guidance on producing a trust or ICS Green Plan. To support the co-ordination of carbon reduction efforts across the NHS and the translation of the national strategy to the local level, the 2021/22 NHS Standard Contract sets out the requirement for trusts to develop a Green Plan. This has been expanded to include the expectation that each ICS develops its own Green

Plan, based on the strategies of its member organisations. The guidance sets out three clear outcomes:

• to ensure every NHS organisation is supporting the NHS-wide ambition to be first healthcare system to reach net zero • to prioritise interventions that improve patient care and community wellbeing whilst tackling climate change and broader sustainability issues • to support organisations to plan and make prudent capital investments whilst increasing efficiencies. In the ‘Delivering a ‘Net Zero’ National Health Service’ report, two clear and feasible targets were outlined for the NHS:

• The NHS Carbon Footprint: for the emissions we control directly - net zero by 2040 • The NHS Carbon Footprint Plus: for the emissions we can influence - net zero by 2045 7.3.2 HCT is committed to being a sustainable healthcare provider that acts responsibly to minimise our impact on the environment and reduce our carbon footprint in line with national targets and is working to develop and deliver its Green Plan. We have allocated funding in our capital plan for this year and future years to enable delivery as part of a broader programme of work.

7.4 Hertfordshire and West Essex Integrated Care System (ICS) Update

7.4.1 The Trust continues to engage with the system partners at ICS and ICP level and has been collectively working to understand how the system can best respond to the Health & Care Bill. The Board was grateful to representatives from the ICS and HWE ICPs who joined a Board Development Session to provide a briefing and discuss their priorities and plans with the Board.

7.4.2 Within East & North Herts (ENH) ICP we have continued to work with partners across a range of issues to support the health and wellbeing of the population. This has included the establishment of a joint programme in ENH to improve and expand enhanced services to help both reduce the elective waiting list and improve patient flow through Lister hospital. This programme of work is being jointly chaired by myself and Nick Carver at East and North Hertfordshire NHS Trust (ENHT). We continue to progress the development of models of collaboration with ENHT and have been part of a joint bid to develop the first phase of a community diagnostic hub in ENH. The Partnership Board of the ENH ICP has agreed a Memorandum of Understanding and that the partnership’s priority is to drive improvement and make a positive difference for patients alongside planning for the revised ICS architecture from April 2022.

7.4.3 Within the South and West Herts Health and Care Partnership a high-level model for the Health and Care Partnership Strategy has been tested with Integrated Clinical Advisory Group (ICAG) with development continuing based on their steer. A review of the governance arrangements within the partnership and the interaction with constituent organisations has taken place and a shadow Partnership Agreement has been developed. Work has also continued on future planning and discussions on the alignment of those plans with other place based partnerships, the Mental Health and Learning Disability Collaborative and the ICS are ongoing. A business case for Virtual Hospital (Including all phases of COPD and Heart Function virtual pathways) has been developed along with an implementation plan to launch on 1 November 2021.

7.4.4 Within the Mental Health and Learning Disabilities Collaborative the focus has been on receiving the latest Joint Strategic Needs Assessments (JSNA) for adults and children and young people’s (CYP) mental health alongside the NICHE report looking at the impact of COVID-19 on the anticipated demand for mental health services. All providers, including HCT services for Child and Adolescent Mental Health (CAMH), are seeing a rise in demand and an increase in the severity of need and this is expected to continue. We welcome the agreement to develop the approach to the review of adult services for autism to encompass neuro-diversity more broadly as this aligns with the CYP approach to autism and neuro diversity. The partnership continues to develop its future plans in alignment with the other place based partnerships and the ICS.

8 TRUST UPDATES

8.1 Key changes in our senior leadership team

8.1.1 The Trust has recently appointed two new Board members. Rukshana Kapasi has been appointed as a Non-executive Director (NED) and Rohan Sivanandan as an Associate NED. We would like to welcome both Rukshana and Rohan to the Trust and look forward to working with them in their new roles.

8.1.2 Following a period of working as joint Director of Strategy at East and North Hertfordshire NHS Trust (ENHT) and HCT since October 2020, Sarah Brierley is to move to HCT on a full time basis from August until March 2022. This will enable her to dedicate more time within HCT to leading the development of strategy and the transformation of community services, further building and strengthening collaboration with partners for the benefit of our patients.

8.2 Awards

8.2.1 In June 2021 the Trust was awarded a Stars in the Sky award for the work of the Lymphoedema, Leg Ulcer and Tissue Viability service during the COVID-19 pandemic. Wound Care People, in partnership with the Journal of Community Nursing (JCN), the Journal of General Practice Nursing (GPN), Wound Care Today

and Juzo UK, have awarded the HCT Tissue Viability Service teams the ‘Extra Bright Stars’ prize as a way of saying thank you for all they have done during the pandemic.

8.2.2 Nominations have been submitted for the Health Service Journal (HSJ) Awards 2021 in the categoies of:

• Clinical Leader of the Year category (Dr Elizabeth Kendrick). • Provider Collaboration of the Year category (Long COVID pathway)

The shortlist will be announced on 24 August with winners announced at the awards ceremony on 18 Nov 2021 at the “Evolution” venue in London.

8.2.3 Dr Harsha Master has been nominated in the GP of the year award category of the British Medical Journal (BMJ) Awards 2021 for her work on Long COVID. The shortlist will be announced in July 2021 with virtual awards ceremony taking place on 29 September 2021.

8.3 Other key updates

8.3.1 There are separate Board papers covering Infection Prevention and Control and the Mass Vaccinations programme.

8.3.2 Other updates are included in the Board report from Director of Finance, Systems and Estates and in the report from the Chief Nurse and Medical Director.

END OF REPORT

Board 3rd August 2021 Attachment C2

TRUST BOARD

Title: Month 3 2021/22 Finance Report

Meeting Date: 3rd August 2021

Executive Lead: David Bacon: Director of Finance, Systems and Estates

Author(s): James Thirgood: Deputy Director of Finance, Systems and Estates

For: Note / Discussion

Risk Rating: Amber/ Green

1.0 Purpose & Recommendations

To advise the Trust Board regarding the month 3 2021/22 financial position for the year. The Trust continues to operate under the revised emergency financial arrangements.

The Trust’s current plan for M1-6 has a profiled position as follows:

Month M1 M2 M3 M4 M5 M6 In month position £388k 0 (£24k) 0 0 £24k YTD £388k £388k £364k £363k £364k £388k position

As at month 3 the Trust is reporting a surplus YTD position of £364k. which is in line with plan. While potential savings and underspends have been identified, the certainty and their value are still being reviewed between finance and PMO functions.

The Trust Board are asked to:

(1) Note that the Trust is reporting achievement of the planned position for month 3 Surplus YTD £364k.

(2) Recognise that while some Performance Improvement and Efficiency Schemes have now been identified for 2021/22 work is still to be completed to ensure achievement.

(3) Recognise the level of Trade Receivables and Payables.

(4) Recognise the Trust cash movements

(5) Raise any issues / concerns.

2.0 Key Points for the Attention of the Trust Board

a. Income and Expenditure (I&E) position

• The Trust is reporting a surplus position of £364k for the YTD to month 3. This is in line with the submitted plan which has been profiled across the first half of the financial year.

Summary Income & NHSE/I Actual Variance Expenditure 2021/22 indicative Plan YTD YTD £’000s YTD M1-M3 M1-M3 M1-M3 Income 30,096 34,213 4,117 Employee Costs (21,614) (24,641) (3,027) Non pay Expenditure (8,235) (9,325) (1,090) Net Finance costs (245) (245) (0) Adjustments 362 362 (0) Total Surplus/Deficit 364 364 (0)

• The overall Trust surplus has been made by the sale of assets on 1st April 2021 which made a surplus of £362k and in total all other services across the Trust reporting a breakeven position Month 3 YTD. The Trust is currently in the process of applying to NHSE/I to utilise the surplus to support the capital plan funding.

• The national emergency funding arrangements (block contracts) implemented in 2020/21 have been extended for H1 2021/22. Further guidance from NHSE/I is not expected to be announced until September 2021. Therefore, all the Trust's planning and reporting (with the exception of capital) are only being forecast to 30th September 2021 as per NHSE/I national reporting requirements.

• The current funding arrangements include £210k each month for COVID-19 related expenditure and £967k each month 'Top-up' funding.

• The Trust expects to continue to be reimbursed in full for the expenditure it incurs for the Mass COVID Vaccination Programme (MCVP). Expenditure for the MCVP was £5,787k YTD Month 3.

• The variances against Plan across pay, non-pay and income, YTD and forecast outturn (FOT) are largely as a result of the MCVP. b. COVID-19 costs • The Trust has an allocation of £210k per month within its month 1 -3 funding for COVID-19 costs over and above the enhanced services. The Trust has actively worked with budget holders to challenge costs and ensure we do not exceed the budgeted value. c. Productivity Efficiency Improvement Schemes (PIES) • NHSE/I are yet to finalise the total value of PIES expected for H2 2021/22. The Trust is expecting future efficiency requirements to be at a level more closely aligned to the NHS Long Term Plan and as part of developing the pipeline of schemes, has set an indicative PIES target of circa £3,500k.

• Included in the Trust’s Month 3 YTD surplus position are recurrent and non- recurrent PIES achieved of £302k (including £288k of recurrent PIES).

d. Capital Expenditure • The Trust set a Capital plan totalling 2021/22 for £8,077k. Funded through depreciation charges of £4,200k, the sale of assets £1,100k and use of £2,777k of cash reserves. The Trust has sold assets in April 2021 that provide the funding of £1,100k assumed in the plan.

• As at Month 3, the Trust's capital expenditure is £2,146k YTD against plan £2,731k YTD (£585k behind plan).

• There are 2 significant risks to the capital programme: 1. There are a number of business cases accounting for a significant proportion of the capital plan value that have still to be completed. 2. There is a risk that the costs of approved capital schemes will increase due to UK and worldwide shortages of raw materials

e. Cash plan • The cash balance at month 3 is £36,707k compared to M12 2020/21 (£42,601k) a fall of £5,894k. The net movement in month 3 is a fall in cash held of £1,670k summarised between receipts and payments in the table below.

Summary M3 Receipts £9,556k Payments (£11,226k) Net cash Mvt (£1,670k)

f. Deferred income • The deferred income in other liabilities has decreased by £2,933k YTD Month 3 compared to the prior year. This is in the main due to income that was funded in advance for the MCVP in March 2020/21, £3,889k which has now been fully spent YTD Month 3. • Deferred income of £3,198k relates to CYP services, where actual activity is lower than the scheduled income payments made to the Trust. • £302k relates to income deferred for Enhanced services, where activity YTD is catching up with scheduled payments from East and North Hertfordshire CCG. • £597k relates to the deferral of training income; the Trust is now working hard to accelerate staff training deferred during the pandemic in 2020/21. h. Receivables and Payables Receivables: • The Finance Team continue to work on reducing NHS receivables balances through the agreement of balance exercise and on going communication with relevant organisations. • Outstanding trade receivables decreased by £526k in Month 3 to £2,441k (£2,967k Month 2 2021).

Payables: • Outstanding payables increased by £701k to £5,913k (£5,212k M2 2021). i. Better Payment Practice Code • In Month 3 94% of all of the Trust's invoices by volume have been paid within target and 93% by value. The volume and value of NHS invoices was lower this month, in the main due to SLA reviews outstanding, that are due to be completed shortly. Non NHS invoice payments this month were within target - 96% by volume and 95% by value. • Month 3 YTD the split of all invoices paid within target and by volume & value is 95% and 96% respectively.

j. Mass COVID-19 Vaccination Programme • Month 3 YTD expenditure by the Trust for MCVP is £5,787k (£4,619k pay costs and £1,168k non pay costs). • Forecast expenditure on the programme to Month 6 is £15,184k • The Trust submits regular detailed reporting returns on the programme to NHSE/I and will be fully funded by NHSE/I for all expenditure incurred.

k. Business cases • The Trust has set up a Business Case Surgery to improve the turnaround of cases and support colleagues across the Trust in solving problems and completing business cases, while ensuring all support services are aware of the issue and can support in a timely manner. These meetings have been set up to take place on a monthly basis initially but can be flexed to suit the workflow of the cases being developed.

3.0 Relevant Strategic Objective(s) / Strategies

3.1 This report links to the following Trust Strategic Objectives

1. Outstanding quality and performance 2. Best Value through Innovation

4.0 Risks and Mitigation Plans

Risk Mitigation / Action(s) PIES Target of £3,500k has In 2021/22 following the necessary reduction in PIES identified been set for 2021/22 during the pandemic, the planning and implementation of PIES by Finance, PMO and Strategy teams is now underway again. There is a requirement for the Trust to identify new work streams to make up the shortfall in PIES.

Completion of the Capital Plan There are both global and national shortages in materials and delays in the purchasing in ICT, impacting on the delivery of estate projects and increasing costs. The Trust’s progress against the capital plan continues to be monitored and mitigating actions considered and implemented.

5.0 Quality / Service / Regulatory Impacts

None

6.0 Resource Implications

None

7.0 Actions / Next Steps / Timelines

None

8.0 References, Appendices & Supporting Information References – None Appendices & Supporting Information – See end of this report.

9.0 Glossary / Abbreviations

Author(s) of paper:

James Thirgood Deputy Director of Finance 26th July 2021

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): PPFC 27th July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive David Bacon Director of √ director who is satisfied that (i) the implications for risks, (ii) Finance, Systems and Estates quality/service/regulatory impacts and (iii) resource implications, have been considered.

Company Secretary Sign-Off (Board papers only)

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

Trust Board

Title: Month 3 Finance Report (June 2021)

Sponsoring Director: Director of Finance, Systems and Estates

Author(s): Finance Department

Purpose: The purpose of the report is to provide the Trust Board with HCT’s financial position as at Month 3 – 2021/22.

Action required by the Trust Board:

The Trust Board is asked to note the Trust’s financial position as at 30th June 2021.

Contents

1. Director of Finance, Systems and Estates Key Messages

2. Statement of Comprehensive Income and Expenditure

3. Statement of Financial Position

4. Cashflow Statement

5. Risk to Control Total Achievement

6. Productivity Improvement and Efficiency Schemes (PIES)

7. Income

8. Pay expenditure

9. Non pay expenditure

10. Mass COVID-19 Vaccination Programme Spend

11. Agency staff expenditure

12. Better Payment Practice Code

13. Capital Spend

Director of Finance, Systems and Estates Key Messages

As at month 3 the Trust is reporting to be on plan with a reported surplus of £364k. The underlying plan and performance for the Trust is a break-even each month, with the surplus being the result of a surplus on the sale of one asset from 1st April 2021. The Trust remains operating under emergency financial arrangements for the first half of this financial year and will update the committee when it becomes clear what the second half of the year looks like.

The level of scrutiny to financial performance, on revenue has been extended to include timely payment to non NHS suppliers (Better Payment Practice Code) and capital spend. This alongside further financial planning for H2, a revised long-term plan, ICS and ICP collaboration and reporting is presenting significant challenges for the Trust’s finance team resources. The finance team continue to support internal functions for tenders, contracts, procurement, PIES, business cases and the implementation of Patient Level Costing.

The Trust capital spend programme is slightly behind plan, though assurances are being gained from estates via the Capital Investment Group that these will be brought back in line with planned levels of spend. Global and national risks about the availability of materials are impacting on the pace of the capital programme and may lead to increases in costs. The creation of the Trust’s new Business Case Surgery should enable capital business cases to be completed and approved promptly so that schemes can get underway.

Board 3rd August 2021 Attachment C2

Board 3rd August 2021 Attachment C3

TRUST BOARD

Title: Integrated Care System (ICS) and Integrated Care Partnerships (ICP) Collaboration Update

Meeting Date: 3rd August 2021

Executive Lead: Sarah Brierley – Director of Strategy & Transformation

Author(s): Sarah Brierley – Director of Strategy & Transformation Adam Levy – Assistant Director Strategy & Transformation

For: Assurance and Discussion

Risk Rating: Amber/Red

1.0 Purpose & Recommendations

• The purpose of this paper is: o To provide an update for the Board on the key areas of collaboration between HCT and our partner organisations o To provide assurance for the Board that the necessary attention is being placed on enhancing our understanding of and relationships with key partners and embedding collaboration across the environment in which we operate.

• The paper outlines how we are collaborating and current priority areas in collaborating in a number of systems and areas in which we operate: o Hertfordshire & West Essex ICS o West & South Health & Care Partnership o East & North Hertfordshire ICP o Mental Health & Learning Disabilities Collaborative o Hertfordshire County Council o Primary Care

2.0 Key Points for the Attention of the Board • Following the publication of the ICS Design Framework (June 2021), significant work is being undertaken to prepare the ICS for transition to a single statutory organisation from April 2022. • Each ICP is still working on developing their governance arrangements and are doing so in different ways, details outlined within the attached paper • We are proactively working in each ICP and with all strategic partners to enhance opportunities through collaboration to support delivery of outstanding care, delivering best value for money and supporting patients to achieve best outcomes and experiences

2.0 Relevant Strategic Objective(s) / Strategies

2.1 This report links to the following Trust Strategic Objectives:

1. Outstanding quality and performance 2. Joined-up local care 3. Great place to work 4. Best value through innovation

3.0 Risks and Mitigation Plans

Risk Mitigation / Action(s) There is a risk of failure of • Executive Team leadership in a wide range of high-level HCT to enhance and system meetings sustainably expand the • Targeted relationship management of key stakeholders, reputation, role and including CEOs, Chairs, and senior managers in regulatory contribution of its integrated community services for the bodies. benefit of the • Refresh of Trust & enabling strategies to ensure a ‘golden population/communities that thread’ in Trust-wide activities we serve. (BAF 02 risk) • Joint exploration of alternative models of care in collaboration with other providers • Regular discussions at Executive Team level with commissioners to make colleagues aware of demand challenges and what this entails for the Trust’s services. • Regular attendance at policy briefings to ensure awareness of up-to-date changes in policy at both the local and national levels. • Enhancing HCT's business development/relationship management capacity and capabilities

4.0 Quality / Service / Regulatory Impacts n/a

5.0 Resource Implications n/a

6.0 Actions / Next Steps / Timelines 6.1 Collaboration will continue to be a key priority for the organisation and updates will be brought to each SPEC meeting for assurance

7.0 References, Appendices & Supporting Information n/a

8.0 Glossary / Abbreviations n/a

Author(s) of paper: Sarah Brierley – Director of Strategy & Transformation Adam Levy – Assistant Director Strategy & Transformation August 2021

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: n/a Committee: Date (Month / Year): Strategy Planning& Engagement Committee July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive Sarah Brierley – Director of √ director who is satisfied that (i) the implications for risks, (ii) Strategy & Transformation quality/service/regulatory impacts and (iii) resource implications, have been considered.

Company Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Assistant Board Secretary √ / x

Board 3rd August 2021 Attachment C3

Integrated Care System (ICS) and Integrated Care Partnerships (ICP) Collaboration Update

1. Purpose The purpose of this paper is to provide an update for Trust Board on the key areas of collaboration between HCT and our partner organisations. This paper is designed to provide assurance for Trust Board that the necessary attention is being placed on enhancing our understanding of and relationships with key partners in support of our strategic aims and embedding collaboration across the environment in which we operate. 2. Background and strategic alignment The NHS Long Term Plan is clear that collaboration and cooperation is fundamental in the way that the NHS needs to operate going forward. NHS Trusts are expected to work alongside partner organisations to ensure that patients achieve the best outcomes, with seamless care across organisational boundaries, whilst providing the best value for money for the tax paying public. The current Health and Care Bill lays out proposed NHS legislative changes building on the ambition set out by the NHS Long Term Plan. The statutory establishment of Integrated Care Systems (ICSs) and the development of Place and Provider Collaboratives are set out the structural foundations for collaboration going forward. Whilst there is some slightly different messaging coming out of the Department of Health due to having a new Health Secretary, it is still expected that the White Paper will be approved into law with minimal changes by the start of the next financial year. Additionally, at this stage, it is not expected that the new NHSE Chief Executive would significantly impact on the legislation or the direction of travel in terms of implementation. In March 2021 the Trust Board signed off HCT’s new organisational strategy which, as one of the four strategic objectives, reaffirms our commitment to ‘joined up local care.’ Additionally, in the other three strategic objectives we make clear that working with partners will be a central aspect of how we operate going forward.

3. Collaboration update; July 2021 This section provides an update on how we are collaborating with each different part of the system in which we operate.

3.1.1 Hertfordshire & West Essex ICS Following the publication of the ICS Design Framework (June 2021), significant work is being undertaken to prepare the ICS for transition to a single statutory organisation from April 2022. The Health and Care Bill is, by design, flexible and permissive, meaning that it does not specify expected governance arrangements. Therefore, ICPs remain in the position where they are preparing for the legislation to be enacted so they can respond quickly at that point, reflecting any changes to the anticipated text. Each ICP is still working on developing their governance arrangements and are doing so in different ways. For example, the MH&LD Collaborative has gone down the route of developing a formal MoU, whereas ENH ICP is developing a strategy whilst pressing forward with crucial pieces of work that can then fit in with formal governance changes following the legislative changes expected in April 2022.

1 Board 3rd August 2021 Attachment C3

This is being done through the following stages: • Q1 & Q2 2021/22 – Developing memorandums of understanding, identifying ICP priority areas and developing proposed governance mechanisms • Q3 & Q4 2021/22 – On the back of the MoU, adopting agreed governance mechanisms and operating as a cohesive ICP in shadow form. It is unlikely that there will be any commissioning responsibilities formally devolved to the ICP at this point • Q1 2022/23 – Assuming that the NHS Legislation proceeds through Parliament as expected, ICSs will be established as statutory bodies with the ability to devolve spending and commissioning responsibilities to ICPs.

3.2 West and South Health & Care Partnership (formally Herts Valleys ICP) We primarily collaborate within the West & South Hertfordshire Partnership on our Children and Young People Services and are embedded within the forums and partnership groups seeking to enhance the physical and mental health care that children and young people receive in the west and south of the county. Current focus within this partnership is on the establishment of appropriate governance arrangements and agreement on a set of joined-up transformation priorities. As part of our role as provider of CYP services in West & South Hertfordshire, we are working with ICP partners in the development of the new ICS Children & Young People Strategy. Our Deputy Director for Children & Young People Services is heavily involved in this work and we have had a good level of senior representation and involvement at the strategy development workshops including our CEO and Medical Director. We are also engaged in a number of current ICP focus areas including: • Development of integrated CYP respiratory/wheeze service (joint with WHHT and primary care) • ASD system improvement and redesign • Improving care coordination for children and young people with complex health and social care needs • Developing the Hertfordshire & West Essex ‘Healthier Together’ website (launched w/c 12th July)

3.3 East & North Herts Integrated Care Partnership ENH ICP Strategy – the East & North Hertfordshire ICP is developing a strategy that will identify the key ICP-wide priorities and the ways in which the ICP organisations can work collaboratively to achieve the best outcomes for patients and best value for money. Crucially, the strategy will identify how partners will work together where no single organisation can achieve best outcomes on their own, in particular focussing on reducing health inequalities.

ENH ICP Transformation Prioritisation – ICP partners are working together to ensure that transformation initiatives are appropriately prioritised to focus on areas that will deliver the greatest benefits to patients and the system. In addition, work is continuing to build on the successes of collaborative working undertaken during the pandemic response, seeking to enhance the way we use technology, personalise care, enable patients to remain in their home to avoid hospital admissions and facilitate earlier discharge of patients where possible.

Community Diagnostic Hubs – we are working with ENHT, PCNs and other colleagues within the ICP to develop a model for Community Diagnostic Hubs (CDH). There is a national priority to expand diagnostic capabilities and capacity across the NHS and enhancing the level and amount of diagnostic capabilities that are available within community settings. This will contribute to the reduction of waiting lists, support elective recovery and seek to address inequalities in access to diagnostics.

2 Board 3rd August 2021 Attachment C3

Collaboration with ENHT – ENHT has recently announced the appointment of their new Chief Executive who will replace Nick Carver following his retirement in December. We would like to congratulate Adam Sewell-Jones on his appointment and look forward to working closely together to maintain and enhance collaborative opportunities and leadership of the ENH ICP to deliver best outcomes and experiences for the patients and service users we serve.

3.4 Mental Health & Learning Disabilities Collaborative The MH&LD Collaborative (previously called ICP) was established to ensure that there is sufficient focus on mental health services within Hertfordshire. Our main interaction with the MH & LD partnership is around our Children & Young People Services, particularly CAMHS (Child & Adolescent Mental Health Services). We are embedded within the CAMHS transformation work across the local system which, overseen by the Emotional Health & Wellbeing Board, aims to increase the volume of appropriate mental health support for children and young people. Recent priority within the MH&LD Collaborative has been to understand changes in demand for mental health services as a result of the pandemic. The Collaborative is now seeking to develop a joint proposal for its structure and activities.

3.5 Collaboration with Hertfordshire County Council We collaborate with Hertfordshire County Council in a number of ways, including collaborative service delivery (e.g. our Integrated Community Teams work with HCC Social Workers) and where HCC commission HCT, particularly for a range of children services. Through the development of our clinical strategy, we have identified the need to enhance and deepen our strategic engagement with HCC. This is being taken forward by the Executive Team and we welcome the addition of John Wood as Board Advisor in this respect.

3.6 Collaboration and Engagement with Primary Care We continue to engage with Primary Care Networks in East & North Hertfordshire and have undertaken a significant piece of work listening to GPs and staff regarding mutual communication needs and perceptions. PCNs are a hugely important system partner and we are keen to enhance collaboration opportunities that can provide best outcomes and experiences for patients As part of the clinical strategy engagement work we have discussed with South & West Hertfordshire CCG and PCN colleagues that it would be valuable to increase and enhance our engagement with PCNs in the South and West of the County. This will help us quickly identify and address any issues that arise as well as ensuring we build strong working relationships with stakeholders and partners across all areas in which we operate.

4. Recommendation Trust Board is asked to note this report and consider the level of assurance provided in relation to ICS and ICP collaboration

3 Board 3rd August 2021 Attachment C4

TRUST BOARD

Title: Patient Engagement and Experience Strategy 2021-2024

Meeting Date: 3rd August 2021

Executive Lead: Sarah Browne, Director of Nursing & Quality

Author(s): Cath Slater Deputy Director of Nursing

For: APPROVAL

Risk Rating: Green

1.0 Purpose & Recommendations

1.1 To advise the HCT Board regarding the purpose of the strategy which sets out the Trust’s commitment to use feedback from people who use our services to develop our services and demonstrating changes, improvements and improved experience as a result, confirming the actions required by teams to achieve the outcomes in the strategy.

1.2 To ask the Board to:

Approve the Patient Engagement and Experience Strategy 2021-2024.

2.0 Key Points for the Attention of the Board

2.1 Regular and purposeful engagement and experience feedback benefits patients, the public, the organisation (and our staff) and partner organisations.

2.2 HCT’ s commitment to work in partnership with our communities when reviewing services and ensuring that our patients and their representatives are instrumental in shaping and designing our future services, acknowledging the importance of our patient engagement within our CQI approach.

2.3 Recognising the importance of linking to the local partnerships already in place across our local area and the engagement plans of our Clinical Commissioning Groups (CCGs) and council partners

3.0 Relevant Strategic Objective(s) / Strategies

3.1 This report links to the following Trust Strategic Objectives

1. Outstanding quality and performance 2. Joined-up local care 3. Great place to work 4. Best value through innovation

4.0 Risks and Mitigation Plans

Risk Mitigation / Action(s)

5.0 Quality / Service / Regulatory Impacts

5.1 This strategy will be an essential part of the assurance process for CQC and was highlighted as a gap in our last CQC inspection

6.0 Resource Implications

6.1 Not currently known, there may be some resource implications in identifying volunteer support this is currently being scoped.

7.0 Actions / Next Steps / Timelines

7.1 Review and monitoring through the Clinical Governance subcommittee and the patient engagement forum

8.0 References, Appendices & Supporting Information None.

Author(s) of paper:

Name: Cath Slater Designation : Deputy Director of Nursing Date (14/07/2021)

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): Strategy Planning and Engagement Committee July 2021 Executive Team July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive director Sarah Browne √ / x who is satisfied that (i) the implications for risks, (ii) Director of Nursing & Quality quality/service/regulatory impacts and (iii) resource implications, have been considered.

Company Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Assistant Board Secretary √ / x

Patient Engagement and Experience Strategy 2021 – 2024

HCT Board August 2021 HCT’s commitment to engaging with our patients and communities in a meaningful way.

HCT is committed to working in partnership with patients, the public and local communities to ensure that our services are responsive to local needs and that patients, the public and wider stakeholder communities are involved in to help improve and develop our services. HCT believes that the quality of care we deliver will be improved by engaging with and by learning from the experience of patients, their families, carers and the wider community. The three-year strategy outlines how HCT will aim to continue to provide exceptional experiences to all who use our services and, with their involvement and the involvement of the wider community, further develop and improve the quality of services. SWOT analysis

Strengths: • Well connected and established relationships with key voluntary and community organisations • Effective use of patient stories to board. • HCT staff passionate about the patients being at the centre of the care we provide. Weaknesses: Lack of engagement with the smaller volunteer organisations. Reduced patient experience team resource in HCT. No systematic processes for co design SWOT analysis cont’d

Opportunities: The pandemic is an opportunity to reset HCT in the community. An opportunity to embed patient engagement in service development. To better understand what our patients and communities need. Threats: Operational pressures in current climate. Time constraints for staff to engage. Risk of becoming stagnant in our apporcah. Purpose of this Strategy

The purpose of this strategy is to set out the Trust’s commitment to use feedback from people who use our services and demonstrating changes, improvements and improved experience as a result: • Develop a culture that places excellent patient experience and continuously improving patient safety at the heart of everything we do. • Establish the principles and expectations for involving patients. • Commit to embedding an assisted communication tool within services. • Make meaningful changes to services based on feedback which reflects the needs of our communities. • Seek out and learn from good and outstanding practice within HCT and in other organisations and share this learning across the organisation. Key headlines….

Regular and purposeful engagement and experience feedback benefits patients, the public, the organisation (and our staff) and partner organisations. Outcomes for patients, the organisation, partner organisations and regulators. We acknowledge the importance of our patient engagement within our CQI approach. Key priority areas: • Communicate • Actively Listen • Involve • Inclusion Measures of Success

Under each of the four headings we have identified key outcome measures from 2021 to 2024, examples: • Demonstrate a range of innovative ways of listening to the views of children and young people using our services • Identify learning disability champions in each service area to further support LD awareness – ‘Purple Star’ training for HCT staff and services. • Increase the diversity of communication channels we use to communicate with the public and stakeholders including use of channels for different equality groups. • Ensure that ‘experts by experience’ (patients) are part of service re design through our QI approach. Next Steps:

In HCT we listen to and learn from our patients. Patient and public engagement is essential in order to improve the quality of the services provided, ensuring that the care delivered meets the needs of those using the services and exceeds their expectations of experiencing the services.

The strategy will be reviewed in December 2022, or earlier if appropriate, as we work closer with our partners or if there are any structural changes within the local NHS.

Board 3rd August 2021 Attachment D1

Medical Director and Director of Nursing Report

1.0 Executive update from Medical and Nursing Directorate

1.1 The report gives an overview of new areas of development as well as updates from relevant areas of work.

2.0 Safeguarding Children

2.1 Safeguarding Children team have supported a Serious Case Review, that had been delayed due to Criminal proceedings. The anonymised report was due to be published on 13th July 2021, but there has been a delay in publication. A Domestic Homicide Review has also been commissioned by the Community Safety Partnership for a mother who was murdered by her partner, with the Safeguarding Children team being involved in its development. In both cases arrangements were put in place to support staff.

3.0 Safer Care Nursing Tool Update in Community Nursing

3.1 HCT are taking part in a national study to look at a Safer Care nursing tool for community nursing. We have piloted this within the Welwyn and Hatfield Integrated Community Team (ICT). Data collection took place between 21st and 27th June 2021 with every staff member on duty completing a paper data collection sheet identifying patient dependency, time spent with patient, travel time and documentation time. Outcome measures are being reviewed by NHS England and NHS Improvement (NHSE/I) and once this has been completed findings will be shared and next steps agreed.

4.0 Good To Outstanding (G2O)

4.1 The Good To Outstanding (G2O) Steering Group meetings recommenced at the end of May 2021. The purpose of the group is to develop actions and receive assurance regarding progress in achieving continuous quality improvement across all services, and to support the Trust on its journey towards becoming an ‘Outstanding’ organisation. A Good To Outstanding Framework has been developed which incorporates workstreams covering shared governance and collaboration, and enabling the People Strategy, with continuous quality improvement in our journey for all services being rated as either ‘Good’ or ‘Outstanding’ - a workplan for this is in development. A Quality mission statement is also being produced to be included in the Clinical Strategy which is currently in development.

5.0 Allied Health Professionals (AHP)

5.1 The Business Case to support the Occupational Therapist (OT) Apprenticeship programme has been approved, enabling recruitment to backfill services whilst two of our non-registered staff participate in the University of Hertfordshire programme to become registered OTs. The

community teams have successfully recruited to additional OT, Physiotherapy (PT) and Technical Instructor posts to lead and contribute to the delivery of the Frailty Clinics in the community. The AHP Clinical Educator working between HCT and East and North Herts Hospital Trust (ENHT) has identified priority areas for supporting student placement expansion, working with higher education institutions. 5.2 Emma Brown, Early Stroke Discharge Clinical co-ordinator has been appointed to a one year secondment as a East of England (EoE) Regional Clinical Fellow starting in September, this is a great achievement as these posts are highly sought after. Emma is also the vice-chair of the East of England Stroke Rehabilitation Clinical Advisory Group.

6.0 Pharmacy

6.1 The Electronic Prescribing and Medicines Administration (EPMA) project rolled out a three week pilot on Oxford ward in July 2021. It is envisioned that EPMA will be run as ‘business as usual’ in Oxford ward from the start of August 2021 and implementation on our other units will be completed by the first week of October 2021. 6.2 The Trust received the draft External Audit report on Medicines Management for our in-patient areas in June 2021. A number of findings and recommendations have been made for improvement around the storage of medicines and completion of drug charts. An action and assurance plan has been developed and will be reporting to Audit Committee in September. 6.3 Pharmacy continues to support the Mass Vaccination Programme from a clinical and medicines management perspective.

7.0 Prevention of Admission (POA)

7.1 Pathways established for managing patient in the community covering deep vein thrombosis (DVT’s), intravenous antibiotics for cellulitis, pneumonia and urinary track infections, giving subcutaneous fluids and treating patients with heart failure. 7.2 The remote monitoring service allowed earlier discharge of COVID-19 patients from hospital and the ability to wean down oxygen and pick up any deterioration quickly. So far over 60 patients have used this pathway with good patient compliance and feedback. POA has also integrated technology to do video consultations and remote ward rounds. 7.3 88% of referrals have same day nursing visits. Between January and June 2021, 1354 POA referrals were received which includes the management of 318 DVTs, 90 infections, 30 cardiac conditions and 47 Respiratory conditions. 7.4 The Service has been collaborating with East of England Ambulance Trust (EEAST), ENHT, out of hours and Hertfordshire Partnership Foundation Trust (HPFT) on the development of further pathways and support to other organisations. Future developments include considering how POA will fit into a model for the two-hour rapid response at home service, in line with national guidance for ageing well by 31st March 2022. 7.5 In June The Clinical Lead was invited to 10 Downing Street on behalf of POA to be personally thanked by the Prime Minister for the work POA has done during the pandemic.

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8.0 Primary Care Network (PCN) relationships

8.1 HCT now has regular meetings with the Primary Care Network (PCN) Clinical Directors. Topics discussed include POA, frailty and long COVID clinics. The Deputy Medical Director meets the chair of the PCN Clinical Directors group regularly to plan the calls and discuss issues.

9.0 Dental Service

9.1 Cheshunt move - the Hoddesdon clinic is relocating to a new clinic in Cheshunt on 26th July. This clinic is larger – going from two to three surgeries and will be a centre of excellence for anxiety management and sedation under our specialist Sadie Hughes. Sadie is president elect of the national dental sedation group – the Society for the Advancement of Anaesthesia in Dentistry (SAAD) and is passionate about improving patient experience and reducing anxiety. She is trained to provide dental Cognitive Behavioural Therapy (CBT) and is liaising with HPFT and the health liaison team to promote desensitisation work for anxious patients with learning difficulties and autism. 9.2 We have achieved a fantastic outcome for some patients who were struggling to have their vaccine. The dental team have worked with Hertfordshire County Council (HCC) health liaison team to support patients with multiple failed attempts to have their vaccine via Utilsign dental check-ups. The roving vaccination team and senior dental nurse team worked tirelessly and so far, we have had 100% success for this group helping 10 – 15 individuals to avoid COVID. 9.3 The dental team have been offering webinars on oral health for end of life and have worked with Hertfordshire Care Providers Association (HCPA) and hospice care to deliver this work.

10.0 Research & Development

10.1 A large proportion of the National Institute for Health Research (NIHR) Clinical Research Network (CRN) portfolio research activity, including studies hosted within HCT, were placed ‘on hold’ during the first phase of the COVID-19 pandemic. A number of these have now re- started, dependent on the specific focus of the study or data collection methods. The Trust, in collaboration with the University of Hertfordshire and ENHT has submitted a bid to the NIHR Health Services and Delivery Research Programme, which is focussed on our work with patients with long COVID. Confirmation of the outcome of the bid is expected later this month. 10.2 HCT partly funded a study with the University of Hertfordshire, focussed upon the use of videoconferencing and online technology to facilitate communication between health and social care professionals and care homes during the peak of the COVID-19 pandemic. A summary infographic showing main findings is provided at Appendix A. 10.3 The Trust has continued to work with the ICP Research Collaboration with ENHT, HPFT, HCC, The University of Hertfordshire, the PCNs in East and North Hertfordshire, EoE Clinical Research Network and the North Thames Clinical Research Network. The Collaboration is seeking to establish the East and North Hertfordshire Integrated Care Partnership (ICP) as a centre of excellence for research. We are currently exploring options to undertake an ICP- wide commercial study involving a trial of a new antibiotic with patients with recurrent urinary tract infections.

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10.4 There are a number of studies currently pending for adoption/approval by HCT including: the utilisation of a treatment for excess salivation in children with neurological disorders; self-care in young children with neurological impairments; a randomised controlled trial of compression therapies for the treatment of venous leg ulcers; a long COVID data study and a study focussed upon the experience of OTs working within integrated (health and social care) services. 10.5 Michelle Stennett of the Dentistry team has been involved in an important piece of research studying ethnic variations in overweight prevalence. Michelle’s work with the Department of Epidemiology and Public Health at University College London (UCL) has recently been published in The European Journal of Public Health. The paper is very relevant for the work the Trust is doing on childhood obesity, as well as work on targeting inequalities among ethnic minorities.

Dr Elizabeth Kendrick Sarah Browne Medical Director Director of Nursing & Quality July 2021

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APPENDIX A

5

APPENDIX A

6

Board 3rd August 2021 Attachment D2

TRUST BOARD

Title: Infection Prevention and Control Update

Meeting Date: 3rd August 2021

Author(s): Sarah Browne, Director of Nursing and Quality / DIPC

For: ASSURANCE

Risk Rating: Amber/Green

1.0 Purpose & Recommendations

1.1 To update the Board on Infection Prevention and Control during COVID-19 pandemic.

1.2 To ask the Board to:

Receive the report and: (1) Review actions taken to date (2) Identify any further areas of work

2.0 Key Points for the Attention of the Board

2.1 Infection prevention and control remains a core component of managing the COVID- 19 pandemic.

2.2 HCT continues to follow Public Health England (PHE) and NHSI guidance in regards to infection control principles and personal protective equipment (PPE) requirements.

2.3 Since the last report presented to Quality Committee in May 2021 further actions have been taken in response to PHE and NHSI guidance which includes: - • Review of NHSE/I Infection prevention and control board assurance framework (Version 1.6 30 June 2021). See appendix 1. • Continuing to encourage staff to work from home where feasible. • Ongoing promotion of infection control principles and training, including producing podcast. • Monitoring of Lateral Flow Testing for staff. • Ongoing review of winter planning / surge planning with awareness of interplay between COVID-19, Norovirus and influenza. • Monitoring local prevalence and nosocomial infection rates, including outbreak control

1

• Daily reporting of sickness and self-isolating staff off sick due to COVID-19 related illnesses which has increased slightly: - th o As at 9 July we are reporting 1.3% of Trust staff off sick due to COVID-19 related illness (0.3% with COVID-19 related sickness). Our overall staff sickness rate is 4.4%. o This increase is seen mainly in regards to staff self-isolating • Ongoing clinical visits to inpatient areas and use of telecon/video conferencing facilities to support clinical staff. • Ongoing daily reporting on the numbers of COVID-19 positive patients within inpatient facilities (0 at present). • Monitoring of COVID-19 vaccination of staff. As of 6th July, 94% of substantive staff have received their first vaccination, of which 91% have also received their second vaccination.

2.4 Regular communications have continued to be in regards to ongoing promotion of infection control principles and learning from local and national outbreaks as well as updates in regards to PHE guidance. Infection Prevention Control team continue to support clinical teams with any infection related queries and continue to undertake regular visits to the inpatient areas. Training continues through on-line training as well as offering face to face training to each inpatient area.

2.5 Ongoing review of the Board Assurance Framework last presented to Quality Committee in May. A new version was published on 30 June 2021 which has been reviewed and again no new risks or gaps in assurance identified.

2.6 Ongoing monitoring of local prevalence and nosocomial infection rates continue as well as monitoring for other infections. The table below confirm there have been no other cases of infections reported within the Trust.

2020/21 Quarter 1 Quarter 2 Quarter 3 Quarter 4 MSSA 0 0 MRSA 0 0 C. diff 0 0

Klebsiella 0 0 E. coli 0 0 Pseudomonas. aer 0 0 Outbreaks (COVID-19) 4 0

2.7 Outbreaks: • There have been no new outbreaks reported since last report.

2.8 Low level counts of Legionella were identified through routine water sampling within one inpatient unit. A number of actions were taken to ensure the safety of patients and staff including a full clean and chlorination of the water systems and followed the instructions as outlined within Heath Technical Memorandum HTM 04-01(Safe Water in Healthcare Premises), ACoP L8 (Control of Legionella) and HSG274 (Legionella Risk Assessment). It is thought the results indicated that there may be a lack of use within the affected outlets caused by staff’s working practices (staff were washing their hands in the sluice rather than at the sink) and due to the warm weather at that time which may have resulted in temperature controls exceeding limits. Guidance was given to staff on the unit and reminders to all staff of the importance of reporting of incidents within the weekly bulletin.

2.9 Since the last report, there continues to be no issues with the supply of Personal protective equipment (PPE). Refresh of guidance to staff continues through regular communications. Further updated guidance is awaited and will be reviewed and any changes communicated to staff.

2.10 The Infection Control Team have reviewed a number of policies and procedures, produced the annual report and undertaken the IPC assessment against the Health and Social Care Act – from which an annual workplan for 2021/22 has been produced.

2.11 The Infection Control team continue to support as required within the vaccination centres across both HWE and BLMK systems.

3.0 Relevant Strategic Objective(s) / Strategies

3.1 This report links to the following Trust Strategic Objectives 1. Outstanding quality and performance

4.0 Risks and Mitigation Plans

There are a number of risks identified from the COVID-19 pandemic which are being managed and monitored through our incident control governance structure.

5.0 Actions / Next Steps / Timelines

5.1 To ensure that infection prevention and control remains core to the management of COVID-19 pandemic but also to ensure staff remain vigilant to the potential for other infections which other areas have been required to manage, an example of this is C.Difficile at a local acute trust. 5.2 To continue to review and implement relevant guidance as published.

6.0 References, Appendices & Supporting Information

Appendix 1 - IPC Board Assurance Framework (reviewed May 2021)

7.0 Glossary / Abbreviations PHE - Public Health England PPE – Personal Protective Equipment BAF – Board Assurance Framework IPC – Infection, Prevention and control DIPC – Director of Infection Prevention and Control.

Author(s) of paper:

Sarah Browne Director of Nursing and Quality / DIPC 9 July 2021

Please note: The information provided is the present situation as of 9 July 2021. A verbal update will be given at the Committee for any updates since the production of the paper.

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): Quality Committee July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as  Date 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 The meaning of any data in the report is clearly  Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive director Sarah Browne √ who is satisfied that (i) the implications for risks, (ii) Director of Nursing & Quality / quality/service/regulatory impacts and (iii) resource implications, DIPC have been considered.

Company Secretary Sign-Off (Board papers only)

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

Publications approval reference: C1337

Infection prevention and control board assurance framework 22 May 2020, Version 1.2

30 June 2021 V 1.6

HCT update July 2021

Foreword

NHS staff should be proud of the care being provided to patients and the way in which services have been rapidly adapted in response to the COVID-19 pandemic.

Effective infection prevention and control is fundamental to our efforts. We have developed this board assurance framework to support all healthcare providers to effectively self-assess their compliance with PHE and other COVID-19 related infection prevention and control guidance and to identify risks. The general principles can be applied across all settings; acute and specialist hospitals, community hospitals, mental health and learning disability, and locally adapted.

The framework can be used to assure directors of infection prevention and control, medical directors and directors of nursing by assessing the measures taken in line with current guidance. It can be used to provide evidence and also as an improvement tool to optimise actions and interventions. The framework can also be used to assure trust boards.

Using this framework is not compulsory, however its use as a source of internal assurance will help support organisations to maintain quality standards.

Ruth May Chief Nursing Officer for England

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1. Introduction

As our understanding of COVID-19 has developed, PHE and related guidance on required infection prevention and control measures has been published, updated and refined to reflect the learning. This continuous process will ensure organisations can respond in an evidence- based way to maintain the safety of patients, services users and staff.

We have developed this framework to help providers assess themselves against the guidance as a source of internal assurance that quality standards are being maintained. It will also help them identify any areas of risk and show the corrective actions taken in response. The tool therefore can also provide assurance to trust boards that organisational compliance has been systematically reviewed.

The framework is intended to be useful for directors of infection prevention and control, medical directors and directors of nursing rather than imposing an additional burden. This is a decision that will be taken locally although organisations must ensure they have alternative appropriate internal assurance mechanisms in place.

2. Legislative framework

The legislative framework is in place to protect service users and staff from avoidable harm in a healthcare setting. We have structured the framework around the existing 10 criteria set out in the Code of Practice on the prevention and control of infection which links directly to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The Health and Safety at Work Act 1974 places wide-ranging duties on employers, who are required to protect the 'health, safety and welfare' at work of all their employees, as well as others on their premises, including temporary staff, casual workers, the self-employed, clients, visitors and the general public. The legislation also imposes a duty on staff to take reasonable care of health and safety at work for themselves and for others, and to co- operate with employers to ensure compliance with health and safety requirements.

Robust risk assessment processes are central to protecting the health, safety and welfare of patients, service users and staff under both pieces of legislation. Where it is not possible to eliminate risk, organisations must assess and mitigate risk and provide safe systems of work. Local risk assessments should be based on the measures as prioritised in the

3 hierarchy of controls. In the context of COVID-19, there is an inherent level of risk for NHS staff who are treating and caring for patients and service users and for the patients and service users themselves in a healthcare setting. All organisations must therefore ensure that risks are identified, managed and mitigated effectively.

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Infection Prevention and Control board assurance framework

1. Systems are in place to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks posed by their environment and other service users

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • local risk assessments are based Local risk assessments undertaken and on the measures as prioritised in reviewed covering office buildings. N/A N/A the hierarchy of controls. The risk Clinical areas following national guidance. assessment needs to be Regular updates given to staff through documented and communicated to bronze, operational, team calls as well as staff; staff bulletin. IPC nurses visits to teams to ensure risk assessments are followed and any new risks identified

• the documented risk assessment Risk assessment of office buildings N/A N/A includes: considered ventilation and operational o a review of the effectiveness of capacity which is actively monitored. the ventilation in the area; o operational capacity; o prevalence of infection/variants of concern in the local area.

• triaging and SARS-CoV-2 testing is Trust adhering to PHE guidance. All N/A N/A undertaken for all patients either at patients tested on admission. This testing point of admission or as soon as continues throughout their stay. possible/practical following admission across all the pathways;

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• when an unacceptable risk of Infection control advice would be sought N/A N/A transmission remains following the for any concerns in regards to risk assessment, consideration to transmission. IPC notified of any positive the extended use of Respiratory cases and support teams with the care of Protective Equipment RPE for the patient patient care in specific situations should be given;

• there are pathways in place which Patients not moved between clinical Transfer letters not always Treating patients as support minimal or avoid patient areas unless necessary and/or for comprehensive potentially positive until bed/ward transfers for the duration discharge Challenges with obtaining confirmed results. of admission unless clinically COVID results in timely imperative; fashion

• that on occasions when it is Identified COVID19 positive wards have Potential gap of up to date Patients in side rooms necessary to cohort COVID-19 or been used previously during surge and lab results and covid status and/or co-horted if results non-COVID-19 patients, reliable will be implemented in future as need prior to transfer not known. application of IPC measures are arises. Use of cohorting in bays as implemented and that any vacated required within infection control support. areas are cleaned as per national guidance;

• resources are in place to enable IPC team in place – some further IPC compliance and monitoring of IPC consultancy also in place for oversight . practice including: IPC undertaken visits to clinical areas. • o staff adherence to hand hygiene; Monthly monitoring reports of inpatient This is self-reported so may Weekly IPC visits to areas, three monthly of community areas, have a bias impatient areas to observe plus observation at weekly IPC visits of practice the inpatient areas.

Physical distances are observed in all N/A N/A o patients, visitors and staff are able to maintain 2 metre social & HCT areas, PPE is provided to all staff physical distancing in all patient providing personal care at the level care areas, unless staff are agreed by the latest guidance, to enable providing clinical/personal care staff to deliver personal care. and are wearing appropriate Patients and visitors are asked to wear 6

PPE; face coverings if able to tolerate and to wash their hands frequently. Numbers of staff are monitored in non-clinical settings to ensure social distancing can be maintained. All staff continue to wear FRSM when on duty in all areas.

o staff adherence to wearing fluid All inpatient areas are visited weekly by N/A N/A resistant surgical facemasks IPC who monitor compliance with FRSM (FRSM) in: and challenge and support practice. . a) clinical . b) non-clinical setting; Within clinical teams FRSM are regularly Consideration to be made Staff motivated to comply o monitoring of staff compliance worn in office areas face coverings are to all staff wearing FRSM with the guidance and will with wearing appropriate PPE, worn challenge each other within the clinical setting;

• that the role of PPE IPC link champions in place guardians/safety champions to embed and encourage best practice has been considered;

• that twice weekly lateral flow Twice weekly lateral flow tests in place for Staff adherence and uptake Ongoing regular antigen testing for NHS patient staff and results are monitored through on testing and reporting communication to staff via facing staff has been implemented operational meetings and IMT. staff bulletin, text and that organisational systems are reminders. in place to monitor results and staff test and trace;

• additional targeted testing of all Further targeted testing would be N/A N/A NHS staff, if your location/site has a undertaken in liaison with IPC support as high nosocomial rate, as required. IPC link with PHE teams. recommended by your local and regional Infection Prevention and Control/Public Health team;

• training in IPC standard infection IPC training in place – mainly e-learning at N/A N/A 7

control and transmission-based present although some ward based visits precautions is provided to all staff; and training undertaken. Intranet redesign IPC measures in relation to COVID- and discussions on virtual training have 19 are included in all staff Induction been implemented and are undergoing and mandatory training; discussion regarding best path for implementation

• all staff (clinical and non-clinical) are trained in: Videos produced to support ‘donning’ and N/A N/A putting on and removing PPE; ‘doffing’ of PPE. o Screen saver on every trust computer o what PPE they should wear for each setting and context; regarding correct PPE to use.

• all staff (clinical and non-clinical) PPE centrally managed in order to ensure N/A N/A have access to the PPE that stock levels are appropriate for clinical protects them for the appropriate needs. Weekly deliveries to areas plus setting and context as per national emergency stock availability as required. guidance;

• there are visual reminders Posters in use in all areas. N/A N/A displayed communicating the importance of wearing face masks, compliance with hand hygiene and maintaining physical distance both in and out of the workplace;

Trust guidance based on PHE guidance. Staff adherence to Regular communication to • IPC national guidance is regularly Continuous review of any updates with guidance. Different staff via newsletters, strict checked for updates and any communication out to staff. Revised interpretations of PPE adherence to PHE changes are effectively guidance and any changes reflected in requirements by other guidance, use of YouTube communicated to staff in a timely trust communication alerts. Use of PHE organisations had videos and Infection way; posters. heightened Staff anxiety. prevention control visits to This is currently staff and teams. exacerbated by the Senior staff supporting Cambridge report regarding clinical areas. FFP3 mask use in all 8

COVID/patient-care situations • changes to national guidance are brought to the attention of boards Risk assessment undertaken and updates of any changes to each BoD. Any N/A N/A and any risks and mitigating changes to PHE guidance is reviewed actions are highlighted; and appropriate actions taken.

• risks are reflected in risk registers Risks are reflected in risk register which is and the board assurance now back to HLRR and BAF which are N/A N/A framework where appropriate; reviewed as part of committee structure. .

• robust IPC risk assessment IPC raised importance of assuring non- N/A Work is underway regarding processes and practices are in COVID infections are still prioritised re-education and place for non COVID-19 infections appropriately. Policies recently revised heightening awareness of and pathogens; and updated concerning all non-COVID the potential increase of alert organisms non-COVID respiratory infections

• the Trust Chief Executive, the Approval process in place via ICC. N/A N/A Medical Director or the Chief

Nurse approves and personally signs off, all daily data submissions via the daily nosocomial sitrep;

• the IPC Board Assurance IPC BAF reviewed and discussed at N/A N/A Framework is reviewed, and Quality Committee and Board. evidence of assessments are made available and discussed at Trust board;

• the Trust Board has oversight of IPC report to each board updates on any N/A N/A ongoing outbreaks and action outbreaks and action plans. The DIPC

(Board member) is alerted to each plans; outbreak and will alert the Board sooner if

required prior to the normal reporting

arrangements 9

• there are check and challenge Clinical visits undertaken – IPC report N/A N/A opportunities by the discussed at Quality committee and executive/senior leadership teams Board. in both clinical and non-clinical areas.

2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • designated nursing/medical teams Clinical teams aware of cleaning with appropriate training are requirements of all patient equipment N/A N/A assigned to care for and treat used in patient bed spaces and products patients in COVID-19 isolation or used, contact times etc. cohort areas

• designated cleaning teams with Specialist trained cleaning contractor appropriate training in required utilised to conduct all COVID-19 related techniques and use of PPE, are cleaning, separate to regular site cleaning N/A N/A assigned to COVID-19 isolation or teams. cohort areas.

• decontamination and terminal All cleaning is conducted in line with PHE N/A N/A decontamination of isolation rooms guidance and as per Risk Assessment or cohort areas is carried out in line and Method Statement (RAMS). with PHE and other national Introduction of Cleaning Guidelines 2021 guidance has also been implemented

10

• assurance processes are in place Monitoring and sign off process in place N/A N/A for the monitoring and sign off via facilities and the senior nursing staff following terminal cleans as part of outbreak management and actions are in place to mitigate any identified risk:

• cleaning and decontamination is All cleaning is conducted in line with PHE To review ongoing Cleaning of work bases for carried out with neutral detergent, a guidance and as per RAMS. requirements within clinical clinical teams has chlorine-based disinfectant, in the Chlorine based products are air dried. bases and as new areas / increased at this present form of a solution at a minimum bases open time. strength of 1,000ppm available chlorine, as per national guidance. IPC advice sought as required If an alternative disinfectant is used, the local infection prevention and Cleaned as part of the site specific control team (IPCT) should be cleaning schedules. N/A N/A consulted on this to ensure that this Carried out in line with national guidance is effective against enveloped as detailed in attached RAMS viruses

• manufacturers’ guidance and Carried out in line with guidance as recommended product ‘contact detailed in attached RAMS N/A N/A time’ must be followed for all Posters are available for staff from IPC if cleaning/disinfectant not already present solutions/products as per national guidance;

• a minimum of twice daily cleaning of: - Areas that have higher All cleaning is conducted in line with PHE N/A N/A environmental contamination guidance, NHS cleaning schedules and rate as set out in the PHE and as per RAMS. other national guidance;

- ‘frequently touched’ surfaces, eg Enhanced cleaning of high touch N/A N/A door/toilet handles, patient call points/usage areas initiated within site bells, over-bed tables and bed cleaning schedules across Trust portfolio. rails; Detailed in Contractors Bedroom 11

Cleaning Access Log

- electronic equipment, eg mobile Communication with staff in regards to N/A N/A phones, desk phones, tablets, cleaning of electronic equipment following desktops and keyboards; agreed advice from IT and Infection control. - rooms/areas where PPE is removed must be Trust does not have specific rooms for N/A N/A decontaminated, timed to removal of PPE. coincide with periods immediately after PPE removal by groups of staff;

• reusable non-invasive care Medical Devices have a clear and concise N/A N/A equipment is decontaminated: process for the inspection, servicing and - between each use repairing of equipment - after blood and/or body fluid Each piece of equipment is listed on the contamination Teams equipment log and is monitored - at regular predefined intervals through the Assurance log by the clinical as part of an equipment lead and IPC team during inspections, the cleaning protocol logs detail the minimum frequency and - before inspection, servicing or the products to use to clean the repair equipment; equipment. Items used frequently have the ‘I am clean’ stickers attached

• linen from possible and confirmed All used linen is bagged as per national N/A N/A COVID-19 patients is managed in guidance and local contractor policy and line with PHE and other national processed off site by specialist linen guidance and the appropriate contractor, in line with PHE guidance and precautions are taken Trust policy.

• single use items are used where Single items are used where possible. N/A N/A possible and according to Single Guidance on singe use items is part of Use Policy the standard principles policy

• reusable equipment is appropriately Cleaning of equipment is considered decontaminated in line with local before any purchase of medical 12

and PHE and other national policy equipment. Policy in place which N/A N/A and that actions in place to mitigate identifies cleaning specifications for each any identified risk; piece of equipment As per RAMS and in line with PHE guidance. • cleaning standards and frequencies are monitored in non-clinical areas Standard and frequencies monitored via N/A N/A with actions in place to resolve facilities team and reported to IPC Forum. issue in maintaining a clean Log books available for staff to monitor environment; issues when needed

• where possible ventilation is maximized by opening windows Staff and areas encouraged to ventilate N/A N/A where possible to assist the dilution as much as possible by opening windows of air.

3. Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance

Key lines of enquiry Gaps in Assurance Mitigating Actions Evidence Systems and process are in place to ensure: • arrangements around antimicrobial Pharmacy support to inpatient areas. Electronic prescribing Pharmacy increased stewardship are maintained Pro-active medicines optimisation and (Electronic Prescribing and amount and expertise level medicines management support which Medicines Administration of its support to the contributes to appropriate antimicrobial use (EPMA) system has inpatient units. EPMA and stewardship. Very few antimicrobials commenced programme programme being taken are used within the Trust roll out, with two new forward as well as sourcing members of staff employed own in-house pharmacy . to help facilitate • mandatory reporting requirements Pharmacy teams have continued are adhered to and boards continue conducting regular audits within inpatient N/A N/A to maintain oversight areas as per their audit programme.

4. Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion 13

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • implementation of national guidance Posters placed in key areas of in-patient N/A N/A on visiting patients in a care setting areas advising of COVID-19 risks and guidance. Reduced visiting implemented within inpatient areas. This is being continuously reviewed.

• areas in which suspected or Plan in place to allow identification of N/A N/A confirmed COVID-19 patients are COVID-19 +/- sites/wards as required where possible being treated in dependent on pandemic. Ongoing review areas clearly marked with of level of demand and phased plan in appropriate signage and have place to support. restricted access

• information and guidance on Trust website contains basic information N/A N/A COVID-19 is available on all Trust with links to further websites and contact websites with easy read versions numbers.

• infection status is communicated to Relevant department and organisations N/A N/A the receiving organisation or are informed of infection status prior to department when a possible or transfer. Infectious status on transfer form confirmed COVID-19 patient needs available on systmOne for use to be moved;

• there is clearly displayed, written Posters in place N/A N/A information available to prompt patients’, visitors and staff to comply with hands, face and space advice;

• Implementation of the Supporting Currently being reviewed by IPC Advisor Assessment against the tool IPC constantly reviewed by excellence in infection prevention for consideration of actions by the Trust. kit and action plan to be the team who have excellent and control behaviors This will be reported vis the normal formal produced for consideration links with the clinical teams 14

Implementation Toolkit has been committee structures within the Trust by the IPC Forum and inpatient areas considered C1116-supporting- excellence-in-ipc-behaviours-imp- toolkit.pdf (england.nhs.uk)

5. Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • Screening and triaging of all Screening and triaging in place as per N/A N/A patients as per IPC and NICE IPC guidance. PCR testing of patients on guidance within all health and admission and weekly thereafter,(unless other care facilities is undertaken specific reasons not to). to enable early recognition of COVID-19 cases;

• front door areas have MIU’s and outpatient departments have Some outpatient Staggering of appointments appropriate triaging clear triaging guidance for attending departments small, making to minimise number of arrangements in place to cohort patients. Inpatient units admit to single it difficult to facilitate social patients present at any one patients with possible or rooms where status is not known distancing time. Use of video confirmed COVID-19 symptoms conferencing within and to segregate them from non services and MIU. COVID-19 cases to minimise the risk of cross-infection as per national guidance

• staff are aware of agreed This is currently being reviewed by the template for triage questions to IPC nurses across the Herts area to N/A N/A ask; produce a standard list. Currently have HCT list in place

MIU’s undertake assessment on entry to • Triage is undertaken by clinical unit inpatient areas plan where the patient N/A N/A staff who are trained and will be placed and they are assessed by a 15

competent in the clinical case qualified nurse and doctor. definition and patient is allocated appropriate pathway as soon as possible;

• face coverings are used by all People are notified on entry to all HCT N/A. N/A. outpatients and visitors; buildings. Masks are available if required for patients (and as per 15/06/2020) all

patients and visitors being asked to wear

face coverings.

Prioritisation of side rooms has been a N/A N/A • individuals who are clinically constant agenda item to ensure side extremely vulnerable from rooms/co-hort bays are being used to COVID-19 receive protective efficiently. Work is now taking place IPC measures depending on regarding prioritisation of side rooms their medical condition and concerning infections outside of COVID treatment whilst receiving based upon risk assessment, both as a healthcare e.g. priority for requirement to isolate and protect single room isolation; patients

• clear advice on the use of face masks is provided to patients Patients are encouraged and supported Reduced ability for a Patients encouraged if and all inpatients are to use surgical facemasks where able to number of patients due to assessed as medically fit to encouraged and supported to their medical condition in use face mask. use surgical facemasks inpatient areas (particularly when moving around the ward) providing it is

tolerated and is not detrimental

to their (physical or mental)

care needs;

• monitoring of Inpatients Patients are encouraged and supported N/A N/A compliance with wearing face to use surgical facemasks where able to masks (particularly when this is observed when the IPC visit the moving around the ward) words and teaching undertaken if 16

providing it is tolerated and is required. not detrimental to their (physical or mental) care needs;

• patients, visitors and staff are able to maintain 2 metre social N/A. N/A & physical distancing in all Restriction to patient visiting in place

patient care areas; ideally Screens in place for majority of reception segregation should be with areas –staff being supplied with masks separate spaces, but there is and visors if required potential to use screens, e.g. to protect reception staff.

• isolation, testing and instigation of contact tracing is achieved N/A N/A for patients with new-onset Patients within inpatient areas swabbed symptoms, until proven and isolated. Staff follow PHE guidance negative; for contract tracing.

• patients that test negative but display or go on to develop Patients are retested if remain or become N/A N/A symptoms of COVID-19 are symptomatic and isolated/co-horted as segregated and promptly re- appropriate tested and contacts traced promptly;

• there is evidence of compliance Robust weekly testing process in place with routine patient testing for inpatients in addition to admission N/A N/A protocols in line with Key screening. Community patients covered actions: infection prevention via test and trace guidance. and control and testing document;

• patients that attend for routine Processes in place for checking patients appointments who display prior to attendance for appointments. N/A N/A 17

symptoms of COVID-19 are Virtual technology in use for majority of managed appropriately. routine appointments to reduce risks. Patients / relatives attending clinics are again reviewed for any signs or symptoms prior to access.

6. Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • Patient pathways and staff flow are One way systems in place where able to Some estates do not Staff and patients reminded separated to minimize contact facilitate this. However the red ward areas enable one-way / of social distancing between pathways. For example, and red areas within MIU’s are managed separation measures, use of PPE and this could include provision of separately to the amber and green areas. IPC precautions separate entrances/exits (if Therefore maintaining the separation of available) or use of one-way areas. entrance/exit systems, clear signage , and restricted access to communal areas; Regular change/revisions • all staff (clinical and non- clinical) PHE guidance disseminated clearly and in PHE guidance did cause Regular communications to have appropriate training, in line on multiple forums, including staff initial anxiety and staff, videos, IPC support to with latest PHE and other guidance, bulletins and screen savers. uncertainty in many staff clinical areas, Senior to ensure their personal safety and members clinical on-site support working environment is safe

• all staff providing patient care are Training and guidance has been provided Lack of anti-chambers for IPC visits to clinical areas to trained in the selection and use of by the Infection Prevention and Control in-patient areas for doffing advise staff. PPE appropriate for the clinical team, local ward managers and senior PPE proves challenging for YouTube videos made in a situation and on how to safely don staff. Senior management staff have also adherence to PHE patients home to show how and doff it been involved in ad-hoc training. Videos guidance. Caring for to don and doff. Use of and screen savers are available to staff patients in own homes prompt cards as aide as guidance. restricts access to suitable memoire. environment for safely donning and doffing PPE. 18

Additional information/guidance provided by clinical colleges and the latest Cambridge report have caused anxiety that has required additional management and understanding.

• a record of staff training is IPC training recorded, available monthly. Record of staff in regards Regular communications to maintained; to donning and staff, aide memoires and doffing/specific COVID-19 videos. Managers training not recorded. supporting and training staff. • adherence to PHE national Spot checks undertaken by managers No specific PPE audit guidance on the use of PPE is and weekly by IPC team. Hand hygiene Regular visits to teams and regularly audited with actions in and care bundle audits remain in place. clinical areas by senior place to mitigate any identified managers and IPC team to risk; review adherence.

• hygiene facilities (IPC measures) and messaging are available for Information available to staff and visitors Adherence by staff and all patients/individuals, staff and vis use of posters, reminders by staff to public Ongoing communications visitors plus regular communications to visitors to minimise COVID-19 staff.

transmission such as: Screen savers, videos and posters are o hand hygiene facilities available to all teams and additional can including instructional posters; be provided when required. o good respiratory hygiene measures; o staff maintaining physical and social distancing of 2 metres wherever possible in the workplace unless wearing PPE as part of direct care; o staff are maintaining physical and social distancing of 2 19

metres when travelling to work (including avoiding car sharing) and remind staff to follow public health guidance outside of the workplace;

o frequent decontamination of equipment and environment in both clinical and non-clinical areas;

clear visually displayed advice o on use of face coverings and

facemasks by

patients/individuals, visitors and by staff in non-patient facing areas.

• staff regularly undertake hand All staff are encouraged by the Trust N/A N/A hygiene and observe standard communications to observe excellent infection control precautions hand hygiene. All staff aware of 5 moments of hand hygiene – as per IPC training and hand hygiene audits in place

• the use of hand dryers should be Audit of hand dryer locations conducted N/A N/A avoided in all clinical areas. Hands across Trust sites. Identified hand dryers should be dried with soft, have been disconnected/isolated and absorbent, disposable paper towels hand towel dispensers installed and from a dispenser which is located waste bins provided. close to the sink but beyond the risk of splash contamination, as per national guidance

• guidance on hand hygiene, including drying, should be clearly Guidance supplied in all toilet areas and N/A N/A displayed in all public toilet areas as at all hand hygiene stations/sinks well as staff areas 20

• staff understand the requirements Guidance and communications provided N/A N/A for uniform laundering where this is across the trust concerning laundry not provided for on site procedures (as per IPC guidance and the Dress Code and Personal Presentation Policy).

• all staff understand the symptoms Staff are aware and reminded frequently N/A N/A of COVID-19 and take appropriate of both symptoms to look for in action in line with PHE and other themselves and family members and also national guidance if they or a the protective requirements necessary member of their household display any of the symptoms.

• a rapid and continued response Ongoing surveillance in place across through ongoing surveillance of systems and within Trust. Link with public N/A N/A rates of infection transmission health. All hospital onset infections would within the local population and for be investigated through RCA methods. hospital/organisation onset cases All staff reporting positive tests or need to

(staff and patients/individuals); isolate through contacts are reported to

IPC daily for further action if required.

N/A N/A • positive cases identified after admission who fit the criteria for Investigation and outbreaks reported as per PHE / NHSE/I guidance investigation should trigger a case

investigation. Two or more

positive cases linked in time and place trigger an outbreak investigation and are reported;

• robust policies and procedures are Policies and procedures in place, IPC N/A N/A in place for the identification of team responsible for managing the and management of outbreaks of meetings and ensuring the documentation infection. This includes the of them. documented recording of outbreak meetings. 21

7. Provide or secure adequate isolation facilities

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • restricted access between Community hospitals/clinics only in place. N/A N/A pathways if possible, (depending QVM/Danesbury – single wards. on size of the facility, HEH – two ward areas run as one – but prevalence/incidence rate can be separated dependent on need low/high) by other infection rate. Red and green pathways patients/individuals, visitors or maintained separately within the MIU and staff; with all admissions to the inpatient areas.

• areas/wards are clearly Ward/areas clearly signposted when this signposted, using physical barriers was required. Will be reintroduced if/when N/A N/A as appropriate to required patients/individuals and staff understand the different risk

areas;

Patients are isolated and/or co-horted • patients with suspected or appropriately. Each patient is considered Universal promotion and Promotion from confirmed COVID-19 are isolated separately in regards to infection risk and focus on COVID-19 has managements and IPC in appropriate facilities or which area of acute hospital (Black, Red, affected clinical observation teams to advise of risk designated areas where Amber, Green status) has been nursed in and mindfulness of other from other alert appropriate; to determine which unit to transfer to and alert organisms organisms whether can be co-horted or for side room.

Consideration is also given as to whether

the patient can be safely cared for within the Trust or whether they require specialist

intensive care.

PHE guidance is followed if patients who N/A • areas used to cohort patients with are symptomatic/asymptomatic with N/A suspected or confirmed COVID-19 negative screens are identified and the are compliant with the appropriate actions taken 22

environmental requirements set out in the current PHE national guidance;

N/A N/A • patients with resistant/alert Advice has been shared that awareness organisms are managed concerning other infectious organisms according to local IPC guidance, must remain high, especially concerning including ensuring appropriate MDR-GNB patient placement.

8. Secure adequate access to laboratory support as appropriate

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions There are systems and processes in place to ensure: • testing is undertaken by competent Staff have been trained in how to and trained individuals undertaken COVID-19 screening. No N/A N/A laboratory within organisation. Laboratories identified for testing have been agreed by PHE.

• patient and staff COVID-19 testing Patient swabbing undertaken as per is undertaken promptly and in line national guidance. Staff testing N/A N/A with PHE and other national undertaken using national portal. HCT guidance has worked with system to support Drive through when access was an issue.

• regular monitoring and reporting of the testing turnaround times with Monitoring undertaken and issue reported There has been delays in Issues escalated to public focus on the time taken from the to public health turnaround times, but health if required and patient to time result is available; appears to be improved HETCG

• regular monitoring and reporting Monitoring undertaken N/A N/A that identified cases have been 23

tested and reported in line with the testing protocols (correctly recorded data);

• screening for other potential Screening undertaken as per IPC advice N/A N/A infections takes place including MRSA and GI infections

• that all emergency patients are N/A N/A tested for COVID-19 on Majority of patients are transfers, but all admission; would be tested on admission.

N/A N/A • that those inpatients who go on to Testing undertaken as per PHE guidance develop symptoms of COVID-19 both on admission, at day 3 and every 7 after admission are retested at the days and if symptoms develop or contacts point symptoms arise; have been identified

• that emergency admissions who Re-testing undertaken as per PHE N/A N/A test negative on admission are guidance as above retested on day 3 of admission, and again between 5-7 days post admission;

• that sites with high nosocomial Testing would be undertaken as per rates should consider testing Public health and IPC agreement and COVID negative patients daily; guidance – Not required to date N/A N/A

• that those being discharged to a care home are tested for COVID- Testing undertaken as per guidance and 19 48 hours prior to discharge care homes informed of the results N/A N/A (unless they have tested positive within the previous 90 days) and

result is communicated to

receiving organisation prior to

discharge;

• that patients being discharged to a 24

care facility within their 14 day Transfer information given prior to isolation period are discharged to transfer – HCT part of care home and N/A N/A a designated care setting, where testing cells to ensure compliance across they should complete their system remaining isolation;

• that all Elective patients are tested 3 days prior to admission and are N/A to HCT asked to self-isolate from the day N/A N/A of their test until the day of admission.

9. Have and adhere to policies designed for the individual’s care and provider organisations that will help to prevent and control infections

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure that: • staff are supported in adhering to all IPC policies including those for other alert N/A N/A IPC policies, including those for organisms in place and available on the other alert organisms intranet, staff are encouraged to contact IPC when additional advice is required N/A N/A • any changes to the PHE national Changes to national guidance are guidance on PPE are quickly managed through gold, silver and bronze identified and effectively management routes and communicated via Communications department within 24 communicated to staff hours. Information uploaded and updated

on intranet

N/A N/A • all clinical waste related to All waste management continues to take

confirmed or suspected COVID-19 place as per national guidance and is cases is handled, stored and reported on through the IPC Forum by the managed in accordance with Facilities team. Waste audits are current national guidance undertaken by the Facilities team, with additional support from the IPC Team if 25

required. N/A N/A

• PPE stock is appropriately stored Teams have access to PPE which is and accessible to staff who require stored locally. Main supply of PPE is it stored centrally and audited daily.

10. Have a system in place to manage the occupational health needs and obligations of staff in relation to infection

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Appropriate systems and processes are in place to ensure: • staff in ‘at-risk’ groups are identified Robust risk assessment process in place, N/A Risk assessments have and managed appropriately with staff being individually assessed been undertaken. including ensuring their physical against a range of risk factors. Trust Risk assessment and psychological wellbeing is processes are confirmed as being in line spreadsheet holds supported with national guidance. Any health information on all staff concerns/conditions discussed. Red risk individual risk levels and rated staff had been redeployed/advised work role risk levels, with a to work from home as appropriate for their focus on full assessments safety. for red risk categories as a top priority.

• that risk assessments are Risk assessments undertaken and N/A N/A undertaken and documented for appropriate actions taken and any staff members in an at risk or communicated out through all staff shielding groups, including Black, bulletin and Team Briefings Asian and Minority Ethnic and pregnant staff;

• staff required to wear FFP reusable Staff required to wear FFP masks have N/A respirators undergo training that is been fit tested and training given in their N/A compliant with PHE national use. A record of this is maintained by guidance and a record of this responsible person (Mark Whiting). training is maintained and held centrally;

26

• staff who carry out fit test training Fit testing has been undertaken by a N/A N/A are trained and competent to do qualified individual although moving so; forward they are looking to buy in this service

• all staff required to wear an FFP N/A N/A respirator have been fit tested for This has occurred when needed and is a the model being used and this recognised reason for re-testing should be repeated each time a

different model is used;

N/A N/A • a record of the fit test and result is The records are held by the responsible given to and kept by the trainee person (MW) and are available on and centrally within the request. Each staff member tested has organisation; been issued with record of their test. N/A N/A • those who fail a fit test, there is a This has not yet been required but would record given to and held by be available should it occur, IPC support trainee and centrally within the would be given to identify alternative organisation of repeated testing devices on alternative respirators and hoods;

• members of staff who fail to be N/A N/A adequately fit tested a discussion This has not yet been reported to IPC as should be had, regarding re having occurred but the systems and deployment opportunities and processes are in place for staff options commensurate with the redeployment should that be necessary staff members skills and

experience in line with nationally

agreed algorithm;

N/A N/A • a documented record of this This has not yet been reported to IPC as discussion should be available for necessary but would occur should the the staff member and held situation arise centrally within the organisation, 27

as part of employment record including Occupational health; N/A N/A • following consideration of reasonable adjustments e.g. This has not yet been reported to IPC as respiratory hoods, personal re- necessary but would occur should the usable FFP3, staff who are unable situation arise to pass a fit test for an FFP respirator are redeployed using

the nationally agreed algorithm

and a record kept in staff

members personal record and Occupational health service record; N/A N/A • boards have a system in place Currently the lists of staff trained to use that demonstrates how, regarding FFP3 masks and those trained to fit test fit testing, the organisation is held by the member of staff maintains staff safety and responsible. The names have not been provides safe care across all care shared with the Board however the settings. This system should numbers have through Gold, Silver and include a centrally held record of Bronze Command. These can be results which is regularly reviewed provided to the board as and when by the board; required. Community teams not split This remains under review • consistency in staff allocation is All staff including those redeployed during due to numbers of COVID- and is risk assessed as maintained, with reductions in the the initial waves stayed within their teams 19 positive patients and needed with assistance of movement of staff between different some sharing of staff did occur when size of teams. the IPC team areas and the cross-over of care there were red and green wards owing to pathways between planned and the need to maintain safe staffing levels. elective care pathways and urgent All patients treated as potential positive. and emergency care pathways, as Re-enforcement of IPC guidance. per national guidance Wards were split to COVID-19 positive and negative with staff allocation to each area during each SURGE. Will continue to review requirements in line with increase in COVID-19 positive patients. 28

• all staff adhere to national guidance Guidance is available and has again been As a community trust HCT Regular spot checks and on social distancing (2 metres) reissued by the DIPC to all staff. Regular are reliant on Staff communications including wherever possible, particularly if not communications and spot checks in place adherence to guidance and posters, stickers on desks. wearing a facemask and in non- in regards to social distancing. Clear them taking personal Computer screens/docking clinical areas; message to all staff that if cannot adhere responsibility to do so. stations removed to support to 2 metre social distancing- that PPE is spacing of desks. to be worn.

• health and care settings are Risk assessments being updated to sites N/A N/A COVID-19 secure workplaces as to confirm those identified as COVID-19 far as practical, that is, that any secure. Further comms to staff in regards workplace risk(s) are mitigated to office areas.

maximally for everyone; Risk assessments have been undertaken and are reviewed regularly. These

assessments have highlighted any issues

in particular buildings and remedial actions have been put in place

• staff are aware of the need to Posters are available on the majority of Staff adherence to Regular communications. wear facemask when moving doors and staff do challenge each other if guidance Risk assessments of areas. through COVID-19 secure areas; required. Ongoing communication to staff re use of PPE

• staff absence and well-being are The information is collated daily and staff N/A N/A monitored and staff who are self- are supported both by the management isolating are supported and able to structures but also by the IPC team. access testing; HR/People team in place to monitor staff absence and well-being. Wellbeing calls made to all staff self-isolating. Any staff newly self-isolating are contacted to arrange prompt testing. Staff absence is discussed daily across all management streams. N/A N/A • staff who test positive have

adequate information and support Staff who have tested positive are to aid their recovery and return to 29

work. contacted by HR/People support and also managers in order to assess their physical and mental wellbeing. This is provided by the local management structures but IPC staff are also available to all staff should they require extra guidance or support

Key to abbreviations:- PPE Personal Protective Equipment PHE Public Health England NSDR National Supply Disruption Response FFP Filtering Face piece (FFP3 masks) HR Human Resources BAME Black, Asian and minority ethnic IPC Infection Prevention and Control IIR Fluid Resistant surgical face mask MDR-GNB Multidrug-resistant Gram-negative bacteria (infection) ENHT East and North Herts NHS Trust BoD Board of Directors PAH Princess Alexandra NHS Trust CAS Central Alerting System Don /Doff ‘Do put on’ / Do take off’ IPC Infection Prevention and Control

30

rd Board 3 August 2021 Attachment D3

TRUST BOARD

Title: Mass Vaccination Programme

Meeting Date: 3rd August 2021

Executive Lead: Sarah Browne, Director of Nursing and Quality

Author(s): Sarah Browne, Director of Nursing and Quality

For: ASSURANCE

Risk Rating: Amber

1.0 Purpose & Recommendations

1.1 To update the Board of HCT’s role as lead provider in the mass vaccination programme.

1.2 To ask the Board to: Receive the report and: (1) Review actions taken to date (2) Identify any further areas of work

2.0 Key Points for the Attention of the Board

2.1 The COVID-19 vaccination programme continues in line with national timeframes covering Vaccination centres and roving model (nursing/residential homes and housebound patients).

2.2 18 Vaccination Centres are presently open (as we took over St Margaret’s Hospital site). They continue to open and flex operational hours according to national programme, vaccine allocation and uptake on bookings. Due to reduction seen in bookings over last two weeks, all sites are now also operating walk-in vaccinations during opening times. As of the end of June 826,655 vaccinations had been administered across the 18 sites.

2.3 HCT continue to work with both systems to increase uptake of vaccination across all cohorts, with more focus at present on looking at wider options of roving/pop up/mobile units. Work is being planned and undertaken covering: - 2.3.1 Hertfordshire and West Essex (HWE): - 2.3.1.1 Sites being identified to take forward pop-up/bus vaccination to different areas covering Waltham Abbey, Waltham Cross, Chigwell and Harlow.

1

2.3.1.2 Support being given to vaccinate care home in Much Hadden. 2.3.1.3 Roving teams to support further vaccinations required for housebound/care home residents. 2.3.2 Bedfordshire, Luton, Milton Keynes (BLMK): - 2.3.2.1 Pop-up site at Farley Hill community centre for walk-in appointments for Pfizer. 2.3.2.2 Vaccination in-reach being scoped with Bedfordshire Fire & Rescue and Bedfordshire Police for emergency services staff and families. 2.3.2.3 Working with Cranfield University with regards to vaccinating students before the end of term (as have different term dates) 2.3.2.4 Vaccination in-reach at John Lewis warehouse and distribution centre in Magna Park, Milton Keynes covering different shifts with John Lewis working as hub to other bushiness on the site. 2.3.2.5 Scoping further in-reach with Amazon warehouses in Luton and Central Bedfordshire.

2.4 Workforce requirements remain the main risk for each lead provider. HCT has continued to progress with active recruitment into all the roles required, working with regional and system workforce leads. Ongoing recruitment is expected to continue as further staff move back from some of the secondments and mutual aid.

2.5 A project team remain in place to take forward the different phases of the vaccination programme. This is supported with the full operational senior team to take the day to day operational management forward. The team of Operation Directors and Associate Directors support oversight of the centres and on-call support across both the systems 7 days a week. The operational team is presently being reviewed in line with rationalisation of sites being considered for phase 3.

2.6 Phase 3 interim guidance has been released from JCVI and we are working with both BLMK and HWE systems to identify what is required from September onwards. Second dose vaccinations have all been brought forward to 8 weeks, but we will still be required to administer second vaccinations through September. The interim guidance for boosters published on 1 July 2021 states: -

• ‘JCVI advises that any potential booster programme should begin in September 2021, in order to maximise protection in those who are most vulnerable to serious COVID-19 ahead of the winter months. Influenza vaccines are also delivered in autumn, and JCVI considers that, where possible, a synergistic approach to the delivery of COVID-19 and influenza vaccination could support delivery and maximise uptake of both vaccines. • Any potential COVID-19 booster programme should be offered in two stages: o Stage 1. The following persons should be offered a third dose COVID-19 booster vaccine and the annual influenza vaccine, as soon as possible from September 2021:

. adults aged 16 years and over who are immunosuppressed . those living in residential care homes for older adults . all adults aged 70 years or over . adults aged 16 years and over who are considered clinically extremely vulnerable . frontline health and social care workers. o Stage 2. The following persons should be offered a third dose COVID-19 booster vaccine as soon as practicable after Stage 1, with equal emphasis on deployment of the influenza vaccine where eligible: . all adults aged 50 years and over . adults aged 16 – 49 years who are in an influenza or COVID-19 at-risk group . adult household contacts of immunosuppressed individuals’. • Systems to consider a ‘make every contact count’ approach to winter vaccination. This means building in the offer – where practical and appropriate – for those attending vaccination clinics to also have other health checks. • In the majority of cases, local systems should plan for a minimum of 40% of COVID-19 booster vaccination through general practice and a maximum of 75%. • Consider the best delivery access for population requirements covering community pharmacy, pop ups an and mobile units. • It is still unclear as the requirements at present for 12-17 year olds.

2.7 Staff COVID-19 vaccination continues to be monitored. As of 6th July, 94% of substantive staff have received their first vaccination, of which 91% have also received their second vaccination. Work continues to monitor second doses.

3.0 Relevant Strategic Objective(s) / Strategies

3.1 This report links to the following Trust Strategic Objectives 1. Outstanding quality and performance

4.0 Risks and Mitigation Plans

• BAF-12 - There is a risk of failure to meet regional target date and target numbers for delivery of the mass vaccination programme on behalf of Bedford, Luton and Milton Keynes (BLMK) and Herts and West Essex ICSs which could impact Trust's organisational reputation and credibility. Contractual requirements, delivery timescales, workforce gaps, Estate and IT infrastructure issues could impact on the deliverability of the programme, create winter capacity pressures and adversely impact the effectiveness and quality of care provided to the local population.

5.0 Actions / Next Steps / Timelines

5.1 To take forward project planning working with leads across both HWE and BLMK systems. 5.2 To continue to work with lead providers and regional team to take forward mass vaccination programme dependent on vaccine availability in accordance with JCVI guidance.

6.0 References, Appendices & Supporting Information

7.0 Glossary / Abbreviations JCVI – Joint Committee on Vaccination and Immunisation BLMK – Bedfordshire, Luton and Milton Keynes HWE – Hertfordshire and West Essex ICS- Integrated Care System

Author(s) of paper: Sarah Browne Director of Nursing and Quality 8 July 2021

Please note: The information provided is the present situation as of 8 July 2021. A verbal update will be given for any updates since the production of the paper.

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): Quality Committee July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive Sarah Browne √ director who is satisfied that (i) the implications for risks, (ii) Director of Nursing & Quality / quality/service/regulatory impacts and (iii) resource implications, DIPC have been considered.

Company Secretary Sign-Off (Board papers only)

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

Board 3rd August 2021 Attachment D4

TRUST BOARD

Title: Safe Staffing Report Q1

Meeting Date: 3rd August 2021

Executive Lead: Marion Dunstone Chief Operating Officer

Author(s): Yasha Rai – Unplanned care pathway lead.

For: Noting and Assurance

Risk Rating: Amber/Green

1.0 Purpose & Recommendations

1.2 To advise the Board of the staffing levels across all HCT Community Hospitals in Q1

1.3 To ask the Board to:

(1) Note the report.

2.0 Key Points for the Attention of the Board

2.1 Bed Capacity is back to contracted number to aid patient flow.

2.2 All redeployed staff have returned to their substantive roles.

2.3 The Band 5 vacancy rate is high in Herts and Essex Community Hospital (HEH) unit only and a targeted piece of work will be undertaken with long line agency staff in the next quarter.

2.4 Appraisal figures remain below the Trust target in Danesbury and HEH, Queen Victoria Memorial Hospital (QVM) have achieved above 91% in this quarter.

2.5 Staffing ratio was altered back from 1:12 to 1:8 during Q1.

3.0 Relevant Strategic Objective(s) / Strategies

3.1 This report links to the following Trust Strategic Objectives

1. Outstanding quality and performance 2. Joined-up local care 3. Great place to work 4. Best value through innovation

3.2 Links to: 1. Outstanding quality and performance 2. Joined up local care 3. Great Place to work

4.0 Risks and Mitigation Plans

Risk Mitigation / Action(s) Should there be a significant surge in covid If further capacity is required this will be capacity requirements , the resource will considered as part of system wide decision not be available to safely staff the making community beds B5 vacancy rate Agency and bank shifts out on NHSP and daily meetings with ward manager to fill shifts.

5.0 Quality / Service / Regulatory Impacts

Nil

6.0 Resource Implications

6.1 Work Force costs

7.0 Actions / Next Steps / Timelines

Nil

8.0 References, Appendices & Supporting Information

Nil

9.0 Glossary / Abbreviations QVM = Queen Victoria Memorial Hospital HEH = Herts and Essex Community Hospital CHPPD = Care Hours Per patient Day

Author(s) of paper: Yasha Rai Date July 2021

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): Quality Committee July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive Marion Dunstone x director who is satisfied that (i) the implications for risks, (ii) Chief Operating Officer quality/service/regulatory impacts and (iii) resource implications, have been considered.

Company Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Assistant Board Secretary √ / x

Board 3rd August 2021 Attachment D4

Safe Staffing Report for Community Inpatient Units for Q 1 April-June 2021

1. Introduction This report provides the Quality Committee with an overview of the nursing staffing levels within Community Inpatient Units, during Q1. The report is based on local data some of which has been validated, as some elements of formal reporting has recommenced during this time. HCT has continued to work in line with NHS England applied threshold of fill rates of 80% and above for Registered Nurses (RN). At the beginning of Q1, staffing levels returned to pre COVID staffing ratios of 1:8 at Herts and Essex and QVM and 1:6 at Danesbury. The Inpatient Units report their staffing levels to the In Reach Team daily and a report detailing daily staffing levels, risks and mitigation is circulated to the Senior Team for information. Where necessary, the Senior Team will reallocate staff across the units to ensure safe staffing levels are maintained on all units. This process has not changed throughout the response to the pandemic.

2. Executive Summary At the start of Q1, 6 additional beds remained open at Danesbury. Throughout April and in discussion with system partners, the beds were de – escalated and numbers of beds returned to the normal commissioned capacity at the beginning of May 21.

Redeployed staff returned to their substantive posts with the exception of 3 RNs and 2 HCA’s who were offered secondments to the roles that they had been redeployed to as a result of their individual COVID risk assessments. These secondments continue to be reviewed in conjunction with the people team at regular intervals.

Staff who were previously redeployed at the height of the pandemic, who have returned to their substantive roles, and have an Amber risk assessment, are supported by their ward manager and may be temporarily redeployed, if it is not possible to mitigate their risk, as a result a COVID +ve patient being admitted to the unit they work on . Quality Committee 20th July 2021 Attachment 5.6

The table below shows the minimum staffing numbers that have been in place during Q1 for each unit per shift across all units during Q1.

Unit Day Night RN HCA RN HCA Herts and 4 4 3 3 Essex QVM 3 4 2 3 Danesbury 4 5 2 4 (24 beds in April)

Danesbury 3 4 2 2 (18 beds in May and June)

Demand for COVID+ve bed capacity continued to reduce during Q1, with QVM remaining as the dedicated site for COVID+ve admissions.

Throughout Q1, safe care data demonstrates that the actual Care Hours per Patient per Day (CHPPD), were predominantly above the required levels across all 3 units

The acuity of patients across all of the Community Inpatient Units remained relatively stable during Q1. The majority of patients were a level 1b, meaning they had a high level of dependency and nursing needs. This is to be expected as the enhanced community teams continue to support the discharges for the less complex cohort of patients who are able to be safely manged within their home environment.

Despite the challenges of COVID 19, there has continued to be successful recruitment across all units with all vacant unregistered posts recruited to. Recruitment continues for therapy posts and registered nurses, with Herts and Essex continuing to have vacancy across a number of band 5 posts. The new Ward Manager at Herts and Essex Hospital commenced her new role in Q1.

Appraisals and mandatory training data for Q1 shows units have significantly improved and are above 90% for mandatory training and above 77% for all 3 units with appraisals. Quality Committee 20th July 2021 Attachment 5.6

Acuity/Dependency Tool Measurement (for reference)

Level 0 Care requirements may include the following (Multipli • Elective medical or surgical admission er =0.99* • May have underlying medical condition requiring on-going treatment ) Patient • Patients awaiting discharge • Post-operative/post-procedure care - observations recorded half requires hourly initially then 4-hourly hospitalis • Regular observations 2 - 4 hourly • ation • Early Warning Score is within normal threshold. Needs • ECG monitoring • Fluid management met by • Oxygen therapy less than 35% provision • Patient controlled analgesia • Nerve block of • Single chest drain normal ward • Confused patients not at risk cares. • Patients requiring assistance with some activities of daily living, require the assistance of one person to mobilise, or experiences occasional incontinence

Level 1a Care requirements may include the following (Multiplier =1.39* ) • Increased level of observations and therapeutic interventions Acutely ill • Early Warning Score - trigger point reached and requiring escalation. patients • Post-operative care following complex surgery requiring • Emergency admissions requiring immediate therapeutic intervention. intervention • Instability requiring continual observation/invasive monitoring • Oxygen therapy greater than 35% +/- chest physiotherapy 2- 6 hourly or those who • Arterial blood gas analysis - intermittent are • Post 24 hours following insertion of tracheostomy, central lines, UNSTABLE epidural or multiple chest or extra ventricular drains with a • Severe infection or sepsis GREATER POTENTIAL to deteriorate. Quality Committee 20th July 2021 Attachment 5.6

Level 1b Care requirements may include the following (Multiplier = 1.72*) • Complex wound management requiring more than one nurse or takes more than one hour to complete. Patients • VAC therapy where ward-based nurses undertake the treatment who are in a • Patients with Spinal Instability/Spinal Cord Injury STABLE • Mobility or repositioning difficulties requiring the assistance of condition two people but are • Complex Intravenous Drug Regimes - (including thoserequiring dependant prolonged preparatory/administration/post-administration on nursing care) care to • Patient and/ or carers requiring enhanced psychological support meet most owing to poor disease prognosis or clinical outcome or all of the • Patients on End of Life Care Pathway activities of • Confused patients who are at risk or requiring constant supervision daily living. • Requires assistance with most or all activities of daily living • Potential for self-harm and requires constant observation • Facilitating a complex discharge where this is the responsibility of the ward-based nurse

QVM Hospital Safe Care Data Q1

The data below shows that predominantly throughout Q1, staffing levels ensured that actual care hours per patient (CHHPD) each day were above what was required based on the acuity of all patients in the beds.

Patients by type over time shows the acuity of the patients admitted into the beds during Q1, and as expected, most of the patients were assessed as level 1b; this is the normal patient profile that is admitted into QVM. During Q1 the maximum number of patients at any one time admitted to the unit who required 1-1 supervision was 2, causing an increase in for unregistered staff at times.

The use of bank and agency workers reduced in Q1 due to a reduction in staff sickness, staff returning from shielding/redeployment and closure of escalation beds. Registered nurse bank and agency usage in was reduced from 11.34% in Q4 to 8.73%, unregistered staff bank and agency usage was down from 24.7% in Q4 to 11.6% in Q1. Quality Committee 20th July 2021 Attachment 5.6

Danesbury Hospital Safe Care Data Q1

The data below shows predominantly throughout Q1, staffing levels ensured that actual care hours per patient (CHHPD) each day were meeting what was required based on the acuity of all patients in the beds.

Patients by type over time show the acuity of the patients admitted into the beds during Q1, with a majority of the patients assessed as level 1b. This is also reflected in the use of staff to support 1-1 supervision. During Q1 the maximum number of patients admitted to the unit who required 1-1 supervision at any one time was 2. Quality Committee 20th July 2021 Attachment 5.6

The use of bank and agency workers was reduced due to a reduction in staff sickness, staff returning from shielding/redeployment due to COVID risk assessments and closure of escalation beds. Bank and agency staff reduced in Q1 in comparison to Q4: bank and agency registered nurse usage was 4.87% compared with 7.55%. Unregistered staff bank and agency usage reduced to 34.3% from 49.5% in Q4 Quality Committee 20th July 2021 Attachment 5.6

Herts and Essex Community Hospital Safe Care Data Q1

Submission of the acuity data for Herts and Essex Hospital has improved this quarter compared to Q4 but there continues to be gaps. The number of substantive registered Nurses remains low. Recruitment continues with limited success despite the offer of a Golden Hello. Many agency nurses pick up regular shifts and work is ongoing to encourage them to consider a substantive post.

From the data that is available staffing levels have ensured that actual care hours per patient (CHHPD) each day were just above what was required based on the acuity of all patients in the beds.

Patients by type over time show that the acuity of patients admitted to Herts and Essex during Q1 does appear to be lower to that of QVM with one period where were patients assessed as level 0.

The use of bank and agency HCA workers was reduced due to a reduction in staff sickness, staff returning from shielding/redeployment due to COVID risk assessments and closure of escalation beds. Bank and agency usage for unregistered staff was 20.94% in Q1 compared with 41.66% in Q4. The use of bank and agency registered nurses increased as staff that had been redeployed to Herts and Essex returned to their substantive posts towards the end of Q4 alongside a substantive registered nurse who has been on long term sick. Use of bank and agency staff during Q1 increased to: 26.93% compared with 19.77% in Q4. Quality Committee 20th July 2021 Attachment 5.6 Hertfordshire Communityr,•1:bj NHS Trust

unit • He rts Essex Hos pital 7 __ v From • 01/0 4/ 2021 To • 80/06 /2 021 Output As CHPPD Q,

Required vs Actual CHPPD Vnriance From Reqmr d CHPPD

, '., 11IL,i1lu ,1.1J,IIIIL ,I1,J ...L.,11 , J... Ji . 1 °'l.,.._ I M-M-ffll N.r.!1111 • ■ Required CHPPD ■Actua l CHPPD

Pat,ents By Typ@ Over nm@ Assigned Hours Breakdown ., , ...... ,.. , ...... - ,." -· ►-

■ 1 :1 ■Level O ■TDTA L ■Substant ive Bank ■Agency

Unit • He, ts Ess.e:ic Ho s p it al 7,_ v From· 01 / 01/2021 To • 31 / 03 / 2021 Qufj)ut As CHPPD

Required va Act\Jal CHPPD Variance From Requited CHPPD

...

...... 1 l,,.1. l1 .1. 11I ..1 11 1

■ R"'l uired CHPPD ■Aetual CHPPD

Patients By Type Chier Time Ass1gned Hour• Breokdown

•. .I i.:... , ...., •.••■• ,, • .... ,.. I '• M. ··.... ,....I.,;; : ,.- lL ...

■ 1:1 ■Le ve l O Level 1e Level 1 b ■TOTAL ■Substant ive Bank ■Agency

Outst anding services ealthier communities Quality Committee 20th July 2021 Attachment 5.6

Mandatory Training

Mandatory Training Q1 96% 95% 94% 93% 92% 91% 90% 89% 812 Community Hospital Services 812 Community Hospital Services 812 Danesbury C12405 Herts & Essex C15160 QVM C15110

In all the 3 units mandatory training levels are maintained above the trust target of 90%. There was improvement across 2 units from Q4 to Q1 with HEH achieving 95% from 91%, and a slight improvement at Danesbury,90.5% to 91%. QVM saw a reduction in compliance from 96% to 92%.

Appraisals

Appraisal Rates Q1 95%

90%

85%

80%

75%

70% 812 Community Hospital 812 Community Hospital 812 Danesbury C12405 Services Herts & Essex Services QVM C15110 C15160 Quality Committee 20th July 2021 Attachment 5.6

Appraisal rates have remained stable at QVM, with improvements seen at both HEH and Danesbury compared to Q4. Danesbury remains below the trust target of 90%, however there is a plan in place to maintain the upward trajectory of improvement.

Risks: Patients with additional needs The Community Inpatients Units admit patients onto all units who have additional needs. These include patients who are at risk of falls, plus-size patients, patients requiring escorts to allow them to attend out-patient appointments, patients with Deprivation of Liberty Safeguards in place, etc. These patients require additional staff to provide enhanced care for their stay on the units. Commentary on the use of 1-1’s is now provided in each unit’s specific section of this report.

Patient Safety

Falls

In Q1 the total number of falls across the community hospitals was 37 compared to Quarter 4 with 53 falls. The numbers across all units have improved, this can be directly related to the improvement in staffing levels across all units and the reduction in the acuity of patients.

Pressure Ulcers

There has a reduction in the number of pressure ulcers reported in Q1. Both QVM and Danesbury reported 0 PU’s in April and May, with HEH have reporting 3 in April and 1 in May. In June Danesbury reported 0 PU QVM reported 2 and HEH reported 3 PU’s.

Serious Incidents

There were no SI’s reported in Q1.

Patient Experience

Complaints

There were 3 complaints were received for the bed bases in Q1:

• 2 complaints regarding concerns with standards of care in QVM. • 1 complaint regarding discharge and support at home in QVM.

At the time of writing this report, all 3 complaints had been reviewed and responded to.

Yasha Rai Unplanned care pathway lead. Board 3rd August 2021 Attachment D5

TRUST BOARD

Title: Learning from Deaths 2021/22 April-May report

Meeting Date: 3rd August 2021

Executive Lead: Dr Elizabeth Kendrick, Medical Director

Author(s): Claire Peck Patient Safety Specialist

For: Information and Assurance

Risk Rating: Green

1.0 Purpose & Recommendations

1.2 To advise the Board regarding: − An overview of deaths occurring and outcomes of the reviews − The work of the Learning from Deaths Panel

2.0 Key Points for the Attention of the Board

2.1 Two Learning from Deaths Panels were held during April and May 2021 and were chaired by the Medical Director. 2.2 No inpatient deaths and 4 community deaths were reported during April and May meeting the criteria for review. 2.3 9 deaths were reviewed at panels in April and May, 9 were assessed as being ‘Definitely not avoidable’. 2.4 The Panel and learning from deaths processes are continue to develop. The Panel and its process, continues to develop and recent changes will support improved sharing of learning that is identified from the Learning Disabilities Mortality Review (LeDeR) programme and Child Death Overview Panel (CDOP). To support discussion specialist leads are invited to Panel, including for example the Children and Adult Safeguarding leads and Infection, Prevention and Control Nurses. 2.5 Work has begun to raise awareness about the Quality Priority relating to providing feedback to families after the death of a loved one in one of the inpatient units. To date no deaths have occurred in the inpatient units meaning it has not been possible to trial the approach and get feedback. In 2021/22 progress against the key performance indicators for this priority will be monitored by the Panel and reported in this report.

3.0 Relevant Strategic Objective(s) / Strategies

3.1 This report links to the following Trust Strategic Objective: − Outstanding quality and performance

4.0 Risks and Mitigation Plans

None to note

5.0 Quality / Service / Regulatory Impacts

5.1 Report provides assurance that the process for reviewing deaths is in place and that panels are held regularly, chaired by the Medical Director.

6.0 Resource Implications

None

7.0 Actions / Next Steps / Timelines

n/a

8.0 References, Appendices & Supporting Information

None

Appendices & Supporting Information

None

9.0 Glossary / Abbreviations

None required

Author(s) of paper: Claire Peck Patient Safety Specialist June 2021

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): Clinical Governance Subcommittee June 2021 Quality Committee July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive director Elizabeth Kendrick √ / x who is satisfied that (i) the implications for risks, (ii) Medical Director quality/service/regulatory impacts and (iii) resource implications, have been considered.

Company Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Assistant Board Secretary √ / x

LEARNING FROM DEATHS REPORT

2021/22 April-May

The Learning from Deaths quarterly report summarises information and learning from the review of deaths. This report provides: 1. An overview of deaths occurring meeting the criteria for completing case note review; 2. Updated data for the year; 3. An overview of mortality reviews undertaken; 4. Learning identified; 5. Key points and next steps.

1. Overview of deaths within scope for review

Inpatient unit deaths 2018/19 2019/20 2020/21 2021/22 End of year total End of year total End of year total Q1 Q2 Q3 Q4 Total Danesbury Neurology Service 0 2 9 0 0 Herts & Essex Hospital 2 3 14 0 0 Queen Victoria Memorial Hospital 2 3 12 0 0 Total 4 8 35 0 0 To note: On 11/03/2020 the World Health Organisation declared COVID-19 a pandemic and the increase in inpatient deaths seen during 2020/21, is associated with the pandemic. In October 2020 NHS England/Improvement issued new definitions for hospital acquired Covid-19 infections to support identification of deaths that required investigation as a patient safety incident.

No inpatient deaths have occurred in April- May 2021.

Community deaths 2018/19 2019/20 2020/21 2021/22 End of year total End of year total End of year total Q1 Q2 Q3 Q4 Total Specialist Palliative Care 2 0 0 0 0

Lymphedema service 0 0 1 0 0 Lower Lea Valley ICT 1 1 3 0 0 North Herts ICT 2 1 2 0 0 WelHat ICT 5 0 8 3 3 Stevenage ICT 1 2 3 0 0 Stort Valley and villages ICT 0 0 2 1 1 Upper Lea Valley ICT 0 2 2 0 0 E&N Neuro rehab 0 1 0 0 0 Discharge Home to Assess N/A N/A 1 0 0 Care home enhanced service N/A N/A 1 0 0 Total 11 7 23 4 4

There has been an increase in reporting of community deaths. In part this is due to increased awareness of the criteria for reporting community deaths. The majority of these deaths were reported as we had seen the patient in the last 7 days, the death was unexpected and the cause of death is unknown: in many cases there is a delay in receiving the cause of death from GPs or the coroner meaning that the death meets the Trust’s criteria for review at the time of reporting.

A profile of community patients who died during April and May, including age and known cause of death, is included below:

Age No. of patients 85-89 1 90+ 3

Causes of death - 1a on death certificate (number of patients) − Chest infection - Respiratory tract infection − Gram Negative Septicaemia - Metastatic Carcinomatosis

Deaths of children and people with learning disability

Child deaths The Named Nurse Safeguarding has developed a process, agreed by the chair of the Child Death Overview Panel (CDOP), where lessons identified through the review of child deaths at the CDOP are presented to the HCT Learning from Deaths panel by the Named Nurse. Learning from the CDOP held in May 2021 was shared with the Learning form deaths Panel on 10/06/2021.

Learning has been identified regarding safeguarding of young adults around the time of transition form children’s to adult services: work streams are in place to address this.

Deaths of people with learning disability It is expected that the deaths of all people with learning disability aged four years and over are reported to the Learning Disabilities Mortality Review (LeDeR) programme; reporting a death is not an indication of failings in care.

The LeDeR programme across Hertfordshire is currently coordinated by the Health and Community Commissioning team, Hertfordshire County Council. HCT has representation on the Hertfordshire LeDeR Steering Group and the Improving Health Outcomes Group (a group with representation from all health and social care providers in Hertfordshire working to improve health outcomes for people with a learning disability).

Information from case reviews discussed at the LeDeR steering group are shared at the Learning from Deaths panel and shared with HCT’s Learning Disability Strategy group to inform HCT’s strategy and areas of focus.

In April 2021 NHS England and Improvement published a new LeDeR Policy: Learning from Lives and Deaths- People with a Learning Disability and Autistic People: an article to be shared with all staff has been drafted to outline the changes to the policy and how they may affect HCT staff: see appendix 1.

2. Overview of structured judgement reviews undertaken

The following dashboard has been developed taking into consideration: − The ‘assessment of avoidability’ scoring used by NHSI and which HCT has adopted; − Trusts are expected to “provide estimates of how many deaths were judged more likely than not to have been due to problems in care” (National Guidance on Learning from Deaths); deaths assessed as scoring 1,2 and 3 fall into this category; − Where the deaths of HCT patients with learning disability have been reviewed, these will be included and separate commentary will be provided as this supports the Learning Disability Mortality Review (LeDeR) programme. −

Mortality reviews Panel assessment of avoidability 2021/22 2021/ completed and assessed at Probably Probably 2022 Definitely Strong evidence Slight evidence Definitely not Panel avoidable (more avoidable but avoidable of avoidability of avoidability avoidable (community and than 50:50) not very likely inpatient) 1 2 3 4 5 6 Q1 9 0 0 0 0 0 9

Q2

Q3

Q4

*number of deaths recorded here are those reviewed during this 2 month period- the quarterly figure will be updated in subsequent reports

• Learning from Deaths panels were held in April and May 2021. • 9 deaths were reviewed and assessment of avoidability agreed. • All 9 deaths were assessed by the Panel as being definitely not avoidable.

3. Learning identified

Learning is gathered through review and discussion of the Structured Judgement Reviews by senior doctors, nurses, allied health professionals and managers who attend the Panel. Key points of learning are then summarised and communicated to all staff via Sharing Lessons in Practice (all-staff trust communication), with specific learning being directed to the relevant service managers.

Themes of learning identified by the Panel are collated in an ‘Emerging Patterns’ tracker in order to identify areas of concern. The tracker has been revised to support early identification of areas of concern to be shared with the Clinical Quality team and support their clinical quality improvement work.

Whilst deaths reviewed during April and May did not identify any deaths judged more likely than not to have been due to problems in care, some areas of care were identified that could have been better. Some examples are included below which have been added to the Emerging Patterns document:

 Mental capacity should be assessed in a timely way where cognitive decline is noted and consideration of application for deprivation of liberty safeguards where required to support safe care provision.

 Where patients are at risk of pressure damage is it important to provide advice about preventative care and essential to document what advice has been given.  When visiting elderly patients with a suspected infection a full set of clinical observations should be completed in order to identify or rule out sepsis: it is important not to rely on temperature alone- use of the NEWS2 tool and the Sepsis 6 is helpful to support identification of potential sepsis.  Missed opportunities to discuss advance care planning are frequently identified: when considering the surprise question “would I be surprised if this patient were to die in the next few months, weeks, days?”, it is useful to consider a person’s age and comorbidities even if the patient appears relatively well.  The Rockwood Frailty score should be used regularly. The process of undertaking the review, together with the individual score; − Helps make sure the person as a whole is considered; − Provides a prompt for asking the ‘surprise question’; − Is a trigger to consider if advance care plans/end of life discussions are indicated and have taken place?  When patients are referred to a service with a DNACPR this is an ideal opportunity to review that document and discuss a treatment and escalation plan with the patient and their family.  Fluid charts need to be used appropriately for those patients that need them. When used they need to be completed fully and accurately and the findings of the charts be acted upon.  Despite end of life care being provided to a high standard, the end of life and last days of life care plans are not used consistently to support best practice.

4. Conclusions and next steps

1) Work has begun to raise awareness about the Quality Priority relating to providing feedback to families after the death of a loved one in one of the inpatient units. To date no deaths have occurred in the inpatient units meaning it has not been possible to trial the approach and get feedback. In 2021/22 progress against the key performance indicators for this priority will be monitored by the Panel and reported in this report.

2) The next Panel is scheduled for July 2021. The Panel and its process, continues to develop and recent changes will support improved sharing of learning that is identified from the Learning Disabilities Mortality Review (LeDeR) programme and Child Death Overview Panel (CDOP). To support discussion specialist leads are invited to Panel, including for example the Children and Adult Safeguarding leads and Infection, Prevention and Control Nurses.

Claire Peck, Patient Safety Specialist June 2021

Appendix 1

Learning from Lives and Deaths-People with a Learning Disability and Autistic People (LeDeR) Policy 2021 NHS England and Improvement

What is the LeDeR programme? LeDeR was commissioned by NHS England to support the review the lives and deaths of all people, aged four years and above, with a learning disability, to understand the circumstances leading to the death and whether such deaths could potentially be avoided in the future through improvements to health and care services.

From 2021, adults who have a diagnosis of autism without a learning disability will also be eligible for a LeDeR review: further information about this will be shared when NHS England and Improvement publish this.

The East and North Hertfordshire CCG have had the lead responsibility for the LeDeR programme across Hertfordshire and the programme is implemented through Hertfordshire County Council who manage the process with involvement from all Hertfordshire health providers. From June 2021 the lead responsibility will be with the Herts and West Essex Integrated Care System.

The learning identified form the LeDeR steering group is fed up to the Improving Health Outcomes Group (IHOG) which is a Hertfordshire wide group who ensure that local and national recommendations from the LeDeR programme are addressed across organisations. Una Monaghan is the Trust’s representative on this group.

The HCT Patient Safety team should be alerted to the deaths of people with a learning disability (aged 4 and above) and autistic people (18 and over) who are known to HCT at the time of their death. They will ensure that all such deaths are reported as part of the LeDeR programme via the NHS LeDeR website.

Currently HCT has some staff trained to carry out reviews under the LeDeR programme, however in future the way reviewers are employed, trained and carry out reviews will be different to ensure standards and independence from service providers. Further information about this will be shared with our reviewers.

Why is LeDeR important? People with a learning disability die, on average, 20 years younger than the general population. This may partly be due to wider conditions and other disabilities that people with learning disability are living with, but many people with learning disabilities and autistic people also experience care and health inequalities which impact on their lives and contribute to their earlier deaths.

For people to be able to live as full and long a life as possible, it is important to understand if care and health were provided as they should have been, according to a person’s individual needs, and for improvements to be made when it is identified that care fell short.

More information To report a death that meets the above criteria please email [email protected]

More information can be found on the NHS England Learning Disability Mortality (death) Review Programme web pages or from Claire Peck, Patient Safety Lead (Patient Safety Specialist) via [email protected] If you have any questions about learning disability please contact: - Una Monaghan, Clinical Director Special Care Dental Service 01727 732051 / [email protected] Una is the HCT Clinical Lead for Learning Disability - Naomi Bignell, Named Nurse for Safeguarding Adults, MCA and PREVENT lead 07785 433688 / [email protected] Naomi has a background in learning disability nursing

Claire Peck June 2021

Board 3rd August 2021 Attachment D6

TRUST BOARD

Title: Review of HCT 2020/2021 deaths in line with NHS England/Improvement definitions for hospital acquired COVD-19 deaths

Meeting Date: 3rd August 2021

Executive Lead: Sarah Brown Director of Nursing and Quality

Author(s): Claire Peck Patient Safety Specialist

For: Information

Risk Rating: Green

1.0 Purpose and Recommendations

1.1 To advise the Board regarding: • An overview of deaths related to COVID-19 occurring in HCT during 2020/21

2.0 Executive Summary

2.1 There were 35 inpatient deaths during 2020/21, of these 25 had COVID-19 listed on the death certificate 2.2 16 of the patients acquired COVID-19 prior to admission to a HCT inpatient unit. 2.3 5 of the patients probably acquired COVID 19 whilst an inpatient in a HCT unit. 2.4 4 of the patients definitely acquired COVID-19 whilst an inpatient in a HCT unit. 2.5 3 deaths that occurred in January 2021, at Herts and Essex Hospital and Danesbury, were part of a COVID-19 infection outbreak at these sites. Both outbreaks have been investigated and managed in line with the HCT Outbreak Policy. 2.6 All deaths were reported as a patient safety incident and investigated by the service manager in line with the HCT Incident Policy. 2.7 All deaths were reviewed in line with HCT Learning from Deaths Policy and process.

Board 3rd August 2021 Attachment D6

3.0 Relevant Strategic Objective(s) / Strategies

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

4.0 Appendices and Attachments

(1) None

Author(s) of paper:

Name Claire Peck Date: May 2021

Board 3rd August 2021 Attachment D6

To be completed as part of paper

Committee Consideration

This Report has previously been considered by the following committees: Committee: Date (Month / Year): Quality Committee July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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. 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable Sarah Browne √ / x executive director who is satisfied that (i) the implications Director of Nursing and for risks, (ii) quality/service/regulatory impacts and (iii) Quality resource implications, have been considered.

Board Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Company Secretary N/A

Board 3rd August 2021 Attachment D6

Review of HCT 2020/2021 deaths in line with NHS England/Improvement definitions for hospital acquired COVD-19 deaths

Situation:

In March 2020 the World Health Organisation declared COVID-19 a pandemic.

In October 2020 NHS England/Improvement issued new definitions for hospital acquired Covid-19 infections to support identification of deaths that required investigation as a patient safety incident. Definitions are as follows:

Community-Onset (CO) A positive specimen date less than or equal to 2 days after hospital admission or hospital attendance. Hospital-Onset Indeterminate A positive specimen date 3-7 days after hospital admission. Healthcare-Associated (HO.iHA) Hospital-Onset Probable A positive specimen date 8-14 days after hospital Healthcare-Associated admission. (HO.pHA) Hospital-Onset Definite A positive specimen date 15 or more days after hospital Healthcare-Associated admission. (HO.dHA)

A ‘Probable’ or ‘Definite’ hospital-onset healthcare associated COVID-19 infection is a patient safety incident and should be reported and responded to according to the trust’s existing policies.

Background:

All HCT inpatient deaths are reported as a patient safety incident on the Trust’s incident reporting system (Datix). Service managers investigate these incidents in line with HCT’s Incident Policy. Case note reviews are completed using the structured judgement review (SJR) approach. The SJRs are reviewed by the Learning from Deaths Panel, chaired by the Medical Director, who consider if the death could have been avoided and identify further actions to be taken in light of any learning that is identified.

During the f the COVID-19 pandemic HCT inpatient units have cared for patients infected with COVID-19 which in some cases resulted in a patient’s death. All of these cases were reviewed as part of the Trust’s ‘Learning from Deaths’ process and any learning identified was shared with individual teams and also via Sharing Lessons in Practice. In all cases where it was identified that COVID-19 had been acquired in HCT care, the death was assessed by the Learning from Deaths Panel to have slight evidence of avoidability (score 5).

A review of deaths in HCT’s inpatient units from April 2020 until March 2021 has been undertaken to identify which deaths meet the NHSE/I definitions of a hospital onset infection.

Board 3rd August 2021 Attachment D6

Assessment:

In 2020/21 a total of 58 deaths occurred that met the Learning from Deaths Policy criteria for review, 23 deaths were in the community and 35 in HCT inpatient units.

The 35 deaths occurring in the inpatient units have been considered, specifically in relation to those patients where COVID-19 was recorded on the death certificate. Information relating to the 35 inpatient deaths is presented below.

From April to November 2020 there were 16 inpatient deaths. 9 of the 16 deaths had COVID-19 listed on the death certificate.

There were 4 deaths due to COVID-19 where patients had been admitted with a positive swab result or were confirmed as being positive within 2 days of admission, therefore not acquired in HCT care

There was 1 death where COVID-19 was suspected and later confirmed which therefore meets the definition for Hospital-Onset Probable Healthcare-Associated (HO.pHA) – a positive specimen date 8-14 days after hospital admission.

4 deaths met the definition for Hospital-Onset Definite Healthcare-Associated (HO.dHA) – a positive specimen date 15 or more days after hospital admission.

From December 2020 to March 2021 19 deaths occurred in HCT inpatient units, 16 of the deaths had COVID-19 listed on the death certificate.

There were 12 deaths due to COVID-19 where patients had been admitted with a positive swab result or were confirmed as being positive within 2 days of admission, therefore not acquired in HCT care.

There were 4 deaths where COVID-19 was suspected and later confirmed which therefore meet the definition for Hospital-Onset Probable Healthcare-Associated (HO.pHA) – a positive specimen date 8-14 days after hospital admission.

No deaths met the definition for Hospital-Onset Definite Healthcare-Associated (HO.dHA) – a positive specimen date 15 or more days after hospital admission.

Summary: • Of the 58 deaths reported during 2020/21 meeting the criteria for review, 35 were inpatient deaths • Of the 35 inpatient deaths, 25 had COVID-19 listed on the death certificate • 16 of the patients acquired COVID-19 prior to admission to a HCT inpatient unit. • 5 of the patients probably acquired COVID-19 whilst an inpatient in a HCT unit. • 4 of the patients definitely acquired COVID-19 whilst an inpatient in a HCT unit.

Board 3rd August 2021 Attachment D6

• 3 deaths that occurred in January 2021, at Herts and Essex Hospital and Danesbury, were part of a COVID-19 infection outbreak at these sites. Both outbreaks have been investigated and managed in line with the HCT Outbreak Policy. • All deaths were reported as a patient safety incident and investigated by the service manager in line with the HCT Incident Policy. • All deaths were reviewed in line with HCT Learning from Deaths Policy and process.

Recommendations: • Future COVID-19 deaths meeting the criteria for probable or definite onset must be considered as a potential patient safety incident and review undertaken to confirm if further investigation is required and if so the level of investigation. • In cases where COVID-19 was acquired in an acute hospital prior to transfer to a HCT inpatient unit, confirmation that the patient was transferred with COVID-19 should be shared with the acute trust for awareness. • In those cases where COVID-19 was acquired in HCT care, information gathered as part of the SJR should be reviewed by the Infection Prevention and Control team to consider any information and learning regarding infection prevention and control practices. • In all cases where COVID-19 was the cause of death, to identify whether the family were provided with adequate information following the patient’s death, including an opportunity to talk with the senior ward doctor or nurse and ensure that the leaflet devised for this purpose has been shared with the family.

Claire Peck, Patient Safety Specialist May 2021

Board 3rd August 2021 Attachment D7

Board Committee Chair’s Assurance Report

Quality Committee

Date of Board Meeting: 3 August 2021 Committee Chair: Sarah Wren

Date of Report: 20 July 2021

Dates of Committee Meetings Held Since Last Board Meeting: none

Date of Next meeting: 21 September 2021

Item Subject Director’s Committee Committee Chair’s Ref Risk Assurance Observations Assessment Assessment (H/M/L) (R/AR/ (R/A/G) AG/G) Risks Arising From Minutes / Tracker Updates: Tr1 Tracker Tracker reviewed and all actions completed or on track

4 Risk 4.1 Board Assurance Not Not applicable Risks aligned to the Framework and High applicable Committee were reviewed in Level Risk Register detail. Action to review where health inequalities risk is presently aligned to as agreed should be reporting to quality committee.

5 Assurance 5.1 CQC update Green Green Report received. Recommendation agreed for improvement plan to be signed off and remaining longer term actions to be monitored through identified workstreams. Discussion undertaken around maintaining assurance of the actions completed and confirmation given in regard to the use of the quality wheel review to monitor this.

5.2 Quality Priorities Q1 Amber/ Green Amber/ Quarter 1 report received. Green

5.3 Clinical Service verbal Presentation given detailing Recovery Update recovery of services across Board 3rd August 2021 Attachment D7

system and HCT and specific challenges and risks.

5.4 COVID-19 Deaths Green Green Detailed report presented in Report 2020-2021 line with NHSE/I definitions of a hospital onset infection

5.5 Mass Vaccination Report received in regard to update Amber Amber Vaccination programme covering roving model, staff vaccination and vaccination centres. Discussion undertaken covering the reduction in uptake and actions being supported across both systems and HCT staff that have not taken up opportunity of the vaccination.

5.6 Safer Staffing Amber/Green Amber/Green Quarter 1 report received. Community hospitals have returned to pre-pandemic bed numbers and staffing ratios. Verbal update given covering increasing sickness due to isolation impacting on staffing the units. HEH continues to experience high registered vacancies but supported with long term agency staff. Committee also informed that HCT is participating in ICS international recruitment pilot.

5.7 Complaints report Green Green Quarter 1 complaints report update received covering HCT and vaccination centres. Report also covered enhances PALs contacts and compliments received. Action agreed to look at % of complaint to activity for each service.

Report received covering 5.8 Serious Incident report Green Green April and May detailing two incidents reported for which investigations are in progress. Update from SI assurance panel given detailing learning from previous incident reported. Board 3rd August 2021 Attachment D7

Updated IPC report received 5.9 Infection prevention Amber/Green Amber/Green and discussed in detail. and Control BAF Updated BAF from 30th June update also presented – no new risks identified for the Trust. No new outbreaks or infections for the Trust reported.

Report received. No inpatient 5.10 Learning from Death Green Green deaths and 3 community Q1 deaths during time of report. Learning Disabilities Mortality Review (LeDeR) learning and Child Death Overview Panel (CDOP) also now brought into panel. Shared attendance and learning also being undertaken with ENHT.

Assurance reports from two 5.11 Clinical Governance Sub Committee Not applicable Not applicable subcommittees received with assurance report minutes and action tracker. This also included approved policies and SOPs at Clinical Advisory Group.

Assurance report received 5.12 Good to Outstanding Plan Not applicable Not applicable with draft framework and Terms of Reference.

6.00 Key Items for Noting

- Learning from Deaths Reports / Panel - Clinical Recovery presentation - Special meeting held to receive Annual reports 14th July – where leads presented reports covering Infection Control, Complaints, Adult Safeguarding, Looked after Children and Children Safeguarding.

7.00 Confidential – Serious Case review Serious Case Review Serious case review and media statement presented. Board 3rd August 2021 Attachment D7

At present this has not been released as further work is in progress with family before report is made public. Assurance given that staff involved had participated in learning events and reflections and supported through investigation and criminal hearings.

8.00 Key Items for Escalation

• None

Supporting Papers for information

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

- Clinical Recovery Presentation - Safe Staffing report – with high vacancies in one unit, but supported with long term agency - Updated IPC BAF Annual reports approved: - - Complaints - Infection Control - Looked after Children (LAC) - Safeguarding Children - Adult Safeguarding. (These will be uploaded on the website and copies are available on request)

Definitions and Key:

Green Amber/ Green Amber/ Red Red

(A) Executive Director’s Risk Assessment

High (Red)

Board 3rd August 2021 Attachment D7

Risks associated with this issue:

(1) Include high scoring risks (15+) which have been recorded on the appropriate risk register (i.e. 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 (i.e. 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 Board 3rd August 2021 Attachment D7

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.

Board 3rd August 2021 Attachment E1

TRUST BOARD

Title: Service Recovery Report and Performance Report – June 2021 data

Meeting Date: 3rd August 2021

Exec Lead: Antonia Robson, Associate Director, Integrated Business Services

Author: Roshan Jhoree, Head of Analysis & Reporting Andy Saunders, Deputy Director of Contracts, Performance and Business Management

For: ASSURANCE

Risk Rating: Amber/Red

1. Executive summary

1.1 Activity reporting for 2021/22 is compared to 2019/20; this is due to the impact of the pandemic in 2020/21 and to ensure we have an informative comparator and accurate representation of recovery. In June, overall activity was higher than June 2019 by 3.3%. Adult services were 7% higher and Children and Young People’s (CYP) services were 2% lower (although in CYP there was an increase in June compared to May). 1.2 Referrals are up in Q1 by 10% on 2019/20 levels (16% for CYP and 5% for Adults), with particularly strong growth in referrals seen in June (CYP up 26% and Adults up 16% vs June 2019).

1.3 The performance dashboard for June is in Appendix 1.

1.4 In relation to waiting times the picture is generally very positive. At the end of June 2021, the number of patients waiting within 18 weeks for non-Consultant-led services (with an 18-week target) remained at 94%. Performance in Consultant-led Referral to Treatment (RTT) services remained below target (the target is 92% of open waits should be less than 18 weeks) with 86% recorded in June but this is a strong improvement on May performance by 6%. RTT performance is below 2019 levels by 6% but there is a strong improving trend.

1.5 As at the end of June 2021, there were 38 patients (four from Consultant-led services) waiting over 40 weeks. This reduced by 22 patients from May and is a 64% improvement compared to June 2019 (105 waiters over 40 weeks). Of these patients, 11 are waiting over 52 weeks, which is a reduction of four patients from May.

1.6 ‘Substantial Assurance’ rating received from internal auditors for Service Recovery audit (July 2021).

2. Recommendations

2.1 Board members are asked to note the contents of this report for assurance.

3. Progress with service recovery – overall activity levels

3.1 Compared to June 2019 there is an overall positive variance of 3.3%. Adults services were 7% higher and Children’s services 2% lower in June 2021 than in June 2019.

3.2 The table below shows the services with the greatest negative variations compared to June 2019:

Table 1.

Children’s Speech & Language Therapy (SLT) activity levels are down by 29% compared to June 2019. The service has received a large number of Education Health and Care Plan (EHCP) referrals which is the Herts County Council (HCC) element of the contract in 20/21 and the current year. In Q1 15% of all SLT referrals were EHCP and this activity is having a significant impact on the overall service. This activity and the associated assessments are statutory requirements. The type of activity associated with EHCPs can often be indirect such as report writing and liaison. This means that an increase in the EHCP activity also results in additional time away from other direct patient contacts. The service is working with HCC and the wider Education system around the impact of increased EHCP requests.

School Nursing activity is down 16.6% compared to June 2019 levels. The National Child Health Measurement (NCMP) has been suspended until next school year for 2021 and as a comparison, only 3% of the total activity for June 2019 is attributed to NCMP. Further analysis is required on the variance as there are also some immunisation activities recorded against School Nursing in June 2019 and not in June 2021. This analysis will be provided in the next report to give a more accurate comparison.

3.3 Activity overall for Adults and CYP services has been increasing month on month from April and is now back at 2019 routine levels. Referrals are up in Q1 by 10% (16% for CYP and 5% for Adults) with particularly strong growth in referrals seen in June (CYP up 26% and Adults up 16% vs June 2019). Contacts are just 1% below 2019 levels for Q1 (1% positive for Adults and 5% negative for CYP). Activity (contacts) - month on month recovery trend can be seen in Fig.1 below:

3.4 Forecast trajectories for referrals and contacts are being developed for the Adults and CYP directorates and will be available in the next report.

Fig 1.

4. Waiting Times

4.1 In June, the number of patients waiting within 18 weeks for non-Consultant led services with an 18-week target remained at 94% and achieving the local target of 92% (see Fig 2 below); this is now higher than June 2019 performance by 2%. Performance in Consultant-led RTT services remains below target (the target is 92% of open waits should be less than 18 weeks); however strong progress was made with 86% of patients waiting within 18 weeks recorded in June which is a 6% increase from previous month and only below June 2019 levels by 6%. The number of patients waiting over 18 weeks for Consultant-led services reduced by 131 patients on previous month.

Fig 2. Percentage of patients waiting within than 18 weeks

4.2 In terms of long waiters, as performance continues to improve the operational focus for 2021/22 is now on reducing the number of long waiters over 40 weeks whilst continuing to closely monitor patients over 18 weeks. The services with long waiters and those not achieving their respective waiting time targets are shown in Table 2 below. Operational teams continue to prioritise those waiting longest as well as those with more urgent clinical needs.

Patients Patients Patients % waiting waiting waiting Waiting HCT Service 52+ 40+ 18+ within 18 weeks weeks weeks weeks Consultant Led 18 Week Services Community Paediatrics 0 4 157 79% Paediatric Audiology 0 0 154 81% Non Consultant Led - Target 18 Weeks Diabetes E&N (Nursing) 0 2 14 93% Diabetes E&N (Consultant pathway) 7 11 54 48% East & North Herts Neuro Rehab Service - Community 0 3 60 80% Adult Occupational Therapy Service E&N (Acute Therapies) 0 0 36 77% Adult Physiotherapy Service E&N (Acute Therapies) 0 0 19 91% % within services Non Consultant Led - Target shorter than 18 Weeks Target specific target MSK Triage E&N 0 1 56 93% 55% 6 Weeks Childrens Occupational Therapy 0 4 188 75% 63% 14 Weeks Children's Speech & Language 1 5 59 95% 72% 10 Weeks Integrated Diabetes Service 3 8 33 90% 62% 6 Weeks Step2 Mental Health & Emotional Well-Being 0 0 8 98% 57% 4 Weeks Total 11 38 972 Table 2.

4.3 There were 38 patients waiting over 40 weeks for an initial appointment for our services at the end of June 2021; a reduction of 22 patients from the previous month.

4.4 There were 11 patients waiting over 52 weeks for an initial appointment for our services at the end of June 2021; a decrease of four from May. The majority of these are waiting for Consultant appointments with the East and North Diabetes services and now have appointments booked.

4.5 Challenges remain in the East and North Diabetes service but there has been positive engagement from East & North Herts Trust which has now confirmed its Consultant offer and which, if delivered, is sufficient to meet the service need. This service currently has oversight on a weekly basis by the Director and Deputy Director of Operations.

4.6 Paediatric audiology had been previously highlighted as a service with a high number of long waiters; however, performance has been very strong in June. The service improved from 64% of patients waiting within 18 weeks in May to 81% in June. There was a reduction of 173 patients waiting over 18 weeks from previous month. Community Neuro service recovery continues with a reduction from 108 patients waiting over 18 weeks in January to 60 in June. The service improved to 80% of patients waiting within 18 weeks – a 3% increase from previous month.

4.7 The waiting list position in Children’s Speech and Language Therapy remains similar to previous month with five waiters over 40 weeks. There is now only one patient waiting over 52 weeks. In Children’s Occupational Therapy the waiting list position is worsening with an increase of 15 patients waiting over 18 weeks from previous month to 188; however, the service reduced its 40+ week waiters - down to four from seven in June. Referrals have increased by 28% for Q1 2021 compared to Q1 2019 for Children’s therapy services, creating difficulty for the services to both meet new demand and address the waiting lists.

4.8 In relation to Autism Spectrum Disorder (ASD) diagnosis - a follow up assessment within Community Paediatrics - countywide investment has been agreed to support additional capacity to address backlog (there are currently 1065 waiters with an average wait of 48 weeks for open referrals). HCT is currently carrying out 30 - 35 extra assessments per month against new indicative target of 92 extra. The investment supports an element of outsourcing and procurement is underway to secure more capacity.

5. Risks to Delivery of Service Recovery

6.1 Whilst there are particular services where recovery is more challenging and at higher risk as described above, there are also general risks to HCT service recovery at an overall level. The overall recovery risks identified previously are shown in the bullets below. The impact of these to date has been limited through effective mitigating actions as can be seen in the performance set out in this paper. With the incidence of COVID-19 growing again, the risk associated with the first two bullets has increased. In particular at the current time we are concerned about the potential impact of significant numbers of staff required to self-isolate on service delivery and recovery.

• Delivery of service recovery is impacted by further COVID-19 peaks/ demand pressures and the need to redeploy staff to surge enhanced services and hence reduced delivery capacity for recovery of planned care services. • Delivery of recovery is impacted by staff availability due to sickness, self- isolation/ shielding requirements, impacts of lockdowns e.g. due to childcare/ caring responsibilities, competition for bank/ agency staff, bad weather/ travel problems. • Delivery of service recovery is impacted by the need to redeploy staff deliver the COVID-19 vaccination programme and hence reduced delivery capacity for recovering planned care services. 6.2 We agreed at the May 2021 People Performance and Finance Committee (PPFC) meeting to reflect on the High Level Risk Register the particular risks faced in some services around recovery - and specifically to reflect the recovery risks for the Diabetes Service and for CYP Therapies. The specific risks for Community Paediatrics and ASD assessment, Diabetes and CYP Therapies are now recorded on the High Level Risk Register.

6.3 A further risk which we have discussed previously at PPFC is that recovery is unequal and health inequalities are further exacerbated (e.g. due to failure to seek healthcare input/referral; lower levels of self-advocacy; digital poverty impacting on access) if there is insufficient focus/differentiated approach for those at risk of inequalities. We are taking forward work to analyse and develop an action plan in relation to health inequalities and are mindful of this risk in our recovery planning.

Appendix 1 – June Performance Dashboard

Authors of paper:

Roshan Jhoree, Head of Analysis & Reporting Andy Saunders, Deputy Director of Contracts, Performance and Business Management

21 July 2021 END OF REPORT

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): PPFC July 2021 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive Antonia Robson, Associate √ / x director who is satisfied that (i) the implications for risks, (ii) Director, Integrated Business quality/service/regulatory impacts and (iii) resource implications, Services have been considered.

Company Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Assistant Board Secretary √ / x

Board 3rd August 20221 Attachment E2

TRUST BOARD

Title: Equality Reports – WRES and WDES

Meeting Date: 3rd August 2021

Author: Alison Ryder - Associate Director of People

For: APPROVAL

Risk Rating: Amber/Red

1.0 Purpose & Recommendations

1.1 To advise the Board of the key points arising from analysis against race and disability equality measures in line with statutory requirements.

2.0 Key Points for the Attention of the Board

2.1 The Trust is required to publish a Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) Report annually. The deadline for submission of the data this year is the 30th August 2021. The reports are normally approved for publication by the Trust Board.

2.2 The WRES Report analyses the experience of Black, Asian and Minority Ethnic (BAME) staff compared with that of white colleagues against nine indicators. Some of these are determined through reviewing workforce statistics and others through the NHS Annual Staff survey responses. The report covers the period April 2020 to March 2021. The full WRES report is provided at appendix 1.

2.3 The main points to note in the WRES report are:

Indicator Comments RAG Indicator 1 The ethnic profile of the Trust is reflective of the local population and there is good representation of BAME staff in senior bands 8a, 8d and particularly in the medical and dental staff groups (albeit these bands/groups comprise small numbers). There are however gaps at 8c, 9 and VSM/Board levels. Indicator 2 Applicants from a white background are slightly more likely to be appointed after shortlisting than applicants from a BAME background at 1.53 (equal being 1.00). This is slightly up on last year. Indicator 3 BAME staff are 1.83 times more likely to enter formal disciplinary proceedings than their white colleagues, although this figure has greatly improved over the last two year. We have very small numbers of formal disciplinary cases (9 in the two-year monitoring period). Indicator 4 53% of BAME staff have accessed non-mandatory training this year, compared to 50% of white staff. The relative likelihood of accessing training has remained relatively stable and equal for the last 4 years. Indicator 5 The proportion of staff reporting that they have experienced harassment or abuse from patients remained stable for all staff this year. Interestingly a lower proportion of BAME staff (17%) reported this than white staff (22%). Our scores were also significantly better than the Community Trust average. Indicator 6 There was a significant improvement in staff experiencing bullying or harassment from other staff this year, particularly for BAME staff. We were also much better than the Community Trust average. Indicator 7 A higher proportion of our white staff (95%) believe the Trust has equal opportunities for career progression than their BAME colleagues (80%), although both scores have improved compared with last year. We are again above the average for Community Trusts. Indicator 8 The percentage of BAME staff reporting they have experienced discrimination from managers is higher than white colleagues and this has also deteriorated compared with the much-improved position last year. However, our score is better than the Community Trust average. Indicator 9 At March 2020, there were no voting members of the Board from a BAME background. However, the Trust has now successfully appointed a new Non-Executive Director and Associate Non-Executive Director, both from BAME backgrounds, who started in July 2021.

2.4 Therefore, the Trust’s WRES report shows a mixed picture overall, with some really positive areas of improvement, but a number of indicators requiring further action. An action plan is provided at the end of the WRES report, which has been developed in conjunction with the BAME Network and with input from the wider BAME staff meeting.

2.5 The WDES Report analyses the experience of staff living with a disability compared with that of non-disabled colleagues against ten indicators. Again, some of these are determined through reviewing workforce statistics and others through the NHS Annual Staff survey responses. The report covers the period April 2020 to March 2021. The full WDES report is provided at appendix 2.

2.6 The main points to note in the WDES report are:

Indicator Comments RAG Indicator 1 The breakdown of staff reporting themselves as living with a disability shows a lack of disabled staff in several senior bands. However, using the clusters prescribed under the WDES, the most senior band has equal representation because it includes 8b. There are staff with a disability at all other levels in the organisation. The highest numbers of disabled staff (headcount) are in Bands 5 and 6 (with 10 and 18 staff in each band respectively), with the highest percentages being at Band 8b and medical career grades. Overall, disabled staff continue to

make up 3% of the workforce. Indicator 2 Non-disabled applicants are 1.21 times more likely to appointed after shortlisting than disabled applicants. This figure has improved since last year when the likelihood was 2.17. 1.00 would be an equal likelihood, so this is now getting much closer to equal. Indicator 3 There have only been 5 new formal capability cases over the last 24 months, none of them for disabled staff. Most issues are resolved though informal processes. Indicator The proportion of disabled staff experiencing harassment, bullying or 4 a i abuse from patients and the public is higher than for non-disable staff, and has both deteriorated since last year and is worse than the Community Trust average, so a real area of concern. Indicator The proportion of disabled staff experiencing harassment, bullying or 4 a ii abuse from managers is much higher than for non-disable staff, but has substantially reduced since last year and is lower than the Community Trust average. Indicator The proportion of disabled staff experiencing harassment, bullying or 4 a iii abuse from other colleagues is higher than for non-disable staff, although improved since last year and better than the Community Trust average. Indicator Disabled staff are slightly less likely than their non-disabled 4 b counterparts to report incidents of harassment or bullying, although this has slightly improved since last year. This remains below the Community Trust average. Indicator 5 Although fewer disabled than non-disabled staff believe that the Trust provides equal opportunities for career progression, there has been a substantial improvement in scores on this compared with last year and the Trust is above average on this indicator. Indicator 6 More disabled than non-disabled staff have stated that they felt pressure to come into work and this has deteriorated since last year, as well as being well above average. We are working with the Disability and Long-Term Conditions Network to address this. Indicator 7 Fewer disabled than non-disabled staff are satisfied with the extent to which the organisation values their work, although this has improved since last year. HCT is in line with the Community Trust average. Indicator 8 81% of disabled staff report that the Trust has made adequate adjustments to enable them to carry out their work, improved since last year and in line with the average. Indicator The staff engagement score for disabled staff is lower than that for 9 a non-disabled staff and this has remained the same for the last two years. This is slightly below the average for Community Trusts. Indicator The Disability and Long Terms Conditions Network was set up in 2020 9 b and now provides a mechanism for talking directly to disabled staff on their experiences of working at the Trust. This has included discussion about the above Annual Staff Survey results and talking to the group about actions that would improve their working lives. Indicator 10 There is one person living with a disability on the Trust Board, but none declared on the Executive Team. As there are only small numbers on the Board, one or two people have a large impact on the percentages, so overall the Board/Executive is reflective of the percentage of staff living with a disability or long-term condition in the wider workforce.

2.7 Overall, the Trust’s WDES report shows a similar mixed picture to the WRES, with several indicators requiring further action. An action plan is provided at the end of the WDES report and this will be implemented with support from the Disability and Long-Term Conditions Network.

2.8 There is a further equalities report, the Gender Pay Gap report, which is due to be published by the 5th October 2021. This will be brought to the next PPFC meeting with a request to approve the data for submission prior to going to the October Trust Board on the same date as the final deadline. There is not normally the same need for action to address this report, given the predominantly female workforce (93%).

3.0 Relevant Strategic Objective(s) / Strategies

3.1 This report links to the following Trust Strategic Objectives

1. Outstanding quality and performance 3. Great place to work

3.2 Links to: Trust People Strategy and Plan

4.0 Risks and Mitigation Plans

Risk Mitigation / Action(s) There is a risk that the action plans set out We are working with our Staff Networks to in these reports do not impact sufficiently on co-design and test our plans to ensure that the experience of the relevant cohorts of they are meaningful and include actions that staff, so the Trust does not see the will make a significant difference to staff necessary improvement in the indicators. experience.

5.0 Quality / Service Impacts

5.1 Having a diverse workforce, bringing a variety of perspectives, is recognised as helping to support the delivery of high quality services.

6.0 Resource Implications

6.1 Investment may be needed to progress some of areas for improvement. Separate business cases will be brought for any such initiatives.

7.0 Next Steps

7.1 Work to address the issues arising from the WRES and WDES analysis is already taking place under the Trust People Strategy/People Plan and Equality, Diversity and Inclusion Action Plan. Additional actions have been included at the end of the reports, which will be implemented jointly with the Staff Networks to ensure the greatest possible impact on staff experience.

7.2 Work will begin on the Gender Pay Gap report shortly and this will be brought to the next PPFC meeting to meet the 5th October deadline for publication.

8.0 Appendices & Supporting Information

(1) WRES Report 2020/21 (Supporting Paper J6) (2) WDES Report 2020/21 (Supporting Paper J7)

Author of paper: Alison Ryder - Associate Director of People July 2021

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): People Performance and Finance Committee July 2021 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 Description Comments / Exceptions √/ x Quality Domain Complete Information is as comprehensive as possible to It is confirmed that there is no √ inform the board and no significant known facts information from this workforce or statistics which may influence a decision are analysis omitted omitted. Accurate As far as can be reasonable ascertained or Information from ESR is accurate. √ validated, information in the report is accurate. Applicant information from Trac appears to be accurate, but there is less assurance. Relevant Information contained in the report is relevant to Yes √ the matters considered in the report. Up To Information in the report is as up to date as Information timeframe is as set out √ Date reasonably possible in the context of the time at in the statutory reporting which the paper is written requirements Valid Information is presented in a format which Yes √ complies with internal or national models or standards Clearly The meaning of any data in the report is clearly Yes √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive Sarah Browne – Director of Nursing √ director who is satisfied that (i) the implications for risks, (ii) and Quality quality/service/regulatory impacts and (iii) resource implications, have been considered.

Company Secretary Sign-Off (Board papers only)

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

Board 3rd August 2021 Attachment E3

Board Committee Chair’s Assurance Report

People Performance and Finance Committee

Date of Board Meeting: 3 August 2021 Committee Chair: Jeff Phillips

Date of Committee Meeting: 22 June 2021 Date of Report: 4 July 2021

Dates of Committee Meetings Held Since Last Board Meeting: 22 June 2021

Date of Next meeting: 27th July 2021

Item Subject Director’s Committee Committee Chair’s Ref Risk Assurance Observations Assessment Assessment (H/M/L) (R/AR/AG/G (R/A/G) ) Risks Arising From Minutes / Tracker Updates: 7/15 Mass Vaccination Amber/Red Amber/Red Whilst the current arrangement for cost reimbursement continues, the Trust is not at financial risk. However, there is a distinct possibility that NHSE/I will move to a tariff base in the coming months and the risk to the Trust is that the tariff will not cover cost. Furthermore, it is likely that the Trust will have to extend/renew property leases on vaccination sites before the new payment regime is clarified. People 15/4 EU Exit Settlement update Amber/Green Amber/Green Of the 49 EU staff recorded as requiring settled status, only 1 has unknown status, 43 staff have settled status, 5 are pre-settled, but await confirmation. 15/5 Staff Health & Wellbeing Amber/Green Amber/Green Sarah Wren is now the update Trust’s Wellbeing Guardian, supported by the Asst. Director for People.

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The Trust has a range of support mechanisms in place, with particular focus on emotional wellbeing and overall mental health Performance & Finance 15/6 Service Recovery and Amber/ Red Amber/ Red Compared with May 2019, Performance Report activity was down 7.6% overall, with Adult services 3.8% lower, and Children’s 12.7% down. However, this was an improvement over April 2021. With School Nursing now focussed on vision and audiology, activity levels will be lower at this time, which would normally be centred on weight and height checks. In Adults, pulmonary rehab is adversely affected as routine COPD clinics are not taking place, and MSK clinics are on hold awaiting NHSE/I guidance. Waiting times continue to improve, with 18-week non- consultant led now at 94%, and consultant led has improved to 80% against the 92% target. Audiology, community neuro and diabetes remain of concern in Adults, whilst in Children’s, ASD is now making substantial improvement, as has SLT. However, the growth in EHCP referrals is presenting a challenge.

The risks the Trust are facing relate to staff availability due to shielding/isolation and sickness as we approach the next COVID-19 peak and the onset of winter demand pressures. 15/7 Board Assurance Not Not The BAF now has two new framework and High-Level Applicable Applicable risks relating to Income Risk Register Recovery and Expenditure Control 15/8 Financial report Month 2 Green Green The Trust has reported a surplus of £388k for the year

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to date, reflecting the surplus on the sale of Nascot Lawn and an overall break-even position on activity. Further guidance for the second half of the year is still awaited, but the expectation is that there will be some tightening of resources available and a requirement to deliver the full £3.5m PIES target. On capital expenditure, there are a number of business cases yet to be completed, particularly in respect of multi-year projects such as Hoddesdon and Cheshunt centres. But in addition, we face the effects of the global shortage of microchips, and cost and availability pressure on cement, steel sand and other construction materials. 15/9 Patient Level Information Green The patient Level Information and Costing System and Costing system is critical (PLICS) for the Trust as it enters into new tariff based contractual arrangements, which were previously scheduled for implementation on 1st October 2021, but likely to be effective from March 2022. The project is now well advanced, but there are a number of critical issues relating to critical ledger interfaces including workforce, activity and premises floor areas that are yet to be finalised. The impact of PLICS cannot be understated, as it will fundamentally change the way the Trust operates, in respect of how services, staffing, estate management, and finance operate in terms of data structure and communication. 15/10 PIES update Amber/ Red The shortfall from last year amounted to c.£1.1m, which is now part of the £3.5m target for the current year.

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Currently, the Trust is on track to meet its £620k target for the first half of 21/22, and there are schemes being scoped to meet the remainder of the year’s objective. It is recognised that whilst the target figure is forecast to be delivered. It is likely that some elements will be initially delivered through non-recurrent schemes. 15/11 COVID-19 Mass verbal Not The Trust continues to deliver Vaccination update Applicable the vaccination programme. There is an ongoing review of the number of sites being operated with some sites moving location in particular areas due to leasehold facilities availability and some rationalisation of sites in individual geographic areas. The Trust also continues to work with the leaders of ethnic communities to spread the vaccination message, particularly with the older age groups in Luton/ Bedford and Watford 15/12 Business case None

15/13 Herts and West Essex Not Not The project remains on Procurement service applicable Applicable schedule with the TUPE update transfer of staff completed on 1st April. The headquarter site remains an issue to be resolved.

A benefits review is scheduled for September, and a presentation will be made to PPFC in the autumn Any Other Business 15/14 Any Other Business None

Supporting Papers None Summary of Committee governance issues and any other points for the Board’s Attention

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Board 3rd August 2021 Attachment E3

Definitions and Key:

Red Amber/ Red Amber/Green Green

(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.

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Board 3rd August 2021 Attachment E3

Board Committee Chair’s Assurance Report

People Performance and Finance Committee

Date of Board Meeting: 3 August 2021 Committee Chair: Jeff Phillips

Date of Committee Meeting: 27th July 2021 Date of Report: 27th July 2021

Dates of Committee Meetings Held Since Last Board Meeting: 22 June 2021

Date of Next meeting: 28th September 2021

Item Subject Director’s Committee Committee Chair’s Ref Risk Assurance Observations Assessment Assessment (H/M/L) (R/AR/AG/G (R/A/G) ) Risks Arising From Minutes / Tracker Updates: TR 15/6 Minutes re ASD etc Specialist commissioning review is only just getting underway and needs input on the financial structure to avoid the risk of underfunding.

7/15 Mass vaccination Existing COVID-19 funding arrangements are now stable, but it’s too early to form a coherent view of potential move to a tariff-based approach

HWE Procurement progress 15/3 Procurement reconfiguration report needs to be made more relevant to the user organisations People 16/4 HCT People Plan Green Green Action plans now in place for 21/22, in line with the overall People Strategy adopted for 21/25.

16/5 Workforce KPI Targets Amber/Green Amber/Green KPIs have been agreed to support the overall People Strategy and are on target for June. Figures for sickness do not include self-isolation as these vary from day-to-day. Current experience shows a range of 55-90 self-isolating staff.

1

Board 3rd August 2021 Attachment E3

On vacancies, there is an underlying risk of lower numbers going into training.

ICS data now coming through.

16/6 Equality reports (WRES, Amber/Red Amber/Red WRES indicators 2 and 8 WDES) (disciplinary and discrimination comparators) show a small deterioration.

However, WDES indicator 4.ai relating to harassment and abuse from patients and public has deteriorated from last year and is a real cause for concern.

In addition, disabled staff feel they are subject to substantial pressure to come into work (indicator 6), and this has also deteriorated since last year. This does present a major challenge, and work is going on to gain insight into this across the community, through the Disability Network

Performance & Finance 16/7 Service Recovery and Amber/ Red Amber/Red Whilst there continues to be Performance Report significant progress achieved, concern remains about missing referrals, despite a 26% increase in CYP and 16% increase in Adults. There is also inevitable concern about inequalities across all services, but in CYP in particular.

That said, the 18 week target for consultant led remains above target at 94%, whilst non RTT levels improved by 6% to 86% versus the target of 92%.

One item of significance however is the ‘Substantial Assurance’ preliminary rating contained in the Internal Audit report on Service Recovery. This is very well deserved given the efforts staff have been putting in to get service levels back to a more normal footing, but in particular the efforts made to reduce the waiting lists.

SLT levels remain of concern, as they are still 29% below June

2

Board 3rd August 2021 Attachment E3

2019 levels, and requests for Education Health and Care Plans (EHCPs) via HCC are currently very high. These are very time consuming and hence adversely impact the overall service, with 15% of these requests relating to SLT needs.

School nursing is down 17%, but the causes are many and various, and will be reported on in more detail at the next meeting.

Challenges remain in E&NH diabetes, paediatric audiology, ASD diagnosis, although addition capacity is being delivered.

Overall, the main risks continue to be Covid pressure and the need for staff redeployment should it become necessary, vaccination demand levels and staff availability (self- isolation/shielding/lockdowns and sickness)

16/8 Board Assurance framework Not Applicable Not Applicable BAF07 and 08 concerning staff and High-Level Risk Register turnover remain the two most significant risks, with recruitment of registered nurses, occupational therapists and CYP language specialists facing particular difficulties.

On the HLRR, capacity constraints in CYP therapies (OT & SLT) and E&N Diabetes continue to present significant risks to service provision, and in particular PAH are unable to offer the diabetes sessions requested, and ENHT have said they are unable to provide any short term additional support to address their diabetes backlog. Solutions are being sought in terms of service transformation, particularly in respect of ENHT.

16/9 Financial report Month 3 Amber/Green Amber/Green Month 3 YTD shows the Trust performing in line with plan, with a surplus of £364k.

Emergency funding arrangements continue to meet the higher costs of operating in

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COVID secure environments, and the reimbursement of mass vaccination costs continues.

As yet there is no clear guidance on the funding regime for the second half of 21/22. However, as reported last month, there is likely to be a tightening in the funding regime, even if the structural basis remains the same until the end of the year

Work on PIES schemes have yet to finalise projects needed to cover the 3-3.5% target that has been set by the Trust, although the month 3 YTD achievement is in line with the trajectory required to meet the annual target range.

Capital expenditure for the year to date is £2146k, 21% below the planned position at the end of Month of £2731k. Two significant risks exist in respect of achieving the plan – the completion of business plans for a significant proportion of the plan value and the pressure on costs associated with building materials due to the current worldwide shortages of raw materials

16/10 COVID-19 Mass Vaccination verbal Vaccine availability remains update ’lumpy’, with the corresponding uncertainty. However, through all this, workforce planning and delivery has been exceptional – 1000+ recruits and 1000+ has been an outstanding performance.

Mass COVID Vaccination Green Green However, the Trust’s claim for Programme (MCVP) Financial reimbursement has become report subject to greater scrutiny, thereby adding to the demands on staff, but we are now approaching a programme of site rationalisation/lease renewals. However, whilst the Trust is currently seeing lower levels of vaccination demands, planning remains on a worst case basis

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16/11 Electronic Prescription and The full business case was Medicines presented, justifying the need for Administration System the system and its urgency.

The case has been signed off by the Chief Executive, and was duly noted.

16/12 Herts and West Essex Not applicable Not applicable The discussion on the form of Procurement service update the report concluded that it needed amending and editing for the purposes of user organisations. The next report for the September PPFC meeting should be in that new format.

Service HQ location remains to be confirmed. Any Other Business 16/13 Any Other Business None

Supporting Papers None

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

Uncertainty over the financing regime for the second half of 21/22 remains the prime risk to the overall Trust performance for the year

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Board 3rd August 2021 Attachment E3

Definitions and Key:

Red Amber/ Red Amber/Green Green

(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.

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Board 3rd August 2021 Attachment F1

GOVERNANCE MANUAL

July 2021

1

Overview

Corporate governance is the system by which an organisation is directed and controlled, at its most senior levels in order to achieve its objectives and meet the necessary standards of accountability and probity. Effective corporate governance, along with clinical governance, is essential for the Trust to achieve its clinical, quality, regulatory, compliance and financial objectives. Fundamental to effective corporate governance is having the means to verify the effectiveness of this direction and control. This is achieved through integrated governance The NHS Act 2006 (amended Health & Social Care Act 2012) and subsequent regulations set out the legal framework within which the Trust operates. The Accountable Officers’ Memorandum requires Trust Boards of Directors to adopt schedules of reservation and delegation of powers, set out the financial framework within which the organisation operates and how business is conducted and decisions made. These are incorporated into three key documents: Standing Orders (SOs), Standing Financial Instructions (SFIs) and Scheme of Reservation & Delegation (SORD). Implementation of these key statutory documents will only be effective when there is synergy between them. As well as being incorporated in this Manual, these documents have been made accessible via the Trust’s website and Intranet. This Manual also contains a number of other extremely useful documents which provide valuable information about the Trust’s corporate governance systems and processes. Having in one place key documents like the statutory and assurance committees’ terms of reference provides a snapshot of the role and function of the Board and its committees. All staff, especially senior managers, who have decision-making powers are encouraged to read these key documents so that they can be fully apprised of the context in which decisions are made in the Trust and be in a position to advise their direct reports. This document is not only a useful reference guide but a tool that provides valuable information for preparation for CQC Well Led and being able to speak eloquently about how the Trust is governed and its key governance principles.

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Contents

1 INTRODUCTION...... 5 1.1 STATUTORY AUTHORISATION ...... 5 1.2 STRUCTURE OF MANUAL ...... 5 2 GOVERNANCE ...... 7 2.1 CORPORATE GOVERNANCE ...... 7 2.2 CLINICAL GOVERNANCE ...... 7 2.3 FINANCIAL GOVERNANCE ...... 7 2.4 INFORMATION GOVERNANCE...... 7 2.5 INTEGRATED GOVERNANCE ...... 8 3 THE PRIMARY GOVERNANCE DOCUMENTS ...... 9 3.1 STANDING ORDERS ...... 9 3.2 STANDING FINANCIAL INSTRUCTIONS ...... 9 3.3 SCHEME OF RESERVATION AND DELEGATION OF POWERS ...... 9 4 THE BOARD AND COMMITTEES ...... 11 4.1 GOVERNANCE STRUCTURE ...... 11 4.2 BOARD OF DIRECTORS ...... 11 4.3 AUDIT COMMITTEE ...... 12 4.3.1 Reporting Responsibilities ...... 12 4.3.2 Duties ...... 13 4.3.3 Methodology ...... 14 4.3.4 Internal Audit ...... 15 4.3.5 External Audit ...... 16 4.3.6 Delegated Authorities ...... 17 4.4 QUALITY COMMITTEE ...... 17 4.4.1 Objectives ...... 18 4.4.2 Accountability ...... 18 4.4.3 Duties ...... 19 4.5 PEOPLE PERFORMANCE AND FINANCE COMMITTEE ...... 20 4.5.1 Objectives ...... 21 4.5.2 Accountability ...... 22 4.5.3 Duties ...... 22 4.6 STRATEGY, PLANNING AND ENGAGEMENT COMMITTEE ...... 23 4.6.1 Objectives ...... 24 4.6.2 Accountability ...... 25

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4.6.3 Duties ...... 25 4.7 EXECUTIVE COMMITTEE ...... 27 4.7.1 Objectives ...... 27 4.7.2 Accountability ...... 28 4.7.3 Duties ...... 28 4.8 CHARITABLE FUNDS COMMITTEE ...... 29 4.8.1 Delegated Powers and Duties of the Director of Finance ...... 30 4.8.2 Role of the Committee ...... 31 4.8.3 Duties ...... 31 4.9 REMUNERATION COMMITTEE ...... 32 4.9.1 Duties ...... 32 4.9.2 Authority ...... 33 5 PRINCIPLES AND VALUES ...... 34 5.1 NHS CODE OF CONDUCT AND ACCOUNTABILITY ...... 34 5.1.1 Introduction ...... 34 5.1.2 Scope ...... 34 5.1.3 General Obligations...... 35 5.1.4 Code of Conduct & Accountability Policy ...... 35 5.2 NHS CONSTITUTION ...... 36 5.3 NOLAN PRINCIPLES ON STANDARDS IN PUBLIC LIFE ...... 36 5.3.1 Selflessness ...... 36 5.3.2 Integrity ...... 36 5.3.3 Objectivity ...... 37 5.3.4 Accountability ...... 37 5.3.5 Openness ...... 37 5.3.6 Honesty ...... 37 5.3.7 Leadership ...... 37 5.4 FIT AND PROPER PERSONS ...... 37 5.4.1 Kark review ...... 38 5.4.2 Meeting compliance ...... 38 6 CONTROLS ...... 39 6.1 REGISTER OF INTERESTS...... 39 6.2 COMMITTEE SELF-ASSESSMENT ...... 39 6.2.1 Introduction ...... 39 6.2.2 Purpose ...... 39 6.3 INTERNAL CONTROLS ...... 40 6.3.1 Overview ...... 40

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6.3.2 Risk Management ...... 40 6.3.3 Annual Governance Statement ...... 41 6.4 INDEPENDENT CONTROL AND REGULATION ...... 41 6.4.1 Internal Audit ...... 41 6.4.2 Counter-fraud and corruption ...... 42 6.4.3 External Audit ...... 42 6.4.4 Care Quality Commission ...... 43 6.4.5 Health and Safety Executive ...... 43 6.4.6 NHS Resolution ...... 44 6.4.7 Board Licence Conditions ...... 44 7 RESPONSIBLE AND ACCOUNTABLE OFFICERS ...... 45 7.1 MEMBERSHIP OF THE BOARD ...... 45 7.1.1 Voting Members ...... 45 7.1.2 Non-Voting Members ...... 45 7.1.3 Board Vacancies ...... 46 7.1.4 Senior Independent Director ...... 46 7.1.5 Board Secretary ...... 46 7.2 EXECUTIVE DIRECTOR PORTFOLIOS ...... 46 7.2.1 Chief Executive ...... 46 7.2.2 Responsibilities include: ...... 46 7.2.3 Director of Finance, Systems and Estate ...... 47 7.2.4 Director of Nursing and Quality, Chief Nurse ...... 47 7.2.5 Medical Director ...... 48 7.2.6 Chief Operating Officer ...... 48 7.2.7 Director of Strategy ...... 48 7.2.8 Associate Director of People ...... 49 7.2.9 Associate Director of Integrated Business Services ...... 49 7.2.10 Designated Executive / Non-executive Director Lead Roles ...... 50 8 DEFINITIONS AND GLOSSARY OF TERMS ...... 56 9 APPENDICES ...... 59

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1 Introduction

1.1 Statutory Authorisation Hertfordshire Community NHS Trust (the Trust) is a public sector organisation that was established in accordance with the provisions of the National Health Service Act 2006 and under the Hertfordshire Community National Health Service Trust (Establishment) Order 2010 No. 2464 (the Establishment Order). The Trust operates from a variety of sites across Hertfordshire with its corporate office at Howard Court 14 Tewin Road, Welwyn Garden City Hertfordshire AL7 1BW being its registered address. As a statutory body the Trust has specific powers to contract in its own name and to act as a corporate Trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable as well as to the Secretary of State for Health and Social Care.

1.2 Structure of Manual The Code of Accountability for NHS Boards requires the Trust to adopt Standing Orders (SOs) (Appendix A) for the regulation of its proceedings and business. The Trust must also adopt Standing Financial Instructions (SFIs) (Appendix B) as an integral part of Standing Orders setting out the responsibilities of individuals. This Corporate Governance Manual comprises these primary governance documents and other directions and guidance issued by the Secretary of State, through the Department of Health and Social Care and includes: • Standing Orders for the Board of Directors • Standing Financial Instructions • Schedule of matters reserved to the Board of Directors (Scheme of Reservation and Delegation) • Standards of Business Conduct and Managing Conflicts of Interest • NHS Constitution • NHS Code of Conduct and Accountability • NHS Code of Openness • Nolan Principle of Governance • Principles of Board Etiquette • Code of Conduct for NHS Managers (Executive Directors only) Compliance with these documents is required of the Trust, its Executive and Non- Executive Directors, officers and employees, all of whom are also required to comply with the Trust’s Legal and Regulatory Framework. The Trust must also have agreed its own Standing Orders as a framework for internal governance. Standing Orders for the Board of Directors are included in this Corporate Governance Manual.

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All of the above-mentioned documents together provide a regulatory framework for the business conduct of the Trust. The Trust’s Board of Directors also has in place Audit, Remuneration, Quality, People, Performance & Finance and Strategy Planning & Engagement Committees and an established framework for managing risks. It is essential that all Directors, officers and employees know of the existence of these documents and are aware of their responsibilities included within. A copy of this Manual is available on the Trust’s website and intranet and has been explicitly brought to the attention of key staff within the organisation and to all staff via the internal communication routes. Any queries relating to the contents of these documents should be directed to the Assistant Trust Board Secretary, who will be pleased to provide clarification.

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2 Governance Governance has to do with steering an organisation in the right direction and involves the establishment of policies and continuous monitoring of their proper implementation by the members of the governing body of an organization. It includes the mechanisms required to balance the powers of the members (with the associated accountability), and their primary duty of enhancing the prosperity and viability of the organisation. This involves having a balance between the interests of the Agents (shareholders or in NHS and other public bodies, the public) and the Stewards, that is management, charged with running the business. Agents, or those charged with governance ensure that the business is run properly by holding management, who run the business to account. Governance can be subdivided into different sections:

2.1 Corporate governance Corporate Governance is the system by which organisations are directed and controlled. Boards of directors are responsible for the governance of their organisations. The shareholders' (public’ for NHS) role in governance is to appoint the directors and the auditors and to satisfy themselves that an appropriate governance structure is in place. In the NHS, the public is represented by a Council of Governors and Non-Executive Directors in a Foundation Trust whereas in an NHS Trust (that is Non-FT) the Non-Executive Directors represent the interests of the public. These are appointed by the Regulator, NHS England/NHS Improvement.

2.2 Clinical Governance Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish.

2.3 Financial Governance Financial governance refers to the way an organisation collects, manages, monitors and controls financial information. Financial IT includes how organisations track financial transactions; manage performance and control data, compliance, operations, and disclosures.

2.4 Information Governance Information governance, or IG, is the management of information in an organisation. It balances the use and security of information. An organisation can establish a consistent and logical framework for employees to handle data through their information governance policies and procedures these include compliance with the General Data Protection Regulations, Data Protection Act and Freedom of Information.

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2.5 Integrated Governance Integrated governance can be defined as the interrelation between different forms of governance approaches combining the principles of corporate, financial, clinical, information and other types of governance to enable a risk sensitive approach to enable the delivery of the organisation’s strategic objectives.

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3 The Primary Governance Documents

3.1 Standing Orders The Standing Orders (SO) (Appendix A) form a fundamental part of the Trusts Governance Framework. Together with the Standing Financial Instructions (Appendix B) and Scheme of Reservation and Delegation (Appendix C1), when adhered to they protect the Trust’s interests and officers from possible accusation that they have acted improperly.

3.2 Standing Financial Instructions The Standing Financial Instructions (SFIs) form a fundamental part of the Trust’s Governance Framework for the purpose of regulating the conduct of its members and officers in relation to all financial matters with which they are concerned. They shall have effect as if incorporated in the Standing Orders (SOs). The SFIs detail the financial responsibilities, policies and procedures adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law and government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Schedule of Decisions Reserved to the Board of Directors and the Scheme of Reservation and Delegation (SORD) adopted by the Trust.

The SFIs identify the financial responsibilities, which apply to everyone working for the Trust. They do not provide detailed procedural advice. These statements should therefore be read in conjunction with detailed departmental and financial procedure notes.

3.3 Scheme of Reservation and Delegation of Powers No matter how effective a Board of Directors may be it is not possible for it to have hands-on involvement in every area of the Trust’s business. An effective Board controls the business but delegates day to day responsibility to executive management. That said, there are a number of matters which are required to be or, in the interests of the Trust, should only be decided by the Board of Directors as a whole. For effective governance the Board of Directors must have in place arrangements to ensure that there is clarity about how decisions are made and who makes them. In accordance with the Code of Conduct and Accountability, the Board sets out those matters that it explicitly reserves that it shall itself approve or appraise in the Scheme of Reservation and Delegation (Appendix C1) of Powers and those delegated to Committees and officers. All Board members share corporate responsibility for all decisions of the Board and the Board remains accountable for all of its functions, even those delegated to

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individual committees, subcommittees, directors or officers and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role. The Trust’s Standing Orders (Appendix A) and the NHS Code of Conduct and Code of Accountability require that the Trust: • Clearly identifies the types of decisions which are to be reserved for the Board; and • Ensures that arrangements are in place to enable responsibility for other decisions to be clearly delegated to executive management, officers and committees. The purpose of the Scheme of Reservation and Delegation is to empower Directors, and those managers who have been given authority to act on their Directors’ behalf, to take appropriate decisions within a robust corporate framework.

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4 The Board and Committees

4.1 Governance Structure

Figure 1: Board and Board Sub-committee structure

4.2 Board of Directors It is the Board’s duty to: • Act within statutory financial and other constraints • Be clear what decisions and information are appropriate to the Board of Directors and draw up Standing Orders, a schedule of decisions reserved to the Board and Standing Financial Instructions (Appendix B) to reflect these’ • Ensure that management arrangements are in place to enable responsibility to be clearly delegated to senior executives for the main programmes of action and for those senior executives to be held to account for the performance of those programmes’ Establish performance and quality measures that maintain the effective use of resources and provide value for money; • Specify its requirements in organising and presenting financial and other

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information succinctly and efficiently to ensure the Board can fully undertake its responsibilities. • Establish as a minimum Audit and Remuneration committees on the basis of formally agreed terms of reference that set out the membership of the sub- committee, the limit to their powers, and the arrangements for reporting back to the main Board.

4.3 Audit Committee The Hertfordshire Community NHS Trust Audit Committee (Appendix G1) is a standing Committee of the Trust Board. The Committee is authorised by the Board to: • Investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. • Call any employee to be questioned at a meeting of the Committee as and when required. • Obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary. The Audit Committee does not have delegated powers of expenditure as this rests with Officers of the Trust as budget holders in accordance with the Scheme of Reservation & Delegation and Standing Financial Instructions.

4.3.1 Reporting Responsibilities The Committee Chair shall provide written and verbal reports to the HCT Board meeting in public (or in private if appropriate) in a format and at a frequency agreed by the Trust Chair. Such reports shall highlight: • Assurances (positive and negative) • Perceived Risks • Assessment / Follow Up of areas which have been subject to Board Issue Escalation Reports • Matters of Committee Governance or proposed changes thereto Other matters which at the discretion of the Committee Chair merit being brought to the Board’s attention The Committee shall make whatever recommendations to the Board it deems appropriate on any area within its remit where action or improvement is needed

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4.3.2 Duties

4.3.2.1 Governance, Risk Management and Internal Control

4.3.2.1.1 Financial Governance Reporting The Committee shall monitor the integrity of the financial statements of the Trust, including its annual and any interim reports, preliminary results and any other formal announcement relating to its financial performance, reviewing significant financial and funded project reporting issues and judgements which they contain. The Committee shall also review and challenge where necessary: • The consistency of, and any changes to, accounting policies both on a year on year basis and across the Trust; • The methods used to account for significant or unusual transactions where different approaches are possible; • Whether the Trust has followed appropriate accounting standards and made appropriate estimates and judgements, taking into account the views of the external auditor; • The clarity of disclosure in the Trust’s financial reports and the context in which statements are made; and • All material information presented within the financial statements, such as the operating and financial review and the Annual Governance Statement (insofar as it relates to audit and risk management);

4.3.2.1.2 Internal Controls, Assurances and Risk Management Systems The Committee shall: • Keep under review the effectiveness of the Trust’s internal controls and risk management systems, including annual review of the Board Assurance Framework and High Level Risk Register; and • Recommend to the Executive Team risks for inclusion on the High Level Risk Register or Board Assurance Framework and to regularly review and comment on risks on the Register & Framework. • Review underlying assurance processes that indicate the degree of achievement of the organisation’s objectives, the effectiveness of the management of principal risks and the appropriateness of disclosure statements. The Committee shall request and review reports, evidence and assurances from directors and managers on the overall arrangements for governance, risk management and internal control. • Supported by having the Chair of the Quality Committee as a member of the committee, to take into consideration systems and processes associated with clinical / service risks. To include, but not restricted to, monitoring the Trust’s compliance with CQC Registration outcome requirements and risk profile, review of the clinical audit programme and production of the annual Quality Account.

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• Review the adequacy and effectiveness of all control related disclosure statements (in particular the governance statement), together with any accompanying Head of Internal Audit Opinion, external audit opinion or other appropriate independent assurances, prior to submission to the Trust Board. • Highlight non-urgent risks to the Board through the Committee Chair’s reports and escalate urgent risks through the Trust’s risk escalation process.

4.3.2.1.3 Counter Fraud & Freedom to Speak Up The Committee shall: • Ensure that there is an effective anti-fraud culture established in the Trust, with appropriate arrangements to deter, prevent and detect fraud. This will be achieved by: • reviewing and approving of the annual counter fraud work plan; • reviewing regularly the work of the Local Counter Fraud Specialists; • reviewing reports on fraud incidents and actions taken. • Review the counter fraud (Freedom to Speak Up) arrangements for employees to raise concerns, in confidence, about possible wrongdoing in financial reporting or other matters. The Committee shall ensure that these counter fraud arrangements allow proportionate and independent investigation of such matters and appropriate follow up action. • The appointed Local Counter Fraud Specialist shall be given the right of direct access to the Chair of the Board and to the Committee.

4.3.2.1.4 Recommendations to the Board on Key Corporate Submissions • Prior to formal submission / publication the Committee shall consider the following and make such recommendations for approval / adoption by the Board (and the Board as corporate charitable trustees in the case of (e) below) as considered appropriate • Annual Financial Accounts and accompanying disclosures • The Annual Governance Statement • The Annual Report • The Annual Quality Account (taking into account advice from the Chair of the Quality Committee • Charitable Funds Annual Accounts • In support of the above, the Committee shall take into account the annual reports of the Head of Internal Audit and the External Auditors.

4.3.3 Methodology • In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions (internal or external) but will not be limited to these sources. It will also seek reports and assurances from: 14

• Directors and managers as appropriate and • Committees of the Trust concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness. • To assist with its assurance function, to receive, assess and constructively challenge such reports and other documents as the committee requests. • In fulfilling its duties, the Committee shall: • Be mindful of the principles of integrated governance and where necessary consider and communicate risks and impacts that may extend to the wider organisation and which arise through the exercise of its delegated functions. • Link its programme of work to the strategic objectives of the Trust

4.3.4 Internal Audit The Committee shall: • Monitor and review the effectiveness of the Trust’s internal audit function in the context of the Trust’s overall risk management system. • Where the internal audit function is carried out by an external audit firm, the Committee shall be responsible for: • approval of their remuneration, whether fees for audit or non-audit services and that the level of fees is appropriate to enable an adequate audit to be conducted; • approval of their terms of engagement, including any engagement letter issued at the start of each financial year and the scope of the internal audit programme; • assessing annually their independence and objectivity taking into account relevant [UK] professional and regulatory requirements and the relationship with the auditor as a whole, including the provision of any non-audit services; • satisfying itself that there are no relationships (such as family, employment, investment, financial or business) between the auditor and the Trust (other than in the ordinary course of business); • agreeing with the Board the terms on which we offer to employ any former employees of the internal auditor, each case to be judged on its own merits; • monitoring the internal auditor’s compliance with relevant ethical and professional guidance on the rotation of audit partners, the level of fees paid by the company compared to the overall fee income of the firm, office and partner and other related requirements; and • assessing annually their qualifications, expertise and resources and the

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effectiveness of the internal audit process which shall include a report from the auditor on their own internal quality procedures; • Where the internal audit function is not contracted externally, approve the appointment and removal of the head of the internal audit function; • Consider and approve the remit of the internal audit function and ensure it has adequate resources and appropriate access to information to enable it to perform its function effectively and in accordance with the relevant professional standards. The Committee shall also ensure the function has adequate standing and is free from management or other restrictions; • Review and assess the annual internal audit plan; • Review promptly all final reports from the internal auditors with particular focus on high risk reports; • Review and monitor management’s responsiveness to the findings and recommendations of the internal auditor; and • Meet the head of internal audit at least once a year, without management being present, to discuss their remit and any issues arising from the internal audits carried out. In addition, the head of internal audit shall be given the right of direct access to the Chair of the Board and to the Committee.

4.3.5 External Audit The Committee shall: • Identify a panel for the procurement and appointment of the Trust’s external auditors in line with the Local Audit and Accountability Act 2014 and that: • Any such appointment shall be ratified by the Trust Board on the recommendation of the Audit Committee • The panel identified may at the discretion of the Audit Committee be the Audit Committee itself. • Oversee the relationship with the external auditor including (but not limited to): • approval of their remuneration, whether fees for audit or non-audit services and that the level of fees is appropriate to enable an adequate audit to be conducted. • approval of their terms of engagement, including any engagement letter issued at the start of each audit and the scope of the audit. • assessing annually their independence and objectivity taking into account relevant [UK] professional and regulatory requirements and the relationship with the auditor as a whole, including the provision of any non-audit services. • satisfying itself that there are no relationships (such as family, employment, investment, financial or business) between the auditor and the company (other than in the ordinary course of business); • agreeing with the Board the terms on which the Trust offers to employ

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any former employees of the external auditor, each case to be judged on its own merits. • monitoring the auditor’s compliance with relevant ethical and professional guidance on the rotation of audit partners, the level of fees paid by the company compared to the overall fee income of the firm, office and partner and other related requirements; and • assessing annually their qualifications, expertise and resources and the effectiveness of the audit process which shall include a report from the external auditor on their own internal quality procedures. • Meet regularly with the external auditor, including once at the planning stage before the audit and once after the audit at the reporting stage. The Committee shall meet the external auditor at least once a year, without management being present; to discuss their remit and any issues arising from the audit. In addition, the head of external audit shall be given the right of direct access to the Chair of the Board and to the Committee. • Review and approve the annual audit plan and ensure that it is consistent with the scope of the audit engagement. • Review the findings of the audit with the external auditor. This shall include but not be limited to, the following. • a discussion of any major issues which arose during the audit, • any accounting and audit judgements, and • levels of errors identified during the audit. The Committee shall also review the effectiveness of the audit: • Review any representation letter(s) requested by the external auditor before they are signed by management. • Review the management letter and management’s response to the auditor’s findings and recommendations; and • Review and approve the supply of non-audit services by the external auditor. Ensuing that there is in place a clear policy for the engagement of external auditors to supply non audit services

4.3.6 Delegated Authorities On behalf of the Board, the Committee shall review the Trust’s delegated authorities, Scheme of Reservation and Delegation (Appendix C1), Standing Orders (Appendix A) and Standing Financial Instructions (Appendix B).

4.4 Quality Committee The Quality Committee (Appendix G2) is a formal committee of HCT Board. The Committee is authorised to make decisions which are: • Within these Terms of Reference • Specifically referred by the HCT Board

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The Quality Committee is authorised by the Board: • To carry out any activity within its terms of reference. • To seek clarification and further investigation of any quality and governance matter, and to request any relevant information from any employee. • To obtain outside or other independent professional advice with relevant experience and expertise if required. The Committee may recommend actions which require financial expenditure but the Committee itself does not have any delegated powers of expenditure as this rests with the relevant budget holder or otherwise in accordance with powers of authorisation as prescribed in HCT’s Scheme of Reservation and Delegation (Appendix C1). The Committee may establish such sub-committees, forums or project teams as it considers appropriate to support its objectives and duties. Any sub-committee, forum or project team so established shall have terms of reference, including reporting arrangements ratified by HGC/ QC.

4.4.1 Objectives The overall objective of the Committee is to: • Provide assurance to the Audit Committee and the Board on the systems and processes by which the Trust achieves organisational and national objectives. It will ensure the delivery of clinical governance, the safety and quality of clinical services and the management of risk relating to the delivery of healthcare. In fulfilling the objective above, the Committee shall: • Be mindful of the principles of integrated governance and where necessary consider and communicate risks and impacts that may extend to the wider organisation and which arise through the exercise of its delegated functions. • Link its programme of work to the strategic objectives of the Trust

4.4.2 Accountability Quality Committee reports and is accountable to the HCT Trust Board The following sub-committees will report to the Committee: • Clinical Governance Sub-committee • Good to Outstanding Group • Professional Clinical Leaders Group The Chair of the Committee shall provide written and verbal reports to the HCT Board meeting in public (or in private if appropriate) in a format and at a frequency agreed by the Trust Chair. Such reports shall highlight: • Assurances (positive and negative) • Perceived Risks

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• Assessment / Follow Up of areas which have been subject to Board Issue Escalation Reports • Matters of Committee Governance or proposed changes thereto • Other matters which at the discretion of the Committee Chair merit being brought to the Board’s attention

4.4.3 Duties The duties of the Committee are to: • Provide the Board with assurances as to the quality and safety of the Trust’s clinical services • Provide the Audit Committee with assurances as to the robustness and efficiency of the Trust’s systems and processes for the identification and management of risks associated with healthcare governance and the provision of clinical services • To assist with the assurance function, to receive, assess and constructively challenge such reports and other documents as appropriate. • To receive minutes of meetings and reports upon request from any sub- committee, forum or project team established by the Committee and to address any significant issues arising therefrom. • Be consulted with, and consider the impact upon clinical quality engendered by Trust strategies, plans, proposed service developments/changes and financial investments, disinvestments or cost improvement plans • To consider and recommend the following for formal approval by the Board (or any significant changes/ revisions thereto): • Health and Well Being Strategy • Clinical Strategy • Quality Account • Quality Improvement Plan • Quality Priorities • Commissioning for Quality and Innovation (CQUINs) • Clinical Audit Plan (ensuring appropriate links to the Trust’s annual Internal Audit Plan). • To receive assurances as to compliance with statutory and mandatory requirements or standards insofar as they affect the quality of the Trust’s clinical services • To consider the implications for the Trust of external reports, guidance, inquiries and national / local policy intentions insofar as they may impact on the quality of the Trust’s clinical services and to monitor the achievement of any action plans deriving therefrom. • To consider, advise upon and monitor, the quality and governance

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implications, requirements and issues arising from: • Any change in the corporate status of the Trust and/or • Any formal or informal partnership arrangements with other organisations for the delivery of clinical services and / or • Any proposed tender by the Trust for the provision of clinical services and /or • Any proposed sub-contracting of clinical services by the Trust • To consider red rated Internal Audit Reports which have an impact on quality and the delivery of clinical services and to liaise with the Chair of the Audit Committee as appropriate. • To monitor RAG Delivery Plans / Action Plans devised to progress Quality initiatives, meet compliance with regulatory body requirements or implement recommendations from relevant internal/external reports. • To periodically visit services and to request or hold “deep dives” into services or areas of clinical practice where: • Triangulated evidence gives cause for concern or • The area in question is subject to national or local public concern. • To recommend to the Executive Team risks for inclusion on the High Level Risk Register or Board Assurance Framework and to review relevant risks on the Register & Framework • Champion the pursuit of continuously improving service quality and promote the dissemination of identified good clinical and nursing practice across the Trust • To make such recommendations to the Executive Team, Board or Board Committees as considered appropriate

4.5 People Performance and Finance Committee The People, Performance and Finance Committee (Appendix G3) is a formal committee of the HCT Board. The Committee is authorised to make decisions which are: • Within these Terms of Reference • Specifically referred by the HCT Board The People, Performance and Finance Committee is authorised by the Board to: • Carry out any activity within its terms of reference • Seek clarification and further investigation of any governance matter, and • Request any relevant information from any employee • Obtain outside or other independent professional advice with relevant experience and expertise if required

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The Committee may recommend actions which require financial expenditure but the Committee itself does not have any delegated powers of expenditure as this rests with the relevant budget holder or otherwise in accordance with powers of authorisation as prescribed in HCT’s Scheme of Reservation and Delegation. The Committee may establish such sub committees or project teams as it considers appropriate to support its objectives and duties. Any group or project team so established shall have terms of reference, including reporting arrangements, approved by the Committee. The Committee may delegate any of its duties (or parts thereof) under these Terms of Reference to any of its sub committees established under 1.6 above and a record of any such delegation (general or specific) shall be recorded in the Committee minutes.

4.5.1 Objectives The overall objectives of the Committee are to: • Review the financial implications of the delivery of all Trust strategies and where investment or disinvestment is required to deliver Trust objectives. • Be assured that the Trust is using its resources efficiently and effectively and is delivering value for money. • To review people and organisational development plans to ensure the Trust has the right people with the right skills and values to maintain and improve the health and wellbeing of patients in line with the NHS Long term Plan. • Scrutinise proposals for transformation, increased productivity and delivery of efficiencies, and seek assurance that both services and corporate functions are meeting the objective of using resources effectively. (Resources for this purpose are financial, workforce, estate, physical assets and IM&T). • To review and approve any formal mandatory submissions or returns to regulators which relate to resources and where Board visibility or approval is a requirement for those submissions. If timescale permits, the Committee shall make recommendations to the Board. If timescale does not permit, the Committee shall have delegated responsibility on behalf of the Board to make such approval as necessary and report this to the next meeting of the Trust Board for ratification. • To receive reports and assurances from the Executive Team as to the risks, mitigations, delivery, sustainability and status of Trust People Plan, Performance and the deployment of resources and to be assured as to the management of strategic risks for which the Committee is identified as the Lead Committee in the Trust’s Board Assurance Framework. • Through the Chair of the Committee, to provide a “RAG” (Red, Amber, Green) Committee Chair’s assurance report to the Trust Board and to bring to the Board’s attention any matters of significant concern or interest. In fulfilling the objectives above, the Committee shall: • be mindful of the principles of integrated governance and where necessary consider and communicate risks and impacts that may extend to the wider 21

organisation and which arise through the exercise of its delegated functions. • ensure its programme of work aligns to, and supports delivery of, the strategic objectives of the Trust • take into consideration (a) co-relationships and co-dependencies between individual strategic, financial or business issues and (b) factors external to the Trust which may impact positively or detrimentally on the delivery of the Trust’s strategy and objectives.

4.5.2 Accountability The People, Performance and Finance Committee is accountable to the HCT Trust Board. The following groups report to the Committee: • Executive Committee • Executive Performance Review Meeting • People and Organisational Development Steering Group

4.5.3 Duties The duties of the Committee can be categorised as follows:

4.5.3.1 People and Organisational Development • To review people and organisational development plans to ensure we achieve our strategic ambition to be a ‘great place to work’. • To receive assurance that the trust has the required workforce to meet the service demands. • To ensure we operate effectively in the system wide engagement in recruitment, retention and leadership culture. • To ensure the Trust delivers a robust programme of organisational development (OD) to support its ability to operate effectively as a leading provider in the Hertfordshire and West Essex Integrated Care System.

4.5.3.2 Performance • To receive assurance in respect of performance against: • commissioning for quality and innovation plans (CQUIN) • clinical activity, key performance indicators and outcome measures • corporate governance activities and responsibilities • delivery of contractual requirements and expectations of commissioners • meeting the legislative / regulatory requirements of regulators and other bodies

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4.5.3.3 Finance • To review the Trust’s forward financial plans for robustness and with particular reference to sustainability of the Trust and ability to deliver against Trust objectives. • To review the Trusts planned Capital Programme prior to its submission to the Sustainability and Transformation Partnership/Integrated Care System (STP/ICS) for formal approval • To monitor the implementation of capital projects, ensuring that they meet the objectives chosen • To receive a balanced budget prior to the start of each financial year and make recommendations to the Board as to approval. • To review and monitor the implementation of Productivity Improvement and Efficiency Schemes (PIES) and obtain assurance from the executive team as to their deliverability and effectiveness. • To scrutinise current financial performance and assess adequacy of transformation plans to bring performance in line with plan (where necessary). • To monitor action plans from the Executive Performance Review or Business Unit Performance Reviews and their implementation • To review the allocation of resources across the Trust to ensure that these are being used effectively to deliver the Trust’s objectives. • To monitor the Trust’s comparative performance by benchmarking against other Community Trusts • To scrutinise the development of service line reporting and ensure the appropriate allocation of resources to services. • To review changes to contract currencies and their impact on the delivery of services and financial management of the Trust. • To assess, periodically, the skills base within the Finance Department and the adequacy of Treasury and Management Accounting reporting. • To scrutinise the impact of the STP/ICS, on the Trust’s financial position and forecasts.

4.5.3.4 Investments • To approve cash management and investment policies and test compliance with such policies. • To review investment performance and risk.

4.6 Strategy, Planning and Engagement Committee The Strategy, Planning and Engagement Committee (Appendix G4) is a formal committee of the HCT Board. The Committee is authorised to make decisions which are:

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• Within these Terms of Reference • Specifically referred by the HCT Trust Board The Strategy, Planning and Engagement Committee is authorised by the Board to carry out any activity within its terms of reference. It is authorised to: • Seek clarification and further investigation of any governance matter, and • Request any relevant information from any employee. • Obtain outside or other independent professional advice with relevant experience and expertise if required. The Committee may recommend actions which require financial expenditure but the Committee itself does not have any delegated powers of expenditure as this rests with the relevant budget holder or otherwise in accordance with powers of authorisation as prescribed in HCT’s Scheme of Reservation and Delegation (Appendix C1). The Committee may establish such sub committees or project teams as it considers appropriate to support its objectives and duties. Any group or project team so established shall have terms of reference, including reporting arrangements, approved by the Committee. The Committee may delegate any of its duties (or parts thereof) under these Terms of Reference to any of its established sub committees and a record of any such delegation (general or specific) shall be recorded in the Committee minutes.

4.6.1 Objectives The overall objectives of the Committee are to: • Annually review the Trust’s strategic objectives, vision and values as recommended by the Executive Team and make recommendations to the Board for adoption or retention of those objectives. • Scrutinise the continuing development and implementation of the Trust’s strategy and objectives. • To lead engagement with all Integrated Care Systems, Integrated care Partnerships, Alliances and any forms of collaborative or partnership working. • Scrutinise the continuing development and implementation of supporting strategies within the Committee’s remit as delegated by the Board. • Scrutinise proposals for transformation and delivery of efficiencies, and review whether services are meeting the objective of using resources effectively. (Resources for this purpose are financial, workforce, estate, physical assets and IM&T). • Receive reports and assurances from the Executive Team as to the risks, mitigations, delivery, sustainability and status of Trust strategies and to be assured as to the management of strategic risks for which the Committee is identified as the Lead Committee in the Trust’s Board Assurance Framework. • Through the Chair of the Committee, to provide a “RAG” (Red, Amber, Green) Committee Chair’s assurance report to the Trust Board and to bring to the 24

Board’s attention any matters of significant concern or interest. In fulfilling the objectives above, the Committee shall: • be mindful of the principles of integrated governance and where necessary consider and communicate risks and impacts that may extend to the wider organisation and which arise through the exercise of its delegated functions. • link its programme of work to the strategic objectives of the Trust • take into consideration (a) co-relationships and co-dependencies between individual strategic, financial or business issues and (b) factors external to the Trust which may impact positively or detrimentally on the delivery of the Trust’s strategy and objectives.

4.6.2 Accountability The Strategy, Planning and Engagement Committee is accountable to the HCT Board. The following groups report into the Committee: • Executive Committee • Business Planning and Contracting Strategy updates are provided in respect of the Trust Corporate Strategy and enabling strategies.

4.6.3 Duties The duties of the Committee can be categorised as follows:

4.6.3.1 Strategy and Planning • To review annually the Trust’s strategic objectives, vision and values as outlined in the HCT Health & Wellbeing Strategy and as recommended by the Executive Team and make recommendations to the Board for adoption or retention of those objectives. • To scrutinise the continuing development and the implementation of the Trust’s strategy and objectives. • To review the Trust’s Annual Plan (or other mandatory business planning submissions) and ensure consistency with the Trust’s strategy and objectives and HCTs commissioners’ strategies. • To review the People Strategy and monitor delivery against plan. • To lead on the development of the trust’s Commercial strategy. • To review the IM&T Strategy and monitor delivery against plan. • To review the Estates Strategy and monitor delivery against plan. • To review the Market Strategy and monitor delivery against plan. • To review the Finance Strategy and monitor delivery against plan.

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• To review such other strategies as may be delegated by the Board from time to time and monitor delivery against plan. • To consider the supporting strategies within the remit of the Committee in the context of strategies which fall within the remit of other Board Committees. To include, but not be restricted to, Clinical Services, Quality and Risk Management. • In respect of the delivery of all strategies to review the resources applied by the Trust and their adequacy to meet the Trust’s objectives. • To review the Trust’s 5 year capital programme and ensure that planned capital investments are aligned to future service delivery developments. • To use comparative performance benchmark information to inform the future development and delivery of services. • To monitor strategic investments and their delivery of objectives.

4.6.3.2 Business Planning and Contracting • To receive and scrutinise proposed business developments, including enhancements to existing contracts, to ensure proper financial evaluation including impact on the future risk ratings. • Review and make recommendations to the Executive Team in respect of Executive Team proposals to enter into, or withdraw from, competition or partnership arrangements (with one or more other parties) where the value of the contract to the Trust if awarded to the Trust would be greater than £100k but less than £250k per annum. • To be advised, ratify or approve stages of business development tenders in accordance with the financial limits set out in the Trust’s Business Development Tender Manual. • Make recommendations to the Board in respect of any matter relating to any contract with a value to HCT of £250k or greater per annum. (Or such other value requiring Board approval as prescribed in the Trust’s Scheme of Reservation and Delegation). • To review individual bids and acquisitions, to ensure proper financial evaluation and make recommendations to the board as per the Scheme of Reservation and Delegation. • To review, periodically, market analysis undertaken on behalf of, or by, the Trust. • To review exception reports from the PMO.

4.6.3.3 Equality & Community Engagement • To ensure active involvement of staff, services users, carers and other stakeholders in the development of key Trust strategies and plans. • To ensure effective relationship management with key partners, stakeholders and members of the public.

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• To review the Communications and Engagement Strategies and monitor delivery against plan.

4.7 Executive Committee The Executive Committee (Appendix G5) is authorised to make decisions which are: • Within these Terms of Reference • Specifically referred by the Chief Executive Officer The Executive Committee is authorised by the Chief Executive Officer to: • Carry out any activity within its terms of reference. • Seek clarification and further investigation of any Trust related matter, and • Request any relevant information from any employee. • Obtain outside or other independent professional advice with relevant experience and expertise if required. The Executive Committee may recommend actions which require financial expenditure but the Team itself does not have any delegated powers of expenditure, as this rests with the relevant budget holder or otherwise in accordance with powers of authorisation as prescribed in HCT’s Scheme of Reservation and Delegation (Appendix C1). The Executive Committee may establish such Groups or project teams as it considers appropriate to support its objectives and duties. Any group or project team so established shall have terms of reference, including reporting arrangements, approved by the Executive Team. The Executive Committee may delegate any of its duties (or parts thereof) under these Terms of Reference to any of its Groups established above and a record of any such delegation (general or specific) shall be recorded in the Executive Committee notes.

4.7.1 Objectives The overall objectives of the Executive Committee are to: • Ensure delivery of the Trusts’ strategic objectives, as agreed by the Board, and as reflected in an Annual Executive Delivery Plan • Review in detail the performance of HCT against the annual plan approved by the HCT Board. • Identify the need for improvement in performance and for overseeing such improvements. • Support the Chief Executive Officer in fulfilling the role of Accountable Officer for the Trust • Oversee the adoption and implementation of robust arrangements for the operational management of risks to the Trust • Seek assurances from Executive Directors and Business Units as to the

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operational efficacy and efficiency of the systems, processes and policies within the Trust, and to provide such assurances to the Audit Committee and the Board. In fulfilling the objectives above, the Team shall: • Be mindful of the principles of integrated governance and where necessary consider and communicate risks and impacts that may extend to the wider organisation and which arise through the exercise of its delegated functions. • Link its programme of work to the strategic objectives of the Trust

4.7.2 Accountability The Executive Committee is accountable to the Chief Executive Officer as the Accountable Officer of the Trust The following Groups report to the Executive Committee (under review): • Capital Investment Group • Planning, Contracting and Business Development Group • Non-clinical Risk Group • Emergency Planning & Resilience Group • Trust Delivery Team • Digital Strategy Group • Information Governance Group • Estates Steering Group • Workforce & Organisational Development Group • Learning Disability Strategy Group • Joint Negotiating Committee • Executive Performance Review • Business Unit Performance Review

4.7.3 Duties The duties of the Team are to: • Oversee all Trust Executive business including monitoring implementation of the Executive Delivery Plan. • Ensure the appropriate development and implementation of strategies and operational plans to support the delivery of HCT objectives. • Monitor operational, clinical and financial performance and ensure appropriate actions are taken when performance does not achieve agreed standards/trajectories. • Oversee the development of the Board Assurance Framework (BAF) and maintain an ongoing assessment and control of risk across the organisation.

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• Ensure appropriate prioritisation and allocation of resources across HCT • Ensure compliance with regulatory frameworks • Monitor stakeholder engagement plans and impact across HCT and ensure the development of an appropriate framework for future management. • To meet in emergency session if required to pre-empt, manage or co-ordinate the management of, a response to any emergency which may arise and which • threatens the operational efficacy, financial viability or reputation of the Trust or • requires a response to an external emergency that will require deployment of Trust resources or capacity over and above normal, day to day operations • Consider any relevant issues arising from Trust policy and national guidance and to also consider the impact (including risks and resource requirements) of stated forthcoming government policy and / or legislation. • Receive minutes and reports from groups established by and/or reporting to the Executive Team • Approve Trust policies for which the Executive Team is the “designated committee” under the Trust’s Policy on the Development and Management of Clinical and Corporate Procedural Documents.

4.8 Charitable Funds Committee The Corporate Trustee (i.e. Trust Board) has delegated responsibility for the overall day to day management of the Charitable Funds to an independent Committee to be known as the Charitable Funds Committee (Appendix G6). The Corporate Trustee will retain responsibility for: • The Charitable Funds’ overall priorities and strategy • Investment Strategy • Fundraising Strategy • Budgets and spending plans • Annual Accounts and Report The Charitable Funds Committee has been formally constituted by the Corporate Trustee in accordance with the Trusts Standing Orders, delegated responsibility to make and monitor arrangements for the control and management of the Trusts charitable funds and will report to the Corporate Trustee. The Committee is authorised to: • Approve expenditure of Charitable Funds in accordance with delegated limits as set out in the relevant sections of the Trusts Standing Financial Instructions’. • Obtain outside legal or other independent professional advice and

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• Secure the attendance of outsiders with relevant experience and expertise if they consider this necessary. The Committee is empowered with responsibility for: • Day to day management of the investments of the charitable funds in accordance with the approved Investment Strategy, ensuring that: • The scope of the investments is clearly set out in writing and communicated to the Director of Finance • There are adequate internal controls and procedures in place which will ensure that the investments are being exercised properly and prudently • They review regularly the performance of the investments • Acquisitions or disposal of a material nature must always have written authority of the Charitable Funds Committee, or the Chairman of the Committee in conjunction with the Director of Finance. The banking arrangements for the charitable funds should be kept entirely distinct from the Trusts NHS funds. Separate current and deposit accounts should be minimised consistent with meeting expenditure obligations. The amount to be invested or redeemed from the sale of investments shall have regard to the requirements for immediate and future expenditure commitments. The Committee will establish and maintain an approved list of counter parties for investment activities. The Committee will operate an investment pool when this is considered appropriate to the charity in accordance with charity law and the directions and guidance of the Charity Commission. The Committee shall propose the basis to the Corporate Trustee for applying accrued income to individual funds in line with charity law and Charity Commission guidance. The Committee will obtain appropriate professional advice to support its investment activities. The Committee shall regularly review investments to see if other opportunities or investment managers offer a better return.

4.8.1 Delegated Powers and Duties of the Director of Finance The Director of Finance has prime responsibility for the Trusts charitable funds as defined in the SFIs. The specific powers, duties and responsibilities delegated to the Director of Finance are: • Administration of all existing charitable funds • To identify any new charitable funds that may be created (of which the Trust is Trustee) and to deal with any legal steps that may be required to formalise the trusts of any such charitable funds • Provide advice and guidelines with respect to donations, legacies and bequests, fundraising and trading income in line with Charity Commission

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guidance. • Responsibility for the management of investment of funds held on trust • Ensure appropriate banking services are available to the trust • Prepare the Annual Report and Accounts for the Committee to recommend for approval by the Corporate Trustee.

4.8.2 Role of the Committee The purpose of the Committee is to make the most effective use of all available charitable funds, ensuring that the funds are spent appropriately as a financially sustainable organisation.

4.8.3 Duties The duties of the Committee shall be: • To apply the charitable funds in accordance with their respective governing documents consistent with the requirements of the Charities Act 1993, Charities Act 2006 or any modification to these Acts. • To ensure that the Trusts policies and procedures for charitable funds investments are followed. To make decisions involving the sound investment of charitable funds in a way that both preserves their capital value and produces a proper return consistent with prudent investment and ensuring compliance with: • Trustee Act 2000 • The Charities Act 1993 • The Charities Act 2006 • Terms of the fund’s governing documents. • To receive at least twice a year reports for ratification from the Director of Finance for investment decisions and action taken through delegated powers upon the advice of the Trusts investment advisor and the Corporate Trustee. • To oversee and monitor the functions performed by the Director of Finance as defined in the SFIs. • To appoint and review Auditors for statutory audit / independent examination of annual accounts as per guidance from the Charity Commission. • To monitor progress of any charitable appeal funds and to receive reports from the Appeal Fundraising Groups • Proposed budgets will be presented to the sub-committee for approval which will enable the delegated authority to function • To monitor the scheme of delegation for expenditure for the levels set out in the Scheme of Delegation • Expenditure over £1 million must be approved by the Corporate Trustee • To oversee the development of a Charitable Funds Strategy and recommend 31

to the Corporate Trustee for approval and consider the approach to fundraising, the investment of funds, the approach to expenditure and the approval of procedures associated with the use of charitable funds within the regulations provided by the Charity Commission and to ensure compliance with the laws governing charitable funds. • To administer the Hertfordshire Health Charitable Fund in pursuance of its objects as stated in its Declaration of Trust and in accordance with the Charitable Funds Strategy set by the Corporate Trustee. • To ensure the Trust complies with all legal, Charity Commission and Department of Health guidelines as they relate to the administration of Charities. • To advise, where appropriate, on raising funds for the Hertfordshire Health Charitable Fund. • To ensure proper books of account are kept and to review and approve the annual return and annual accounts in line with the requirements of the Charity Commission and laws governing charitable funds. • To review all income and expenditure transactions for all funds. • To review legacies received and ensure that the Trust complies with the terms of the legacy. • To authorise the establishment of new funds and new charities. • To authorise donations when an individual item has a value of more than £5,000 in line with the Trusts SFIs. • To consider the use of professional fundraisers and links with other organisations for major fundraising projects. It is the duty of the Committee to uphold the Code of Conduct for NHS Managers, which includes the seven principles of public life (The Nolan Committee), namely: selflessness, integrity, objectivity, accountability, openness, honesty and leadership.

4.9 Remuneration Committee The purpose of the Remuneration Committee (Appendix G7) is to make decisions to recommend to the Board on the remuneration, terms and service and performance related pay of the Chief Executive and Executive Directors and other members of staff on NHS Very Senior Manager terms and conditions. The decisions will have been reached following due consideration of all relevant internal and external factors, so that they are publicly defensible and reached with probity, discipline and objectivity. The Remuneration Committee will also review and approve all severance payments as required by NHS Improvement Single Oversight Framework. This relates to all staff including Director level.

4.9.1 Duties The duties of the Committee are to:

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• Advise the Board on the pay and contractual arrangements for the Chief Executive and Executive Directors and other members of staff on NHS Very Senior Manager terms and conditions, including the consideration of appropriate allowances, benefits and performance-related remuneration. • Determine the pay and benefits of the Chief Executive and Executive Directors and any other members of staff on NHS Very Senior Manager terms and conditions, having proper regard to the organisations’ circumstances and performance, and of any national arrangements for such staff where appropriate. • Ensure that contractual obligations for individual Executive Directors are reviewed, honoured and remain competitive, including proper calculation and scrutiny of termination payments, taking account of national guidance as appropriate. • Ensure that the total emoluments of all members of the Board are published in the Annual Report. • Review and consider the business case for all severance payments in respect of Chief Executive or Directors, ensuring they are submitted to NHS Improvement for final approval. • Ensure that a business case is developed to support any termination payment in excess of contractual terms and submitted for approval to NHS Improvement, Department of Health and H M Treasury. • Review and consider the business case and efforts made to secure suitable alternative employment for any severance payments in excess of £100,000, ensuring they are submitted to NHS Improvement for final approval.

4.9.2 Authority The Committee is authorised by the Board to: • Make decisions within its terms of reference, including matters specifically referred to it by the Board. • Seek information it requires from any employee of the Hertfordshire Community NHS Trust. • Obtain legal or other independent professional advice and • Secure the attendance of such outsiders with relevant experience and expertise that it considers necessary.

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5 Principles and Values

5.1 NHS Code of Conduct and Accountability

5.1.1 Introduction This Code of Conduct applies to all members and individuals employed or engaged within activities for the Trust (temporary and permanent, full and part time and volunteers regardless of role or position) and forms part of the Trusts governance arrangements. The Code is based upon the general principles of public life and it is the responsibility of each individual to comply with the provisions of the Code. This Code of Conduct should also be read in conjunction with the following Trust policies and national guidance: • Anti- Fraud and Bribery Policy https://nww.hctintranet.nhs.uk/media/5412/f01-v4-0421-anti-fraud-and- bribery.pdf • Standards of Business Conduct and Managing Conflicts of Interest Part 1- https://nww.hctintranet.nhs.uk/media/3080/gr17-standards-of- business-conduct-gifts-hospitality.pdf Part 2 - https://nww.hctintranet.nhs.uk/media/4278/gr17-2-standard-of- business-conduct-conflicts-of-interest.pdf • Code of Conduct for NHS Managers 2002 https://www.nhsemployers.org/~/media/Employers/Documents/Recruit/Code_ of_conduct_for_NHS_managers_2002.pdf • Standards for Members of NHS Boards and CCG Governing Bodies in England, 2012 • Professional Standards – Standards for Board Members https://www.professionalstandards.org.uk/publications/detail/standards-for- members-of-nhs-boards-and-ccg-governing-bodies-in-england-2012 • Freedom to Speak Up: Raising Concerns Policy https://nww.hctintranet.nhs.uk/media/3081/gr23-freedom-to-speak-up-raising- concerns-policy.pdf

5.1.2 Scope Each individual must comply with this Code of Conduct whenever or wherever they act in an official capacity on behalf of or for the Trust. Whilst this Code does not have effect in relation to the individuals conduct other than when it is in official capacity, it is anticipated that a person’s conduct will be in a manner consistent with their professional status and one which will not bring their association with the Trust or its activities into disrepute. 34

This Code of Conduct is designed to build on the good practice that exists within the Trust and to clarify expectations and standards to ensure a consistently high standard of practice is achieved. It also complements organisational policies and procedures within the organisation.

This policy also clarifies the expectations that staff should have a supportive and learning environment and of the Trust which will respond to issues fairly and consistently and supplements the NHS Code of Conduct for Managers (2002).

5.1.3 General Obligations • Individuals must treat others with respect including patients, staff and external stakeholders. • Individuals must make the care and safety of patients their first concern and act to protect them from risk at all times. • Individuals must not do anything, in carrying out their Trust activities, to breach their equality duties. • Individuals must ensure they take responsibility for their own work and show commitment as a team member. • Individuals must not bully or harass any person as this will be subject to disciplinary action.

5.1.4 Code of Conduct & Accountability Policy • Individuals must act with honesty and integrity. • Individuals must not intimidate or attempt to intimidate any person. • Individuals must not do anything which compromises or is likely to compromise the impartiality of those who work for, or on behalf of, the Trust. • Individuals must not use or attempt to use their position as a member improperly to confer on or secure for themselves or any other person, an advantage or disadvantage. • Individuals must, when using or authorising the use by others of the resources within the Trust: • Act in accordance with the Trust’s reasonable requirements. • Ensure that such resources are not used improperly for political purposes (including party political purposes). • Individuals must have regard to any applicable Government policies such as data protection, freedom of information act, making a disclosure in the public interests. • When reaching decisions on any matter, individuals must have regard to any relevant advice provided to them by the Trust’s Chief Executive or Director of Finance where that officer is acting pursuant to his or her statutory duties.

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• The individual must give reasons for all decisions in accordance with any statutory requirements and any reasonable additional requirements imposed by the Trust.

5.2 NHS Constitution The NHS Constitution sets out the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities, which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. The Secretary of State for Health, all NHS bodies, private and voluntary sector providers supplying NHS services, and local authorities in the exercise of their public health functions are required by law to take account of this Constitution in their decisions and actions. It is accompanied by the Handbook to the NHS Constitution, setting out current guidance on the rights, pledges, duties and responsibilities established by the Constitution. The Constitution will be renewed every 10 years and the handbook at least every 3 years. The requirements for renewal are legally binding and guarantee that the principles and values which underpin the NHS are subject to regular review and re- commitment; and that any government which seeks to alter the principles or values of the NHS, or the rights, pledges, duties and responsibilities set out in this Constitution, will have to engage in a full and transparent debate with the public, patients and staff.

5.3 Nolan Principles on standards in public life The Seven Principles of Public Life outline the ethical standards those working in the public sector are expected to adhere to. They were first set out in the Committee’s first report by Lord Nolan in 1995 and they are included in a range of Codes of Conduct across public life. The Seven Principles of Public Life apply to anyone who works as a public office holder. This includes all those who are elected or appointed to public office, nationally and locally, and all people appointed to work in the Civil Service, local government, the police, courts and probation services, non-departmental public bodies (NDPBs), and in the health, education, social and care services. All public office holders are both servants of the public and stewards of public resources. The principles also apply to all those in other sectors delivering public services.

5.3.1 Selflessness Holders of public office should act solely in terms of the public interest.

5.3.2 Integrity Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests 36

and relationships.

5.3.3 Objectivity Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias.

5.3.4 Accountability Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this.

5.3.5 Openness Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing.

5.3.6 Honesty Holders of public office should be truthful.

5.3.7 Leadership Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.

5.4 Fit and Proper Persons The fit and proper person regulation (FPPR) requirements came into force for all NHS trusts and foundation trusts in November 2014. The regulations require NHS trusts to seek the necessary assurance that all executive and non-executive directors (or those in equivalent roles) are suitable and fit to undertake the responsibilities of their role. In order to meet compliance with these requirements, all NHS trusts must ensure they have robust processes in place to assess the suitability of directors at the point of recruitment and throughout their ongoing employment. They are also required to have effective arrangements in place to tackle issues should any concerns be raised about a directors' ongoing fitness and suitability to carry out any such role. The purpose of these requirements is not only to hold board members to account in relation to their conduct and performance but also to instil public and patient confidence in those who have lead responsibility for NHS organisations and the services they provide. The Care Quality Commission (CQC) holds NHS trusts to account in relation to FPPR as part of the key lines of enquiry under their regulatory assessment framework (under their well-led domain). Its role is to assess that NHS trusts have appropriate and effective processes in place to assess directors’ suitability and to take action if they are failing to meet these requirements. While the CQC cannot investigate or prosecute for a breach of the requirements, it can take regulatory

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action against an individual's breach of a regulation, condition of its registration, or other relevant requirement. It can also assess the quality of any evidence presented and whether the NHS trust has appropriately taken this into account. Where the CQC has its own concerns about a director, it has the power to take enforcement action against the employing organisation. Guidance about FPPR requirements can be found on the CQC website (last revised in January 2018).

5.4.1 Kark review In 2019 the Kark review of the fit and proper persons test (FPPT) was published. The review sought to establish why the FPPT for directors was not being applied effectively. The review makes five key recommendations, as follows. • All directors (executive, non-executive and interim) should meet specified standards of competence to sit on the board of any health providing organisation. Where necessary, training should be available. • A central database of directors should be created holding relevant information about qualifications and history. • The creation of a mandatory reference requirement for each director. • The FFPT should be extended to all commissioners and other appropriate arms-length bodies (including NHS Improvement and NHS England). • The power to disbar directors for serious misconduct.

5.4.2 Meeting compliance To ensure compliance with regulatory requirements, NHS trusts must be able to demonstrate to the CQC that they have robust and effective: • Recruitment processes in place to assess the suitability of all newly appointed directors as outlined within the NHS Employment Check Standards • Assessment processes in place to regularly monitor and review the ongoing fitness of directors in their employ. This may form part of pre-existing appraisal and revalidation processes, as appropriate • Arrangements in place to handle concerns about a directors' fitness and suitability in a timely manner, ensuring these are widely communicated and understood by all staff, including processes of appeal for directors • Arrangements in place to share relevant information to health and social care regulators and other bodies (as appropriate), if a director no longer meets the FPPR requirements.

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6 Controls

6.1 Register of Interests Trust Standing Orders (Appendix A) requires members of the Board of Directors to declare: • any pecuniary interest in any contract, proposed contract or other matter which is under consideration or is to be considered by the Board of Directors • any interests including but not limited to any personal or family interests which are relevant and material to the business of the Trust irrespective of whether those interests are direct or indirect, actual or potential. Standing Orders also gives wider definition on the nature of interests including clarification on what is deemed to be ‘relevant and material’. The Register of interests is a publicly accessible document which is: • posted on the Trust’s website • presented to a meeting on the Board in public once per annum and • (For the previous year) published in the Trust’s Annual Report. In addition to the general register, and as prescribed under Standing Orders, all Board and Board committee meetings have as a standing agenda item, declarations of interest which may be specific to the agenda of the meeting in question. Members of staff are also required to declare any relevant interests and secondary employment under the terms of the Standards of Business conduct and Managing Conflicts of Interest Policy (Appendix E).

6.2 Committee Self-assessment

6.2.1 Introduction The Board and its committees are required to annually assess (see Appendix H) their own performance and the adequacy of committee governance including their terms of reference, work plans and communication between the committee, its sub- committees and other relevant groups, with a view to highlighting skills and/or knowledge gaps and identifying areas where improvements can be made.

6.2.2 Purpose The self-assessment process is intended to help improve performance in the following ways: • Refresh the Board’s understanding of its own responsibilities; • Identify important areas of board operation that need attention or improvement; • Measure progress toward existing plans and objectives;

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• Shape the future operations of the Trust; • Define criteria for an effective and successful Board; • Build trust, respect and communication between the Board’s Executive and Non-Executive Directors and the Chief Executive and the Chairman; • Enable individual Board Members to work more effectively as part of a team.

6.3 Internal Controls

6.3.1 Overview The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of the Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, to manage them efficiently, effectively and identify remedial actions.

6.3.2 Risk Management The governance structure within the Trust enables an embedded risk management approach across all corporate and operational services, with discussions being reflected at the key governance committees reporting directly to the Board of Directors. This ensures the identification, assessment, management and monitoring of strategic and operational risks at all levels. In addition, an annual audit cycle of governance due diligence is undertaken by the internal auditors who report to the Audit Committee and provide assurance on the efficacy of the Trust’s governance programme. The annual audit cycle includes an audit of the risk management process, including escalation/de-escalation of risk to and from the High Level Risk Register and the impact upon the Board Assurance Framework (BAF). The risk architecture/risk management process is supported by clearly defined leadership roles in all levels of the Trust from staff to Board members. Every staff member is responsible for identifying, escalating and managing risks within their sphere of competency, supported by their managers, as outlined in the Risk Management Framework. Managers are also required to demonstrate that appropriate control measures are in place and actions are being undertaken to mitigate negative risk and enable positive risk achievement, reporting to their respective lead Executive Director responsible for the aligned portfolio of services. The Trust uses an electronic risk management system. All staff undertake risk management awareness training and an introduction to the electronic risk management system as part of their induction.

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6.3.2.1 Board Assurance Framework (BAF) and High Level Risk Register Risks to the achievement of the Trust's strategic objectives are identified by the Executive Team and entered on the Trust's Board Assurance Framework (BAF). The BAF is submitted for review and discussion by the Audit Committee and the Board of Directors. Risks and their implications are considered by each Board Committee and each BAF risk has a lead Committee identified which monitors and seeks assurance with regards to the management and mitigation of the risk. The BAF is assessed annually for ‘fitness for purpose’ by the Audit Committee. Risks identified at Business Unit level are entered on Business Unit Risk Registers and risks scoring 15 or over are recorded on a ‘High Level Risk Register’ (HLRR). The HLRR is considered monthly by the Executive Team and at each Board meeting. Each High Level Risk has an identified lead Committee which is responsible for assurance in relation to the management of the risk. Risks on the HLRR that are considered by the Executive Team to have a strategic impact are escalated to the BAF.

6.3.3 Annual Governance Statement The Annual Governance Statement is a mandatory disclosure for all central government entities that are required to comply with the government financial reporting manual (FReM). All public bodies including NHS organisations must provide assurance that they are appropriately managing and controlling the resources for which they are responsible. The Annual Governance Statement replaces the Statement of Internal Control. The Accountable Officer has responsibility for maintaining a sound system of internal control that supports the achievement of the Trust’s policies, aims and objectives, whilst safeguarding public funds and departmental assets. The Accountable Officer is responsible for ensuring that the Trust is administered prudently and economically and that resources are applied efficiently and effectively.

6.4 Independent control and regulation

6.4.1 Internal Audit Investigations and checks are carried out by the internal auditors of an organisation. The function of internal audit is based on the auditors understanding of the organisation, including an analysis of the Trust’s corporate objectives and risk profile, The approach is based on a review of annual reports, performance reports and any regulatory requirements as set out in the audit strategy and annual plan, as well as other factors affecting Hertfordshire Community NHS Trust including changes within the sector. Assignments are designed to provide assurance or advisory input around specific risks, reports are prepared and presented to the Audit Committee bi-monthly to update on progress and outcomes and suggested management actions. The work programme on internal audit may have an impact on external audit and internal and external auditors can collaborate.

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6.4.2 Counter-fraud and corruption Service Conditions Section 24 of the Standard NHS Contract relate to expectations surrounding anti-crime arrangements in place within NHS organisations. Under the NHS standard contract, all organisations providing NHS services are required to put in place appropriate Counter Fraud and security management arrangements. The Counter Fraud Standards (CFS) for Providers establish a framework for organisations to review their arrangements against the best practice guidance from the NHS Counter Fraud Authority (CFA). The Standards cover the full spectrum of Counter Fraud work undertaken at the Trust including proactive prevention and deterrence work across all the generic areas of activity. Additionally, it provides guidance and best practice recommendations regarding detection and investigation management processes. Although the CFS play a pivotal role in addressing Counter Fraud issues, input and co-operation from other departments and staff is essential. On an annual basis, organisations are expected to carry out a self-assessment against the standards, known as a self-review tool (SRT), and submit the results to the NHS CFA. The SRT provides a summary of the work conducted over a financial year. The assessment relates to the Counter Fraud arrangements in place at the organisation and is not an assessment of the performance of the Counter Fraud provider or individual. The assessment is divided into the following four areas as set out by the NHS CFA: • Strategic Governance • Inform and Involve • Prevent and Deter • Hold to Account

6.4.3 External Audit External Audit is the process by which annual accounts of public and private sector bodies are subject to external scrutiny, to provide independent assurance that they have been prepared in accordance with relevant legal and professional standards and give a ‘true and fair’ view of the financial performance and financial position of the organisation. External audit can include a wider brief such as giving assurance on quality and performance. External Audit in the public sector is characterised by three distinct features: • Auditors are appointed independently from the bodies being audited • The scope of the auditors’ work is extended to cover aspects of corporate governance and arrangements to secure the economic, efficient and effective use of resources, in addition to the financial statements • Auditors may report aspects of their work to the public and other key stakeholders The audit report has two main purposes: • To give an expert and independent on opinion as to whether the financial

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statements give a true and fair view of the financial position of the organisation at the end of the financial year and its financial performance during the year • To give an expert and independent opinion on whether the financial statements comply with relevant law.

6.4.4 Care Quality Commission The Care Quality Commission (CQC) is the safety and quality regulator for health services and is also the independent regulator for adult social care services in England. The CQC is responsible for making sure that health and social care services provide people with safe, effective, compassionate, high-quality care. The CQC assess and make judgements as to the level of safety and quality of care provided. To make these assessments the CQC looks at information received from the Trust, patients, staff and other organisations and conduct its own inspections. CQC assessment reports are published on the CQC website. The CQC registers health and adult social care services that meet the ‘fundamental standards’ of quality and safety. Before the Trust can carry out any of the activities regulated by the CQC, it must register the service and demonstrate that it will be able to meet a number of legal requirements, including fundamental standards of care. The CQC’s role is to: • Register care providers • Monitor, inspect and rate services • Take action to protect people who use services • Provide an independent assessment of the care being provided by health and social care services, and recommending actions to address major quality issues The Trust is registered with the CQC and its current status is ‘registered without conditions’.

6.4.5 Health and Safety Executive The Health and Safety Executive (HSE) is a UK government agency responsible for the encouragement, regulation and enforcement of workplace health, safety and welfare, and for research into occupational risks in Great Britain. NHS organisations have statutory responsibilities under the Health & Safety at Work Act (1974), the management of Health & Safety at Work Regulations (1999) and a number of other health and safety regulations. The HSE may investigate incidents, provide recommendations and actions to reduce risk and prevent future occurrences. Under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (2013) (RIDDOR) reporting requirements, the Trust is required to report staff incidents or accidents resulting in sickness in excess of seven working days.

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6.4.6 NHS Resolution NHS Resolution (NHSR) is a Non-Departmental Public Body (NDPB) that manages negligence and other claims against NHS in England on behalf of member organisations. Their aim is to help resolve disputes fairly, share learning about risks and standards in the NHS, preserve resources for patient care and help to improve safety for patients and staff. Any claims against the Trust are handled by the Trust solicitors on our behalf. The solicitors work with the Trust to prepare cases which are then forwarded to NHSR for resolution. The Clinical Negligence Scheme for Trusts (CNST) is an indemnity scheme overseen by the NHSR. The CNST handles all clinical negligence claims against member NHS bodies. Annual fees charged to individual Trusts are determined by the number and value of previous claims made. The Liabilities for Third Parties Scheme (LTPS) was established by the NHS and Community Care Act (1990). The scheme is administered by NHSR on behalf of the Secretary of State for Health. The scheme covers liabilities of members in respect of loss, damage or injury arising from a member organisation undertaking its normal function, as defined by the regulations.

6.4.7 Board Licence Conditions The Health and Social Care Act of 2012 sets out the licence and regulator expectations for providers of NHS services including NHS Foundation Trusts and other providers. Although NHS Trusts do not need to hold a provider licence, the Secretary of State requires NHS England / Improvement to ensure that NHS Trusts comply with conditions equivalent to those in the provider licence. NHS Trusts are required to self-certify that they can meet the obligations set out in the NHS provider licence and that they have complied with governance requirements as follows: • effective systems to ensure compliance with the conditions of the NHS provider licence, NHS legislation and the duty to have regard to the NHS Constitution (condition G6) • complied with governance arrangements (condition FT4) The annual self- certification process provides assurance that the Trust is compliant with the conditions of the licence which is routinely monitored through the NHS Oversight Framework.

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7 Responsible and Accountable Officers

7.1 Membership of the Board Under the Trust’s Establishment Order (SI 2010 No. 2464) the Trust has, in addition to the Chairman, four non-executive directors and four executive directors. These full voting members of the Board are as follows:

7.1.1 Voting Members

Title Name Qualifications Period of Notes Appointment

Interim Chair Linda Sheridan FFPH, Previous NED role

MRCGP, MSc 01/06/13 - 31/10/22

Non-executive Jeff Phillips BSc, ACMA, 01/09/11 - 31/03/22

Director FCT

Non-executive Richard Rolt 01/04/20 – 31/03/23

Director

Non-executive Sarah Wren 01/04/20 – 31/03/23

Director

Non-executive Rukshana Kapasi 01/07/21 – 30/06/24 Director

Interim Chief Elliot Howard- 01/11/20 –

Executive Officer Jones

Director of Sarah Browne N/A (substantive) Nursing & Quality, Chief Nurse

Medical Director Dr Elizabeth N/A (substantive) Kendrick

Director of David Bacon FCA, BA, MBA N/A (substantive) Finance, Systems (Open)

and Estate

7.1.2 Non-Voting Members In addition to the voting members, the Board also includes the following non-voting members:

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Title Name Qualifications Period of Notes Appointment

Associate Non- Luke Edwards 25/06/19 – 01/06/21 Executive Director (unremunerated)

Associate Non- Rohan 01/07/21 – 30/06/24 Executive Director Sivanandan

Chief Operating Marion Dunstone BSc (Hons) N/A (substantive)

Officer Dietetics, DMS

Director of Sarah Brierley N/A (substantive)

Strategy

7.1.3 Board Vacancies As at 1 January 2021 there was one Non-executive Director vacancy.

7.1.4 Senior Independent Director The Senior Independent Director role (SID) is currently fulfilled by Jeff Phillips. The primary role of the SID is to: 1. Act as the interface between the non-executive directors and the Chair in the event of issues and disputes 2. Support appraisal of the Trust Chair

7.1.5 Board Secretary The Board Secretary role is fulfilled by the Assistant Trust Board & Committee Secretary.

7.2 Executive Director Portfolios Portfolios for each of the Executive Directors are set out below:

7.2.1 Chief Executive

7.2.2 Responsibilities include: • Overall leadership of the Trust • Chair of Executive Team and Staff Council • Overarching Trust strategy • Role within Integrated Care System (ICS) • Strategic communications and engagement • COVID-10 response

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7.2.3 Director of Finance, Systems and Estate Responsibilities include • Finance Strategy Lead • Financial management and governance • Long Term Financial Model (LTFM) • Performance management • Contract management • Procurement • Corporate governance • Business planning • Risk Management • Information governance and Senior Information Risk Owner (SIRO) • Clinical Systems • Estates • Integrated Care System (ICS) Finance • Integrated Care Partnership (ICP) Finance • COVID-19 Gold Command (joint with Director of Nursing and Quality)

7.2.4 Director of Nursing and Quality, Chief Nurse Responsibilities include: • Executive Lead and advisor for nurses and allied health professionals on the Trust Board of Directors • Safeguarding Children and Vulnerable Adults • Quality and clinical governance • Clinical leadership • Patient safety • Patient experience • Director of Infection Prevention and Control (DIPC) • Executive Director for Freedom to Speak Up • Executive lead for mental health and learning disability (joint with Medical • Director) • COVID-19 Gold Command (joint with Director of Finance, Systems and Estate) • Mass Vaccination response • Equality & Diversity (Communities)

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7.2.5 Medical Director Responsibilities include: • Health and Wellbeing Strategy Lead • End of Life Strategy Lead • Executive lead and advisor for medical, dental and pharmacy professionals on the trust Board of Directors • Clinical leadership • Caldicott Guardian • Responsible Officer for medical revalidation • Accountable Officer for controlled drugs • Guardian for safe working hours • Executive lead for Learning from Deaths • Executive lead for Medicines Management • Executive lead for mental health and learning disability (joint with Director of Nursing and Quality) • GP Engagement • Integrated Care System (ICS) Nursing & Quality • Integrated Care Partnership (ICP) Nursing & Quality

7.2.6 Chief Operating Officer Responsibilities include: • Operational management • Service transformation and improvement • Emergency planning & resilience • Communications with GPs and Primary Care Networks • Integrated Care System (ICS) Operations • Integrated Care Partnership (ICP) Operations

7.2.7 Director of Strategy Responsibilities include: • Strategy development • Alignment of Trust strategy and system-wide plans • Business and commercial development

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• Communications and engagement • Partnerships • Digital and innovation • Quality improvement • System transformation • Integrated Care System (ICS) Partnership working and system transformation • Integrated Care Partnership (ICP) Partnership working and system transformation

7.2.8 Associate Director of People Responsibilities include: • Workforce and Organisational Development Strategy Lead • HR operational delivery • Recruitment • Learning & Development • Organisational Development • Equality & Diversity (workforce) • Workforce planning & Workforce information • Employee and Trade Union relations • Staff appraisals and talent management • Staff engagement, surveys and recognition • Occupational health services • Integrated Care System (ICS) Workforce • Integrated Care Partnership (ICP) Workforce

7.2.9 Associate Director of Integrated Business Services Responsibilities include: • Contract management • Performance management and information • Corporate governance • Information governance • Risk management • Corporate Programme Management Office • Integrated Business Services

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7.2.10 Designated Executive / Non-executive Director Lead Roles

7.2.10.1 Definitions Definitions for designated Executive and Non-Executive Director roles are set out in the table below:

Role Definition

Non-Executive Director Lead Non-Executive accountability to the Board on behalf of the non-executive directors for challenging and seeking assurance from the executive and giving assurance to the Board as to compliance, quality and risk management in relation to a specific area and / or being a non-executive director nomination to meet a statutory / mandatory / Trust policy requirement (and to fulfil the requirements as prescribed).

Champion Promoting awareness and issues and representing the interests of, a defined community at Board level (and with the Executive Team).

Alignment Liaising, advising and challenging on behalf of the non-executive directors with the prescribed executive director lead in respect of a specific strategy or defined piece of work.

Ambassadorial Liaison Representing and promoting the interests of the Trust and fostering good relations with the non-executive directors (or lay equivalent) of external organisations; feeding back significant intelligence to the HCT Board.

Executive Board Lead Executive accountability to the Board (and the CEO as accountable officer) in respect of a statutory, mandatory or Trust policy requirement or a portfolio- related area of work.

Executive Director Locality On behalf of the Executive Team, (i) to act as an Lead ambassador for two-way communications and engagement with GP localities and (ii) to support HCT managers with local GP engagement and issue resolution.

Executive Director Lead Link The executive director who is the primary point of contact and channel of communication, at executive director level, with external organisations. (Either generally or in respect of specific areas).

7.2.10.2 Non-executive Director Lead Roles Non-executive Director lead and champion roles as at 1 January 2021 are set out in the table below:

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Lead Role Non-executive Director

Board Leadership and Development Dr Linda Sheridan

Patient Experience Lead Sarah Wren

Learning from Deaths Lead Dr Linda Sheridan

Trust “Freedom to Speak Up” Lead Richard Rolt

Learning Disability Sarah Wren

Wellbeing Lead Sarah Wren

Counter-Fraud and Anti-Bribery Lead Richard Rolt (Under the Secretary of State’s Directions on Counter Fraud)

Security Lead Richard Rolt

Sustainability Lead Linda Sheridan

Procurement Lead Jeff Phillips

Emergency Planning & Resilience Lead Dr Linda Sheridan

Children’s Champion Jeff Phillips

UNICEF Accreditation Champion Dr Linda Sheridan

Communications and Engagement Lead Dr Linda Sheridan

Equality & Diversity Lead Richard Rolt

7.2.10.3 Non-executive Director Strategy Alignment

Lead Role Non-executive Director

Strategy process and overview Dr Linda Sheridan

Clinical Sarah Wren

People Strategy Jeff Phillips

Estates Strategy Jeff Phillips

Partnership and Growth Strategy Jeff Phillips

Finance Strategy Jeff Phillips

Digital Strategy Richard Rolt

Patient Experience & Engagement Dr Linda Sheridan

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Risk Management Framework Dr Linda Sheridan

Quality Improvement Framework Sarah Wren

7.2.10.4 Non-executive Director Ambassadorial liaison with external organisations

Organisation Non-executive Director

West Hertfordshire Hospitals NHS Trust Dr Linda Sheridan

East & North Hertfordshire NHS Trust Dr Linda Sheridan

Herts Valleys Clinical Commissioning Group Dr Linda Sheridan

East & North Herts Clinical Commissioning Group Dr Linda Sheridan

Hertfordshire Partnership NHS Foundation Trust Jeff Phillips

Hertfordshire Health and Wellbeing Board Dr Linda Sheridan

7.2.10.5 Non-executive Director Locality Leads

Locality Non-executive Director

Lower Lea Valley Jeff Phillips

Upper Lea Valley Jeff Phillips

Stort Valley and Villages Dr Linda Sheridan

North Herts and Royston Richard Rolt

Stevenage Dr Linda Sheridan

Welwyn and Hatfield Sarah Wren

7.2.10.6 Executive Director Board Lead Roles

Lead Role Executive Director

Accountable Officer of the Trust Chief Executive Officer

NHS Constitution Chief Executive Officer

NHS Provider Licence Conditions Chief Executive Officer

Accounting Officer of the Trust Director of Finance, Systems and Estate

Caldicott Guardian Medical Director

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Responsible Officer Under the (Medical Medical Director Profession) Responsible Officer Regulations 2010

Accountable Officer – Controlled drugs Medical Director

Learning from Deaths Medical Director

Research Governance & Intellectual Property Medical Director

Infection Prevention and Control (DIPC) Director of Nursing and Quality, Chief Nurse

Chief Nurse and Lead AHP Director of Nursing and Quality, Chief Nurse

“Freedom to Speak up” Lead Director of Nursing and Quality, Chief Nurse

Patient Safety Director of Nursing and Quality, Chief Nurse

Safeguarding Children & Vulnerable Adults Director of Nursing and Quality, Chief Nurse

Learning Disability Director of Nursing and Quality, Chief Nurse

Customer Care Director of Nursing and Quality, Chief Nurse

Dementia Chief Executive Officer

Health & Safety Director of Finance, Systems and Estate

Senior Information Risk Owner (SIRO) Director of Finance, Systems and Estate

Counter Fraud and Anti-Bribery Director of Finance, Systems and Estate

Sustainability Associate Director of Integrated Business Services

COVID Mass vaccination programme Director of Nursing and Quality, Chief Nurse

Organisational Transition Programme Associate Director of Integrated Business Services

Winter planning and surge Chief Operating Officer

Black, Asian and Minority Ethnic Chief Executive Officer

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7.2.10.7 Executive Director Locality Leads

Locality Non-executive Director

Lower Lea Valley Director of Finance, Systems and Estate

Upper Lea Valley Director of Finance, Systems and Estate

Stort Valley and Villages Associate Director of People and OD

North Herts and Royston Director of Nursing and Quality, Chief Nurse

Stevenage Chief Executive Officer

Welwyn and Hatfield Medical Director

7.2.10.8 Executive Director Lead Links

Organisation Non-executive Director

Integrated Care System (ICS) Chief Executive Officer

Hertfordshire County Council Director of Finance, Systems and Estate (With a specific remit on the Better Care Fund)

Health Scrutiny Committee Chief Executive Officer

7.2.10.9 Board Committee Membership

Committee Membership

Audit Committee Non-executive Directors: Richard Rolt (Chair) Sarah Wren Jeff Phillips

Remuneration Committee Non-executive Directors: Jeff Phillips (Chair - interim) Dr Linda Sheridan TBC Attends: Chief Executive Officer Associate Director of People and OD

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(on invitation)

Quality Committee Non-executive Directors: Sarah Wren (Chair) Richard Rolt Dr Linda Sheridan Executive Directors: Director of Nursing and Quality, Chief Nurse Medical Director Chief Operating Officer Associate Director of People Attends: (open invitation to all Board members)

People Performance and Finance Non-executive Directors:

Committee (PPFC) Jeff Phillips (Chair) (*) Dr Linda Sheridan Richard Rolt Executive Directors: Chief Executive Officer Director of Finance, Systems and Estate Director of Nursing & Quality, Chief Nurse Chief Operating Officer Associate Director of People Associate Director of Integrated Business Services Attends: (open invitation to all Board members)

Strategy Planning & Engagement Non-executive Directors: Committee (SPEC) Dr Linda Sheridan (Chair) Jeff Phillips Sarah Wren Luke Edwards (Associate NED) Executive Directors: Chief Executive Officer Medical Director Director of Strategy Associate Director of Integrated Business Services Attends:

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(open invitation to all Board members)

The Board as Corporate Trustee Non-executive Directors: Dr Linda Sheridan (Chair) Jeff Phillips Richard Rolt Sarah Wren Rukshana Kapasi Executive Directors: Chief Executive Officer Director of Finance, Systems and Estate Director of Nursing & Quality, Chief Nurse Medical Director Attends: (open invitation to all Board members)

Charitable Funds Committee Non-executive Directors: (CFC) Dr Linda Sheridan (Chair) Jeff Phillips Executive Directors: Director of Finance, Systems and Estate Director of Nursing & Quality, Chief Nurse

8 Definitions and Glossary of terms In this Corporate Governance Manual, the following definitions apply:

Term Definition

The 2012 Act The Health and Social Care Act 2012

The 2006 Act The National Health Service Act 2006

The 1977 Act The National Health Service Act 1977

Accountable Officer The person who from time to time discharges the functions specified in paragraph 25(5) of Schedule 7 to the 2006 Act; they shall be the Officer responsible and accountable for funds entrusted to the Trust in accordance with the NHS Trust Accounting Officer Memorandum. They are responsible for ensuring the proper stewardship of public funds and assets. The

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NHS Act 2006 designates the Chief Executive of the NHS Trust as the Accountable Officer

The Board The Board of Directors of the Trust as constituted in accordance with the Trust’s Standing Orders

Bribery Act The Bribery Act 2010

Budget A resource, expressed in financial or workforce terms, proposed by the Board of Directors for the purpose of carrying out, for a specific period, any or all of the functions of the Trust

Budget holder The Director or employee with delegated authority to manage finances (income and expenditure) for a specific area of the organisation

The Chair Is the person appointed by NHS England/Improvement to lead the Board and ensure it successfully discharges its overall responsibility for the Trust as a whole. It means the Chair of the Trust or, in relation to the function of presiding at or chairing a meeting where another person is carrying out that role as required by the Standing Orders.

Chief Executive The chief officer of the Trust

Committee A committee or subcommittee created and appointed by the Trust

Contracting and The systems for obtaining the supply of goods, procuring materials, manufactured items, services, building and engineering services, works of construction and maintenance and for disposal of surplus and obsolete assets

Director A member of the Board of Directors

Director of Finance The chief finance officer of the Trust

External auditor The person appointed to audit the accounts of the Trust, who is called the auditor in the 2006 Act

Financial year Successive periods of twelve months beginning with 1April and ending 31 March Trust

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Trust contract Agreement between the Trust and Clinical Commissioning Groups and/or others for the provision and commissioning of health services

Funds held on Trust Those Trust funds which the Trust holds at its date of incorporation, receives on distribution by statutory instrument, or chooses subsequently to accept under powers derived under the 2006 Act. Such funds may or may not be charitable

Legal advisor A properly qualified person appointed by the Trust to provide legal advice

Nominated Officer An officer charged with the responsibility for discharging a specific function or specific tasks within Standing Orders and Standing Financial Instructions

Officer An employee of the Trust

Partner In relation to another person, a member of the same household living together as a family unit

Protected property This will generally be property that is required for the purposes of providing the mandatory goods and services and mandatory training and education

Registered medical A fully registered person within the meaning of the practitioner Medicines Act 1983 who holds a license to practice under that Act

Registered nurse or A nurse, midwife or health visitor registered in midwife accordance with the Nurses, Midwives and Health Visitors Act 1997

Company Secretary The Secretary appointed under the Standing Orders, the Secretary of the Trust or any other person appointed to perform the duties of the Secretary, including a joint, assistant or deputy secretary.

Standing Financial regulate the conduct of the Trust’s financial matters Instructions (SFIs)

Standing Orders The Standing Orders of the Trust as amended from time to time. Describes the type of organisation, its

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primary purpose, governance arrangements and membership (SOs) to regulate the business conduct of the Trust

Scheme of Reservation The Scheme of Reservation and Delegation is to and Delegation provide details of the powers reserved to the Board of Directors, and those delegated to the appropriate level

for the detailed application of Trust policies and procedures and decision-making. The Board of Directors, however, remains accountable for all of its functions, including those which have been delegated, and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role. All powers of the Trust which have not been retained as reserved by the Board of Directors or delegated to a committee or sub-committee of the Board of Directors shall be exercised on behalf of the Board of Directors by the chief executive. The scheme of delegation identifies those functions, which the chief executive shall perform personally and those which are delegated to other Directors and Officers. All powers delegated by the Chief Executive can be re-assumed by him/her should the need arise.

9 Appendices Appendix A: Standing Orders Appendix B: Standing Financial Instructions Appendix C1: Scheme of Reservation and Delegation Appendix C2: Scheme of Delegation and Reservation Operational Arrangements Appendix D: Emergency Scheme of Delegation Arrangements Appendix E: Business Conduct Part 1: Gifts, Hospitality, Sponsorship and Offers of Payments by Pharmaceutical Companies Appendix E: Business Conduct Part 2: Conflicts of Interest (Declarations, Registration and Management of Interests) Appendix F: Tendering Procedures Appendix G1: Audit Committee Appendix G2: Quality Committee Appendix G3: People Performance and Finance Committee Appendix G4: Strategy, Planning and Engagement Committee Appendix G5: Executive Committee Appendix G6: Charitable Funds Committee Appendix G7: Remuneration Committee Appendix H: Committee Self-Assessment Template Appendix I: Equality Analysis (EA) Form

59 Board 3rd August 2021 Attachment H1

TRUST BOARD

Title: BOARD ASSURANCE FRAMEWORK

Meeting Date: 3rd August 2021

Exec Lead: Antonia Robson, Associate Director of Integrated Business Services

Author(s): Keith West, Senior PMO Analyst

For: REVIEW and APPROVAL

1 PURPOSE & RECOMMENDATIONS

1.1 To share with the Board the latest version of the Board Assurance Framework (BAF) for review and approval.

1.2 The Board is asked to consider whether the BAF fully reflects the strategic risks currently faced by the Trust and whether the risk scores are appropriate.

2 KEY POINTS FOR THE ATTENTION OF THE BOARD

2.1 There are 12 open risks on the BAF. Two of the BAF risks have reached their target risk score, one BAF risk has closed and has been superseded:

• BAF-01 has reached its target score of 9 and it is proposed that this BAF risk is reviewed for closure or refocussed on residual risk in relation to recovery from the pandemic

• BAF-10 has reached its target risk score and it is proposed that this BAF risk is reviewed for closure

• BAF-06 has been closed and is superseded by BAF-13 and BAF-14

• BAF-13 is new this month and has a risk score of 12

• BAF- 14 is also new this month with a risk score of 12

3 RELEVANT STRATEGIC OBJECTIVE(S) / STRATEGIES

3.1 This report links to all of the Trust Strategic Objectives:

4 BOARD ASSURANCE FRAMEWORK RISKS

Ref Mitigated Risk Description Lead ID score There is a risk that as a result of the ongoing and lasting impact Antonia Robson, BAF-01 3x3=9 of the pandemic on Trust services the ability of the organisation Associate Board 3rd August 2021 Attachment H1

Ref Mitigated Risk Description Lead ID score to recover is adversely affected. This could impact on the ability Director of of services to recover their commissioned activities, waiting Integrated lists, and backlogs, the deliverability of the Trust's strategic Business objectives, its ability to deliver on the priorities of the NHS Long Services Term Plan, and the quality of care provided to people.

Failure of HCT to enhance and sustainably expand the Sarah Brierley, reputation, role and contribution of its integrated community Director of BAF-02 4 x 3 = 12 services for the benefit of the population/communities that we Strategy for serve. HCT and ENHT David Bacon, There is a risk that the organisation is unable to effectively Director of BAF-03 implement and embed digital and technological solutions to Finance, 5 x 3 = 15 support effective transformation, improvement and efficiency. Systems and Estates

There is a risk that the long-term health of adults, children and Elizabeth young people served by the Trust is adversely affected as a BAF-04 Kendrick, 4 x 3 = 12 result of health inequalities which have been magnified by the Medical Director COVID-19 pandemic.

Insufficient consistent reporting of clinical measure intervention Elizabeth and outcomes may lead to difficulties in demonstrating BAF-05 Kendrick, 4 x 3 = 12 evidence based clinical interventions potentially leading to Medical Director questions about the clinical effectiveness of HCT services.

There is a risk that the sustained heightened state of readiness, challenges of recovery phase, redeployment, second surge and Alison Ryder, ongoing exposure to uncertainty and stressful situations has an Associate BAF-07 adverse effect on the health and wellbeing, resilience and 4 x 3 = 12 Director of morale of Trust leaders and workforce leading to loss of People engagement, higher absence and increased turnover, thus impacting on the ability of the Trust to deliver its services. There is a risk of an insufficient supply of workforce with the Alison Ryder, right skills and values to enable the Trust to meet current and Associate BAF-08 4 x 4 = 16 future service needs, impacting on the ability to deliver our Director of vision, objectives and the NHS Long Term Plan. People Board 3rd August 2021 Attachment H1

Ref Mitigated Risk Description Lead ID score The inability to maintain present CQC rating and embed and deliver continuous quality improvement to enable movement from Good to Outstanding may result in potential: Sarah Browne, • Director of BAF-09 Loss of confidence by key stakeholders including the local 3 x 4 = 12 population, commissioners and partner organisations, Nursing and • Impact on the Trust’s reputation for delivering safe, effective, Quality well led care and • Reduction in staff morale. There is a risk that as a result of the mobilisation of system, Sarah Browne, regional, and national structures to manage the COVID-19 Director of pandemic, there is the potential for misunderstandings with Nursing and difficulties in escalating issues and achieving co-ordinated Quality / David BAF-10 delivery of coherent services in partnership. This could impact 4 x 2 = 8 Bacon, Director the speed of the Trust's response, the level of support provided of Finance, to the Trust from regional NHSE/I, and ultimately the Systems and effectiveness and quality of care provided to the local Estates population by the health and social care sector. Risk of failure to meet regional target date and target numbers for delivery of the mass vaccination programme on behalf of Bedford, Luton and Milton Keynes (BLMK) and Herts and West Essex ICSs which could impact the Trust's organisational Sarah Browne, reputation and credibility. Contractual requirements, delivery Director of BAF-12 3 x 4 = 12 timescales, workforce gaps, Estate and IT infrastructure issues Nursing and could impact on the deliverability of the programme, create Quality winter capacity pressures and adversely impact the effectiveness and quality of care provided to the local population. Income recovery risk: The NHS is moving towards a new contract and financial framework that is expected to have a David Bacon, greater link for the Trust between Activity and Income. There is Director of BAF-13 a risk that the Trust’s data completeness, and capturing and Finance, 4 x 3 = 12 reporting processes are not robust, resulting in an inability to Systems and demonstrate levels of patient contact and activity that in turn Estates will result in a reduction in income secured by the Trust. Expenditure control risk: There is a risk that Productivity David Bacon, Improvements and Efficiency Schemes and other Director of BAF-14 transformation activities are insufficient to ensure that the Finance, 4 x 3 = 12 Trusts expenditure levels are managed to a level within the Systems and resources available. Estates

Author(s) of paper:

Name: Keith West Senior PMO Analyst

Date: 22 July 2021 Board 3rd August 2021 Attachment H1

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 Committee 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 Description Comments / Exceptions √ / x Quality Domain 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 Information in the report is as up to date as √ Date 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 The meaning of any data in the report is clearly √ Defined explained

Executive Director Sign-Off

This paper has been approved by the accountable executive director Antonia Robson, Associate √ who is satisfied that (i) the implications for risks, (ii) Director of Integrated Business quality/service/regulatory impacts and (iii) resource implications, Services have been considered.

Company Secretary Sign-Off (Board papers only)

This paper has been quality control checked and approved by the Associate Director, Integrated √ Business Services