INTEGRATED BOARD PERFORMANCE REPORT
SAFETY, QUALITY, PERFORMANCE,
WORKFORCE AND FINANCE
February 2012
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
1
INTEGRATED BOARD PERFORMANCE REPORT
1.
ABOUT THIS REPORT
This report is split into five sections, reflecting the integrated approach to performance
within Hertfordshire Community NHS Trust (HCT).
1.
2.
3.
4.
5.
Safety Standards
Quality Standards
Performance Standards
Workforce Standards
Finance Standards
Each section provides a table of the key indicators, with detailed commentary within
each section on those indicators that have been RAG rated Red, or where there has
been a significant change in performance in month. Also included in the commentary
is any change in practice or guidance that has been issued in relation to the indicator
in month. Trajectories against relevant indicators are highlighted in blue, starting with
the letter T.
The format of this report has been reviewed and the summary section has been
amended to include an overall dashboard summary, trends on the top KPIs and a
greater emphasis on analysis and actions being taken to address the issues for Board
review. The top KPIs are derived from the monthly Governance Risk Register
submission to the SHA which is in turn based on Monitor’s key indicators.
Appendix 1 details the triggers by contract type (e.g. national indicator, CQC, NHS
Hertfordshire Contract, External contracts etc).
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
2
1.
SUMMARY OF PERFORMANCE
The table below summarises the indicators performance for February 2012.
Feb-12
Indicators
Measured
Green
Am ber
Red
Safety
24
17 (71%)
2 (8%)
5 (21%)
Quality
3
3 (100%)
0
0
Perform ance
32
26 (82%)
3 (9%)
3 (9%)
Workforce
5
1 (20%)
2 (40%)
2 (40%)
Finance
7
6 (85%)
0
1 (15%)
Totals
71
53 (75%)
7 (10%)
11 (15%)
Areas of Progress

Healthcare associated infections (S2 and S5) – There were no MRSA cases
reported for the fourth consecutive month and no C.diff cases reported for the last
two months. The indicators remain under the ceiling for the year.

Safeguarding Vulnerable Adults SOVA (S26)
SOVA training achieved the 80% target in February and is on trajectory.

National Indicators – HCT achieved the target for the following National Indicators
in February - 18 weeks (P1), GUM (P2, P3) and MIU (P7). HCT are ahead of both
year to date and rolling 12 month targets for Retinal Screening.

Pledge 2 (P9) – The performance target was met with 100% for the third
consecutive month in February. There were 7,536 patients that were seen in
February with no avoidable breaches and 16 legitimate breaches.

VTE (Venous Thromboembolism) Assessments - Performance for February was
100% with all 236 patients having had their VTE assessments.

District Nursing response times (P11, P12) – Response times for 24hr urgent
responses and 48hr non-urgent responses are 100% compliant.

Community Hospitals DTC (P14) - HCT reported 3.6% NHS delays in February a
decrease of 1% from January. Year to date performance is 4.7%, (against a target
of 6%) and the indicator is marked green. The total delays were at 7.5% including
3.9% social delays. Social delays also decreased by 1.3% from last month.

Community matrons (P20) – Caseload numbers are achieving the target figure of
an average of 50 patients per WTE matron.

New birth visits (P25) – Following validation the target was achieved with 91% of
face to face new birth visits completed within 14 days in January.

Human Papilloma Virus (P31) – HCT are above the Trajectory for February with
87% receiving dose 1 and 85% receiving dose 2 immunisations.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
3

Community information data-set (CIDS) – HCT are able to report on 17 of the 19
data items identified by Monitor for data completeness monitoring and have
achieved a completion rate of 95% against the target of 50% (95% of patient
records had these data items recorded in the relevant field).

Finance – Financial Risk Rating (FRR) continues to be 3 (green) overall. Financial
position to month 11 (February 2012) is on plan. Forecast is marginally (£30k)
below planned £1m surplus. Performance against the Better Payment Policy code
to have paid invoices within 30 days is performing well at 94% against a target of
95%.
Areas for Board Review.

Number of Serious Incidents (SIs) reported in month (S9) – Seven serious
incidents were reported to the PCT in February; three incidents of category 3 or 4
pressure ulcers, two incidents concerning breaches of confidentiality and two
incidents reporting an outbreak of infection.
Analysis/Action
The outbreaks during this period were influenza A at Herts and Essex hospital and
Norovirus (diarrhoea and vomiting) at Langley House. The outbreak of influenza A
was complex and contributed to the death of three patients; a debriefing meeting is
planned for March to consider learning. All outbreaks were managed effectively
and safely; HCT were commended by both the PCT and the Health Protection
Agency for high standards of outbreak management.
Prevention of pressure ulcers was further promoted through new arrangements to
enable clinical staff to access essential pressure relieving equipment. Locally held
stocks will ensure patients at high risk receive equipment outside normal hours,
the assessment tool used by Hertfordshire Equipment Service (HES) is being
revised to strengthen the provision of equipment at the preventative stage of care,
and a clinical liaison post in HES to improve partnership working has been agreed.
One breach of confidentiality occurred within the MSK service and one within
Children’s Specialist services. There have now been six serious incidents within
Children’s Specialist services since August 2011. The recommendations and an
action plan identified through the review of all six incidents are being implemented
and an internal audit has been commissioned to provide additional assurance of
progress. Learning from these incidents is being discussed in team meetings in
each of the services.

Patient incidents (S14) – The number of patient-related incidents reported in
January was 422, significantly above the target range of 211 to 335.
Analysis/Action
The increase is due to increased reporting of pressure ulcers, patient accidents,
and incidents related to issues with patient transport. 62% (16 of 26) transport
incidents impacted on patients attending for podiatry. HCT is providing information
on incidents related to patient transport to support the PCT in their contract
management of the transport provider and to understand the impact on patients.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
4

Safeguarding Children (S21, S22) – Staff accessing safeguarding training at level
one and staff working directly with children level two training, remained below the
monthly target for the third consecutive month in February with 89% and 84%
respectively against targets of 90%.
Analysis/Action
Whilst uptake of level 1 Safeguarding children training in month is below the 90%
threshold at 89%, the average uptake across the year is 91%. Uptake of level 2
safeguarding children training has increased by 4% (80% to 84%) representing an
average uptake of 87%. There have been no incidents which would indicate staff
who work with children have not received training appropriate to their role. The
following actions are in place:o
o
o
.
Manual reconciliation of uptake and staff to ensure staff are recorded in the
correct cohort; this will ensure the information reported is valid.
A training programme is in place, including both single and multi-agency
training, which is delivered across Hertfordshire using a flexible model.
Staff are monitored through supervision to ensure they have met their
required training needs.
 Community Matrons - In East & North Herts Community Matrons recorded 7
patients on their caseload with a non-elective (NEL) hospital admission for a
related condition from a total caseload of 625 (1.1%). In the West Community
Matrons recorded one patient on their caseload with a NEL hospital admission for
a related condition from a total caseload of 530 (0.2%). Personal health plans are
being offered to every patient on Matron Caseloads, although there is not currently
a reporting method on SystmOne to record completion of personal health plans.
There are plans for next year to record these on SystmOne when Read coding is
available.
Analysis/Action
Work to determine a baseline level of expected NEL admissions for patients on a
Community Matrons caseload and comparison to reported levels is planned for the
next few months.

Community Hospitals (P16a, P16b) – HCT are achieving the average length of
stay stroke target (42 Days) with an average of 40.1 days, an increase of two days
from the previous month. The non-stroke length of stay has increased by 2.7 days
from last month and is still not achieving the target of 21 days with performance at
27 days. HCT is achieving the ALOS for all patients on the rehabilitation pathway;
however some patients remain outside this pathway for a period of their care e.g.
when medically unwell, non-weight bearing and delayed transfers of care. Overall
the length of stay is 31 days for February.

Integrated community services - Number of patients transferred from acute
hospital/AAU in West Herts (P18)
The number of patients admitted to the integrated community services caseload in
the West from an acute hospital/ AAU is below the cumulative performance for last
year.
Analysis/Action
Performance levels continue to increase and 43 patients were transferred in from
acute hospitals in February, which is above the monthly average levels of 2010/11.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
5

Health Visiting (P26) - In February 86% of children who transferred from out of
area had a face to face contact with a health visitor within five days, (37 of 43
Children). The target of 98% has not been achieved for February.
Analysis/Action
The percentage of children with a face to face contact increased to 86% in
February. Of the six children seen over five working days, two of the visits were
delayed due to the Health Visitor being unable to make contact with the family
through any form of correspondence despite numerous attempts. The target is
being reinforced at team meetings and managers are scrutinising the return
closely. The clinical pathway has been changed with a letter inviting the client to
make contact with the Health Visiting team sent first which has been found
successful with those where English is not their first language; this is then followed
up with phone contact to make an appointment within five days.

Vacancy rates Health Visitor caseload (P27, P28) – The Health Visitor vacancy
rate decreased to 5.5% for February and remains within the 8% vacancy
threshold.
The average caseload is 635 against a target of 500 (November
Figures).
Analysis/Action
The recruitment of trainee Health Visitors will not have an effect upon caseload
numbers until later in their training when caseloads start to be assigned to them.
An action plan has been enacted for further recruitment and to focus posts in the
highest caseload affected areas. Three ‘Return to Practice’ Health Visitors started
the University module to refresh their practice and will apply for posts in June 2012
following their course. Recruitment to vacancies is underway with interviews taking
place in March.

Chlamydia Screening (P30) – HCT completed 95 family planning clinic screens in
February. HCT are currently 17 screens below trajectory and marked amber.
Analysis/Action
Additional screens held at young person’s clinics have yet to be verified by the
HPA and upon inclusion in the year-end total are expected to bring us back on
target.

Workforce W4, W6, W9 and W10
Mandatory fire training remains below target levels at 67%. The Appraisal rate has
increased slightly to 81%, however is still below the target of 90%. The turnover
rate has increased for the first time in five months to 12.8% and is still above the
threshold of 12%. Absence rates continue to decrease to a new low of 3.9%
against a threshold of 3.5%.
Analysis/Action
Both the turnover and absence rates have shown a steady improvement over the
last year. Recruitment activity is now reducing as vacancies are being filled and
the improved staffing levels are contributing towards the downward trends. Work
is underway to gain more information into the reasons why staff choose to leave
the organisation, to help us manage our retention rates. Absence particularly in the
inpatient units continues to be closely monitored.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
6

Finance
Estates expenditure is a continuing pressure. The Income and Expenditure Margin
within the finance risk rating has reduced to a 2 and has marginally dropped below
the 1% trigger point for scoring a 3.
Analysis/Action
Expenditure to year end is being monitored closely. Individual service positions are
reviewed at the monthly performance meetings with each Business Unit. Debtors
with NHS Hertfordshire have been settled and Director of Finance is meeting with
Barnet and Chase Farm Hospital Trust concerning its level of aged debt. Action
taken in recent months to reduce estates expenditure is showing a reducing run
rate per month
Income and Expenditure Surplus component of the Financial Risk Ratings has
altered due to the Trust’s anticipated total income from the PCT increasing by £4m
for depreciation and capital charges for the whole year. Income has increased
whilst forecast surplus remains constant. I&E margin has consequently dropped to
below the 1% trigger point.
Top KPIs
The top KPIs are derived from the monthly Governance Risk Register (GRR)
submission to the SHA which is in turn based on Monitor’s key indicators. The chart
below shows year to date performance against year to date targets. (This differs
slightly from the GRR that measures a monthly snapshot of performance against
monthly indicators)
The chart below shows the historical YTD performance of the top indicators.
Ref
Area
1
Safety
Clostridium Difficile
2
Safety
MRSA
3
Safety
New birth visits
4
Safety
5
Quality
6
Quality
7
Quality
Patient
8
Experience
Patient
9
Experience
Patient
10
Experience
11 Effectiveness
Indicator
Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Trend
↔
↔
↔
Urgent District Nurse response within
24 hours
Delayed Transfers of Care (NHS
delays only)
Minor Injuries Unit - Patients seen with
4 hours
NHS Litigation authority (NHSLA)
clinical negligence level
↔
GUM Access - within 48 hours
↔
Non-urgent District Nurse response
within 48 hours
↔
Financial Risk Rating
↔
Chlamydia Screening
↔
↔
12 Effectiveness HPV (Human Papillomavirus) Uptake
↔
↔
↔
Sean McKeever, Director of Finance
Andrew Chronias, Assistant Director, Performance and Information
20th March 2012
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
7
SAFETY STANDARDS
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
8
SAFETY STANDARDS SCORECARD (1 OF 2)
Current Performance
Ref
S1
Indicator
Contract ref
Excellent Infection Control Rates (objective 1)
Number of Avoidable MRSA
bacteraemia cases in year f or HCT
Exec
lead
2010/11
RAG YTD
performance
Status
Full year
target
YTD target
YTD
actual
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
DQ
5
G
4
4
2
1
0
0
0
0
0
1
0
0
0
0
T0
NHS Hertf ordshire
Contract
DQ
18
G
19
17
9
0
3
2
1
0
0
0
0
3
0
0
T2
NHS Hertf ordshire
Contract
DQ
March 2011
100%
G
Monthly
100%
Monthly
100%
100%
100%
99%
100%
100%
100%
100%
99%
100%
100%
100%
100%
T100%
S3
CQC
Compliance w ith Hand hygiene in all
NHS Hertf ordshire
Community Hospitals w ill be > 95%
Contract
DQ
99%
G
95%
95%
99%
100%
99%
99%
T95%
S4
Compliance w ith Commode Audit in
all Community Hospitals w ill be >
95%
CQC
DQ
98%
G
95%
95%
97%
100%
97%
95%
T95%
S6
% of patients observing staf f
w ashing hands
NHS Hertf ordshire
Contract
DQ
96%
G
90%
90%
97%
S7
Compliance w ith Essential steps
urinary catheter care and ongoing
care w ill be > 95% in all community
hospitals
CQC
DQ
99%
G
95%
95%
100%
DQ
Policy changed
Q3 2010
For
inf ormation
For
inf ormation
71
7
3
6
8
10
3
10
8
16
11
7
S11
The percentage of SIs that have 7- NHS Hertf ordshire
day report completed w ithin 7 days. Contract
Reported monthly
DQ
March 2011
100%
G
Monthly
75%
Monthly
75%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
S9a
The percentage of SIs that have 45- NHS Hertf ordshire
day RCA and action plans
Contract
completed and submitted to PCT
w ithin 45 days. Reported monthly
DQ
March 2011
25%
G
Monthly
75%
Monthly
75%
Monthly
100%
50%
2/4 reports
n/a as no
reports due
this month
100%
100%
100%
100%
100%
100%
100%
100%
100%
T80%
DQ
March 2011
16
For
inf ormation
For
inf ormation
48
23
21
26
31
43
46
52
42
48
53
50
0
0
0
0
0
0
0
0
0
0
0
S2
S5
C.dif f cases occurring > 72 hours
f ollow ing admission into HCT bed
based f acilities (i.e. acquired in our
f acility)
% of patients screened f or MRSA
w hen admitted directly f rom
community (excluding respite
patients). Reported monthly.
NHS Hertf ordshire
Contract
100%
98%
100%
96%
100%
100%
98%
96%
96%
100%
92%
94%
96%
100%
T100
T99%
Excellent Patient Safety (objective 1)
S9
S10
S12
The number of Serious Incidents
reported in month to the PCT against
the PCT SI policy
The number of SI's that remain open NHS Hertf ordshire
to HCT
Contract
CQC
Number of never events
NHS Hertf ordshire
Contract
Number of clinical negligence claims
received in quarter
Number of clinical negligence claims
S13b
closed in the quarter
Number of patient-related incidents
reported in month
S13
Patient Experience
Data Set
Patient Experience
Data Set
CQC
S14
S15
S16
S17
S18
Number of patient-related incidents
reported in quarter that resulted in
severe harm or death
Number of incidents in quarter
w hich allege abuse of patients
w ithin our care w hich have been
reported via incident reporting (and
to police and/or ACS or CSF)
CQC
% of incidents reported to NRLS
w ithin agreed timescale of 30 days
That all non medicine CAS alerts are
managed w ithin the agreed
timescales starting f rom time
received f rom PCT (reported
quarterly)
NHS Hertf ordshire
Contract
NHS Hertf ordshire
Contract
DQ
0
G
0
0
0
DQ
3/0
R
0
0
2
0
0
2
T0
DQ
3/0
R
0
0
1
0
0
1
T0
Monthly
Monthly
incidents
incidents
reported
reported
betw een 211- betw een 211334
334
Average
337
per month
T0
DQ
Average 2010/11
220
R
DQ
0
G
0
0
0
0
0
0
T0
DQ
4
R
0
0
1
0
1
0
T0
DQ
100%
G
100%
100%
100%
DQ
100%
G
98%
98%
100%
272
313
356
300
334
336
308
363
374
331
422
T211-324
CQC
100%
100%
100%
100%
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
9
Healthcare Associated Infections (Indicator S1 and S2) – There were no MRSA cases reported for the fourth consecutive month and no
C.diff cases reported for the last two months. The indicators remain under the ceiling for the year.
MRSA admission screening (S5) – All patients were screened when admitted directly to our community hospitals in February.
Serious Incidents (S9) – Seven serious incidents were reported to the PCT in February; three incidents of category 3 or 4 pressure ulcers,
two incidents concerning breaches of confidentiality and two incidents reporting an outbreak of infection. All seven day and 45 days reports
were completed on time. There are 50 serious incidents that remain open.
Patient related incidents reported in month (S14) - The number of patient-related incidents reported in January was 422, significantly
above the target range of 211 to 335. The increase is due to increased reporting of pressure ulcers, patient accidents, and incidents related
to issues with patient transport. 62% (16 of 26) transport incidents impacted on patients attending for podiatry; HCT is providing information
on incidents related to patient transport to support the PCT in their contract management of the transport provider and to understand the
impact on patients.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
10
Falls analysis
In 2011/12 HCT aims to reduce falls in bed-based units by 20% compared to
2010/11. This reduction will be achieved if a total of 56 or less falls are reported
per month, or if the rate of falls per 1000 occupied bed days per month is no
higher than 8.1. The number of falls decreased in February to 53 falls (8.9 falls
per 1000 occupied bed days) compared to 57 in January (following Datix
validation), with no patients experiencing severe harm as a consequence of
their fall.
This represents a reduction of 23.3% in patient falls compared to 2010/11.
Additional visual prompts on bedroom doors are being used to highlight to all
staff those patients who are at risk of falling in bed-based units where the
layout of the ward hinders patient observation. The benefit of more sensor
mats on chairs in addition to the sensor mats in use on beds is to be
determined following evaluation of a pilot in two bed-based units during March
and April.
Pressure Ulcer Analysis – (reported a month in arrears)
Of the 186 pressure ulcers incident reported during January, 3 (1.6%) were
identified as serious (category 3 or 4) and acquired in HCT care; these are
being investigated through the Serious Incident process.
HCT Pressure Ulcer 2011-12 totals by month
200
180
21
19
160
Prevention of pressure ulcers was further promoted through new arrangements
to enable clinical staff to access essential pressure relieving equipment.
Locally held stocks will ensure patients at high risk receive equipment outside
normal hours, the assessment tool used by Hertfordshire Equipment Service
(HES) is being revised to strengthen the provision of equipment at the
preventative stage of care, and a clinical liaison post in HES to improve
partnership working has been agreed.
7
16
140
48
14
18
120
100
10
21
52
19
47
40
50
20
Cat 4
Cat 3
35
52
46
41
39
Cat 2
80
60
108
93
40
73
95
87
72
70
105
117
72
20
0
Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
11
SAFETY STANDARDS SCORECARD (2 OF 2)
Current Performance
Ref
S19
S20
Indicator
Contract ref
Medicines Management Objective 2
Exec
lead
2010/11
performance
MD
RAG
Status
Full year
target
YTD target
YTD
actual
207
For
information
For
information
MD
9
For
information
DQ
100%
A
DQ
87%
DQ
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
199
accumulative
20
14
24
17
16
22
19
16
25
12
14
For
information
0
0
0
0
0
0
0
0
0
0
0
0
90%
90%
89%
93%
99%
89%
96%
90%
93%
88%
90%
89%
87%
89%
T90
A
90%
90%
84%
81%
94%
88%
89%
84%
99%
92%
90%
80%
80%
84%
T90
96%
G
80%
80%
95%
98%
DQ
88%
G
80%
80%
81%
88%
NHS Hertfordshire
Contract
DQ
92%
G
80%
80%
80%
66%
NHS Hertfordshire
Contract
DQ
84%
R
80%
80%
Quarterly
54%
G
N/A
Level 1
Level 1
Number of medicine adverse
CQC
incidents reported
Number of relevant medicine safety CQC
alerts not managed appropriately or
w ithin timescales
Mar-12
Safeguarding Children
Staff accessing safeguarding
training level 1
All staff w orking directly w ith
S22 children have received level 2
training.
Eligible HV & School Nursing staff
S23a w orking w ith children have clinical
supervision (3 times a year)
Eligible AHP Nursing staff w orking
S23b w ith children have clinical
supervision (2 times a year)
S21
CQC
CQC
CQC
100%
95%
CQC
92%
81%
Safeguarding Adults
S26
S27
The percentage of staff w ho have
received level 1 SVA training
% of relevant staff w ho have
undertaken MCA training (Annual
audit)
66%
65%
51%
72%
70%
69%
69%
74%
55%
76%
80%
80%
54%
T86%
T80%
Clinical negligence
S28
NHS Litigation authority (NHSLA)
clinical negligence level
DQ
Level 0
Level 0
Level 1
Level 1
Level 1
Level 1
T level 1
Medicines Management (S19) - Of the 22 medication incidents reported this month 14 (64%) relate to HCT provided care. The two most
frequently reported medication incidents continue to relate to the administration of anticoagulants (23%, 5 of 22) and insulin (14%, 3 of 22). 7
(32%) incidents this month related to the handling, storage or administration of controlled drugs. No patient harm has been reported.
Safeguarding Children (S21, S22) - Whilst uptake of level 1 Safeguarding children training in month is below the 90% threshold at 89%, the
average uptake across the year is 91%. Uptake of level 2 safeguarding children training has increased by 4% (80% to 84%) representing an
average uptake of 87%. There have been no incidents which would indicate staff who work with children have not received training
appropriate to their role. The following actions are in place:o
o
o
Manual reconciliation of uptake and staff to ensure staff are recorded in the correct cohort; this will ensure the information
reported is valid.
A training programme is in place, including both single and multi-agency training, which is delivered across Hertfordshire
using a flexible model.
Staff are monitored through supervision to ensure they have met their required training needs.
Safeguarding of Vulnerable Adults (SOVA) (S26) – SOVA training achieved the 80% target in February continuing the steady rise from
previous months and is now on trajectory.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
12
QUALITY STANDARDS
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
13
QUALITY STANDARDS SCORECARD
Current Performance
Ref
Indicator
Contract ref
Exec
lead
2010/11
performance
RAG YTD
Status
Full year
target
YTD target
YTD actual
DQ
0
G
<5%
<5%
(2) / 4%
DQ
March 2011
73%
G
80%
80%
88%
71%
69%
92%
87%
94%
94%
89%
88%
For information
For information
172
accumulative
17
13
16
21
15
17
17
For information
For information
164
accumulative
14
13
12
23
17
18
374
accumulative
41
27
33
25
23
45
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
100%
88%
100%
T80%
14
9
15
18
18
16
13
8
12
52
44
17
30
37
Positive User Engagement (objective 1)
Q1
Number of complaints
referred to the ombudsman
in quarter from total
complaints
Q2
Proportion of complaints
resolved w ithin timescale
agreed w ith complainant
(reported monthly)
Q2a
Number of complaints
received in month
DQ
Q2b
Number of complaints
closed in month
DQ
Q3
NHS
Hertfordshire
Contract
Annual Total 192
Ave per month
16
Annual Total 168
Ave per month
14
Number of PALS enquiries
Patient
(for HCT services)
Experience Data
reported monthly
Set
DQ
Annual Total 445
Ave per month
37
Triggers to be
established
follow ing baseline
data collection
Patient
Experience Data
Set
DQ
Annual Total 449
Ave per month
37
Triggers to be
established
follow ing baseline
data collection
DQ
0
Q4
Number of compliments
received in quarter
Q5
EMSA breaches reported in
quarter
Q6
% of patients reporting
NHS
positively about cleanliness
Hertfordshire
of environment in a
Contract
community hospital
DQ
99%
Triggers to be
established
follow ing baseline
data collection
Q7
Number of in patient survey
Patient
returns received and %
Experience Data
rating care received as
Set
good or better than good
DQ
Annual Total 455
Ave per month
38 returns
97%
Triggers to be
established
follow ing baseline
data collection
NHS
Hertfordshire
Contract
G
0
Triggers to be
established
follow ing
baseline data
collection
Triggers to be
established
follow ing
baseline data
collection
0
Triggers to be
established
follow ing
baseline data
collection
Triggers to be
established
follow ing
baseline data
collection
(2) / 4%
0
0
1028
accumulative
182
502
344
0
0
0
0
97%
100%
84%
100%
100%
100%
97%
100%
100%
98%
95%
96%
660 returns
98%
47 returns
100%
61 returns
98%
67 returns
100%
60 returns
99%
40 returns
100%
58 returns
98%
72 returns
99%
60 returns
97%
65 returns
96%
74 returns
96%
56 returns
98%
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
14
Complaints – 18 complaints were received in February this is consistent
with previous monthly figures.
A total of 12 complaints were closed in February, all were resolved within
the agreed timescale with the complainant, compared to 88% in January.
Services receiving the majority of complaints in February 2012 were:



Community Nursing, 4 (22%)
Community Hospitals (West), 3 (17%)
Diabetes, 2 (11%)
3 of the 4 complaints relating to Community Nursing are regarding services
provided in the East and North.
In-patient Surveys (Q6, Q7)
56 inpatient surveys were received for February a decrease of 18 from January. Patients continue to report positively about the cleanliness of
the environment in the community hospitals, with no patients reporting the environment was not very clean.
54 (96%) patients reported very clean
2 (4%) patients reported fairly clean
Overall number of patients reporting care received as good or better than good was 98%.
23 (41%) reported excellent
24 (43%) reported very good
8 (14%) reported good
1 (2%) reported fair
Patients reporting observation of staff washing hands achieved 96% in February.
PALS
HCT received 37 PALS enquiries during February related to HCT services. The majority of enquiries were related to appointment dates, and
delays in receiving appointments. PALS have seen an increase this month of enquires relating to policy and commercial decisions of HCT, for
example the relocation of a baby clinic in St Albans.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
15
PERFORMANCE STANDARDS
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
16
PERFORMANCE INDICATORS (1 of 3)
Current Performance
Indicator
Contract ref
National Indicators (objective 1)
Exec
lead
2010/11
performance
RAG YTD
Status
Full year
target
DO
100.0%
G
95%
95%
DO
100.0%
G
98%
DO
99.9%
G
DO
98%
DO
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
99.9%
100.0%
100.0%
100.0%
99.9%
100.0%
99.8%
99.9%
100.0%
100.0%
100.0%
99.9%
T100%
98%
99.4%
100.0%
100.0%
99.5%
99.6%
99.4%
98.9%
98.7%
99.3%
99.2%
100.0%
99.0%
T100%
85%
85%
99.4%
100.0%
100.0%
99.5%
99.6%
99.4%
98.9%
98.7%
99.3%
99.2%
100.0%
98.9%
T100%
G
95%
95%
97%
99%
3 month
screens
99%
3 month
screens
95%
97%
100.0%
G
100%
94.2%
100.0%
8.5%
21.7%
35.8%
49.6%
60.7%
72.0%
84.2%
96.5%
100.0%
100.0%
100.0%
T100%
DO
81.9%
G
80%
81.0%
82.3%
4.9%
12.8%
21.8%
31.5%
39.8%
47.5%
54.9%
62.1%
67.4%
75.2%
82.3%
T81%
DO
100.0%
G
95%
95.0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
18 Weeks - non-admitted patients - %
of patients being treated w ithin 18 NHS Hertfordshire
w eeks for HCT non consultant led
Contract
services
DO
99.6%
G
98%
98%
99.9%
99.6%
99.8%
99.9%
99.9%
99.9%
99.8%
99.8%
99.9%
100%
100%
100%
T100%
Urgent District Nurse response w ithin NHS Hertfordshire
24 hours
Contract
DO
100%
G
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
DO
95%
G
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
18 Weeks - non-admitted patients - %
NHS Hertfordshire
of patients being treated w ithin 18
Contract
w eeks for HCT consultant led
National Indicator
services
NHS Hertfordshire
GUM - percentage of patients offered
Contract
w ithin 48 hours
National Indicator
NHS Hertfordshire
GUM - percentage of patients seen
Contract
w ithin 48 hours
National Indicator
West Herts New born Hearing
NHS Hertfordshire
Screening - % of babies screening
Contract
w ithin 4 w eeks of birth
National Indicator
Retinal screening - % of diabetic
NHS Hertfordshire
cohort that has been offered an
Contract
annual screen
National Indicator
Retinal screening - % of diabetic
NHS Hertfordshire
cohort that has been screened in
Contract
2011/2012
National Indicator
Minor Injuries Unit - Herts and Essex NHS Hertfordshire
hospital - patients to be seen treated
Contract
and discharged w ith 4 hours
National Indicator
YTD target YTD actual
98%
96%
T95%
SHA Indicators (objective 1)
Non urgent district nurse response
w ithin 48 hours
NHS Hertfordshire
Contract
Community information data set (CIDS) – HCT are able to report on 17 of the 19 data items identified by Monitor for data completeness
monitoring and have achieved a completion rate of 95% against the target of 50% (95% of patient records had these data items recorded in
the relevant field).
National Indicators – HCT achieved the national indicators for 18 weeks consultant led services, GUM and 48hr response time for Minor
injuries unit.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
17
Diabetic Retinal screening (DRSS) (P5, P6) – The service achieved their targets for February. In February 2,201 patients were offered a
screen and 1,381 patients were actually screened. The cohort is currently 19,033 patients and the service have achieved the yearly targets for
both measures, with patients offered and screened achieving the full target ahead of trajectory.
The DRSS 12 month rolling figures for February 2010 to February 2011 are 136% offered and 90% screened and both are above target. An
update for Q4 will be provided in the March report.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
18
New-born hearing screening - % of babies screened within 4 weeks (P7) – The official figures from the National Hearing Screening
Programme for quarter two are confirmed as 98% and achieving the 95% target. Provisional figures for quarter 3 are 96%; these will be
confirmed at the end of quarter four.
Pledge 2 (P9) – The performance target was met with 100% for the third consecutive month in February. There were 7,536 patients that
were seen in February with no avoidable breaches and 16 legitimate breaches.
Urgent District Nurse response within 24 hours/Non urgent district nurse response within 48 hours (P11, P12) – February Audit
District Nursing
All Urgent referrals for district
nursing should be seen within
24 hours (where clinically
appropriate)
100%
Number of urgent
referrals received
103
Clinically appropriate to
be seen within 24 hours Clinically appropriate to be
and seen within 24 hours seen outside of 24 hours
86
17
District Nursing
Non urgent referrals for
district nursing should be seen
Clinically appropriate to
within 48 hours (where
Number of non urgent be seen within 48 hours Clinically appropriate to be
clinically appropriate)
referrals received and seen within 48 hours seen outside of 48 hours
100%
105
40
65
For Urgent referrals seen within 24 hours – The data confirms that over the sample period, a total of 103 urgent referrals were received
and 86 clinically appropriate patients were seen within 24 hours. There were 17 patients who were not clinically appropriate and not seen
within 24 hours; this indicates a 100% response.
Non Urgent referrals seen within 48 hours - The data confirms that over the sample period, a total of 105 non urgent referrals were
received and 40 clinically appropriate patients were seen with 48 hours. There were 65 Patients who were not seen within 48 hours as they
were assessed as not clinically appropriate, this indicates a 100% response. These indicators will continue to be recorded by monthly audit.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
19
PERFORMANCE INDICATORS (2 of 3)
Indicator
Contract ref
Community Hospitals (objective 1)
Exec
lead
2010/11
performance
Current Performance
RAG YTD
Full year
Status
target
YTD target
YTD actual
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
11.3 per
w eek
average
T10
Community Hospitals - Number of
patients per w eek w hose discharge
or transfer from community hospital
is delayed due to NHS delay
NHS Hertfordshire
Contract
DO
15.4 per w eek
average for April
to Mar
A
10 across Herts
per w eek
10 across Herts
per w eek
Community Hospitals - % of bed days
lost due to delayed transfers of care
NHS Hertfordshire
Contract
DO
Average
Total 9.4%
(NHS 5.2%
HCS 4.2%
Both 0.0%)
G
6%
for NHS delays
6%
for NHS delays
Total 8.7%
(NHS 4.7%
HCS 3.9%
Both 0.1%)
Total 10.5%
(NHS 5.7%
HCS 4.6%
Both 0.2%)
Total 7.6%
(NHS 4.3%
HCS 3.2%
Both 0.1%)
Total 8.3%
(NHS 6.1%
HCS 2.2%
Both 0.0%)
Total 10.2%
(NHS 6.4%
HCS 3.8%
Both 0.0%)
Total 9.9%
(NHS 4.9%
HCS 4.9%
Both 0.1%)
Total 8.3%
(NHS 3.9%
HCS 4.2%
Both 0..2%)
Total 8.7%
(NHS 5.2%
HCS 3.4%
Both 0..1%)
Total 9.0%
(NHS 4.7%
HCS 4.1%
Both 0..2%)
Total 6.3%
(NHS 2.7%
HCS 3.5%
Both 0.1%)
Total 9.8%
(NHS 4.6%
HCS 5.2%
Both 0.0%)
Total 7.5%
(NHS 3.6%
HCS 3.9%
Both 0.0%)
DO
89.6%
G
85.4%
86.5%
80.8%
90.5%
88.5%
Community Hospitals - average
occupancy
Community Hospitals - Average
length of stay in HCT community
hospital - TOTAL
Community Hospitals - Average
length of stay in HCT community
hospital - Stroke
Community Hospitals - Average
length of stay in HCT community
hospital - Non Stroke
Community Hospitals - Readmission
rates w ithin 28 days
12.6 per w eek 13.5 per w eek 12.3 per w eek 16.8 per w eek 18.5 per w eek 12.8 per w eek 8.8 per w eek 12.4 per w eek 12.3 per w eek 6.5 per w eek 10.6 per w eek
average
average
average
average
average
average
average
average
average
average
average
88%
88%
84.5%
88.0%
85.0%
81.0%
82.2%
81.5%
83.6%
Non stroke 21
days, Stroke 42
days
Non stroke 21
days, Stroke 42
days
33.9 days
35.6 days
38 days
34.6 days
34.7 days
31.1 days
29.4 days
G
42 days
42 days
Average
38..0 days
36.4 days
40.3 days
35.5 days
41.9 days
34.8 days
39.2 days
38.4 days
40.1 days
R
21 days
21 days
Average
28.6 days
30.8 days
28.7 days
27.2 days
27.3 days
29.5 days
28.2 days
27.0 days
29.7 days
1.2%
G
<2%
<2%
0.8%
1.0%
1.0%
0.7%
0.8%
1.0%
0.5%
0.5%
0.8%
0.7%
1.1%
0.5%
DO
Annual Total 399
Ave per month 33
A
410
375
302
accumulative
27 Average per
month
22
12
19
38
46
22
12
18
33
37
43
G
50
50
52.4
50.4
53.9
54.8
55.5
54.8
54.1
50.0
51.5
50.8
50.0
51.6
Triggers to be
Triggers to be
1019
established
established
accumulative
follow ing baseline follow ing baseline 92 Average per
data collection
data collection
month
83
85
108
88
80
84
102
93
92
105
99
NHS Hertfordshire
Contract
DO
NHS Hertfordshire
Contract
DO
NHS Hertfordshire
Contract
DO
NHS Hertfordshire
Contract
DO
NHS Hertfordshire
Contract
32.3 days
T88%
T<2%
Intermediate care (objective 1)
Intermediate care - Number of
patients transferred from acute
hospital/AAU in West Herts
Community Matrons (objective 1)
Community Matrons - Number of
patients per community matrons is 50
per fully qualified WTE
NHS Hertfordshire
Contract
DO
50.6
Community Matrons - Number of
patients w ho have been prevented
from admission/emergency
attendance
NHS Hertfordshire
Contract
DO
Annual 1419
Ave Month 118
T50
Long Term Conditions (objective 1)
Diabetes -Number of patients
attending structured education
sessions
NHS Hertfordshire
Contract
DO
Annual Total 600
Ave per month 50
Triggers to be
Triggers to be
established
established
follow ing baseline follow ing baseline
data collection
data collection
492
accumulative
44 per month
Average
8
44
54
45
20
38
76
60
20
71
56
Diabetes - Number of patients
completing a personal health plan
follow ing a patient education
programme
NHS Hertfordshire
Contract
DO
Annual Total 600
Ave per month 50
Triggers to be
Triggers to be
established
established
follow ing baseline follow ing baseline
data collection
data collection
492
accumulative
44 per month
Average
8
44
54
45
20
38
76
60
20
71
56
Respiratory -Number of patients
completing structured group
education sessions
NHS Hertfordshire
Contract
DO
Annual Total 295
Ave per month
25
Triggers to be
Triggers to be
established
established
follow ing baseline follow ing baseline
data collection
data collection
122
accumulative
12 per month
Average
38
14
7
12
7
0
23
0
15
6
8
Respiratory -Number of patients
completing a personal health plan
follow ing a patient education
programme
NHS Hertfordshire
Contract
DO
Annual Total 295
Ave per month 25
Triggers to be
Triggers to be
established
established
follow ing baseline follow ing baseline
data collection
data collection
122
accumulative
12 per month
Average
38
14
7
12
7
0
23
0
15
6
8
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
20
Community Hospitals
HCT are achieving the average length of stay stroke target (42 Days) with an average of 40.1 days, an increase of two days from the previous
month. The non-stroke length of stay has increased by 2.7 days from last month and is not achieving the target of 21 days with performance
at 27 days. HCT is achieving the ALOS for all patients on the rehabilitation pathway; however some patients remain outside this pathway for
a period of their care e.g. when medically unwell, non-weight bearing and delayed transfers of care. Overall the length of stay is 31 days for
February.
There were 29 patients discharged over 50 days and this includes four patients discharged over 100 days. The maximum discharge was 120
days at St Albans community hospital, a patient with who had become unwell during the rehab pathway.
Delayed Transfer of Care – HCT reported 3.6% NHS delays in February a decrease of 1% from January. Year to date performance is 4.7%
(against a target of 6%) and the indicator is marked green. The total delays were at 7.5% including 3.9% social delays. Social delays also
decreased by 1.3% from last month.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
21
NHS DTCs
The chart below shows the main reasons for NHS delays in February. NHS delays decreased in February with the biggest decreases in
Patient/Family choice, Housing and awaiting completion of assessments.
VTE (Venous Thromboembolism) Assessments - Performance for February was 100% with all 236 patients having had their VTE
assessments.
Community matrons – Caseload numbers are achieving the target figure of on average 50 patients per WTE matron. There were 1019
patient events reported as having avoided an acute hospital admission so far this year. Personal health plans are being offered to every
patient on Matron Caseloads at present, although there currently isn’t a reporting method on SystmOne available to record completion of
personal health plans. There are plans for next year to record these on SystmOne when Read coding is available.
% of patients who are on the Community Matron caseloads who have an unplanned admission to hospital per month
In East & North Community Matrons recorded 7 patients on their caseload with a non-elective (NEL) hospital admission for a related condition
from a total caseload of 625 (1.1%). In the West Community Matrons recorded one patient on their caseload with a NEL hospital admission
for a related condition from a total caseload of 530 (0.2%). Work to determine a baseline level of expected NEL admissions for patients on a
Community Matrons caseload and comparison to reported levels is planned for the next few months.
Diabetes Education – During February there were 56 attendees. 8 attended the DAFNE classes and 48 attended the DESMOND classes.
The monthly average is 44 attendees per month compared to 50 attendees last year.
Integrated community services - Number of patients transferred from acute hospital/AAU in West Herts (P18)
The number of patients admitted to the integrated community services caseload in the West from an acute hospital/ AAU is below the
performance for last year. Performance levels continue to increase and 43 patients were transferred in from acute hospitals in February
which is above the average levels for 2010/11.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
22
PERFORMANCE INDICATORS (3 of 3)
Current Performance
RAG YTD
Full year
Status
target
YTD target
Exec
lead
2010/11
performance
Health Visiting - % of babies w ho
NHS Hertfordshire
have had a face to face contact w ith
Contract
health visitor w ithin 14 days of birth
DO
Not collected
G
90%
90%
91%
Average
Health Visiting - % of children under
1 w ho transfer into area from other
counties have face to face contact
w ith Health Visiting service w ithin 5
days of notification
NHS Hertfordshire
Contract
DO
Not collected
R
98%
98%
64%
Average
Health Visiting - %vacancy rates in
Health visiting service
NHS Hertfordshire
Contract
DO
6.9%
G
8%
8%
5.6%
5.8%
5.1%
5.5%
Health Visiting - average caseload
size
NHS Hertfordshire
Contract
DO
520
R
<500
<500
635
528
528
525
DO
Reception Year
93.6%
Year 6
89.6%
G
87%
48%
51%
Indicator
Contract ref
Health Visiting and School Nursing (objective 1)
School Nursing - % of children w ho
have had height and w eight
monitored in reception and year 6
NHS Hertfordshire
Contract
YTD actual
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
92%
91%
91%
91%
92.0%
90.0%
92.0%
91.0%
83%
Provisional
T90%
45%
51%
56%
57%
78%
81%
80%
T98%
7.0%
7.8%
3.9%
3.4%
5.2%
6.2%
6.4%
5.5%
T4%
525
525
525
525
635
635
635
635
T510
5%
15%
24%
37%
51%
T63%
102
90
101
105
95
Year 8
73% dose 1
3% dose 2
0% dose 3
Year 8
87% dose 1
69% dose 2
0% dose 3
Year 8
87% dose 1
79% dose 2
0% dose 3
Year 8
87% dose 1
85% dose 2
0% dose 3
Other Children's Services objective 1)
Chlamydia screening - assist PCT in
reaching its target by screening
patients in family planning service
NHS Hertfordshire
Contract
DO
2259
90% of Target
A
1420
1301
1284
HPV - % of eligible children
immunised
NHS Hertfordshire
Contract
DO
Year 8
87% dose 1
87% dose 2
85% dose 3
G
Year 8
85% dose 1
85% dose 2
85% dose 3
Year 8
T75% dose 1
T65% dose 2
T0% dose 3
Year 8
87% dose 1
85% dose 2
0% dose 3
Children's Continuing Care - 95% of
allocated hours are delivered
NHS Hertfordshire
Contract
KT
94%
G
95%
95%
96%
97%
96%
94%
95%
95%
98%
93%
99%
97%
92%
95%
T95%
Children's inpatient unit - Nascot
Law n - Bed occupancy
NHS Hertfordshire
Contract
KT
88.1%
G
90%
>85%
86.3%
87.2%
81.4%
87.1%
83.9%
85.3%
82.0%
94.0%
93.6%
91.3%
84.6%
77.3%
T85%
Children's Community Nursing number of training sessions offered
in year to groups of carers to
support Aiming High agenda
NHS Hertfordshire
Contract
DO
24
G
24
20
20
2
2
2
3
0
2
3
2
2
2
2
T2
Meeting
specification
Meeting
specification
Meeting
specification
Meeting
specification
Meeting
specification
Meeting
specification
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
83
107
130
145
134
192
Year 8
Year 8
87% dose 1 T85% dose 1
85% dose 2 T75% dose 2
0% dose 3 T20% dose 3
Non PCT contracts (objective 2 and 4)
Are HCT meeting the specification for
Sure Start (Saw bridgew orth)
Are HCT meeting the specification for
Sure Start (St Albans)
Meeting
specification
Meeting
specification
CSF
DO
G
CSF
DO
Are HCT meeting the specification for
CSF Speech and Language Therapy
CSF
DO
Meeting
specification
G
Meeting
specification
Meeting
specification
Meeting
specification
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Are HCT meeting the specification for
Step 2
CSF
DO
Meeting
specification
G
Meeting
specification
Meeting
specification
Meeting
specification
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
G
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
23
Health Visiting
New birth visits within 14 days of birth – validation of January performance (P25)
Following validation the final January figure is 91% (Note: The provisional January figure reported last month was 82%). There were 1,149
new births visits in January of which 973 were seen within 14 days, of the 176 not seen within 14 days, 80 were for reasons not in the control
of the service (e.g. in Special Care Baby Unit, patient choice and Midwife still visiting), thus leaving 96 not seen within 14 days (9%). The
February provisional figure of 83% is therefore expected to reach the target after validation.
Health Visiting - % of children under 1 who transfer into area from other counties have face to face contact with Health Visiting
service within 5 days of notification February & February validation (P26) – Of the six children seen over five working days, two of the
visits were delayed due to the Health Visitor being unable to make contact with the family through any form of correspondence despite
numerous attempts. The target is being reinforced at team meetings and managers are scrutinising the return closely. The clinical pathway
has been changed with a letter inviting the client to make contact with the Health Visiting team sent first which has been found successful with
those where English is not their first language; this is then followed up with phone contact to make an appointment within five days.
Vacancy rates, Health Visitor caseload (P27, P28) – The Health Visitor vacancy rate decreased to 5.5% for February and remains within
the 8% vacancy threshold. The average caseload is 635 against a target of 500 (November Figures). The recruitment of trainee Health
Visitors will not have an effect upon caseload numbers until later in their training when caseloads start to be assigned to them. An action plan
has been enacted for further recruitment and to focus posts in the highest caseload affected areas. Three ‘Return to Practice’ Health Visitors
started the University module to refresh their practice and will apply for posts in June 2012 following their course. Recruitment to vacancies is
underway with interviews taking place in March.
School Nursing - % of children who have had height and weight monitored in reception and year 6 (P29) – with 51% of children
measured in reception and year 6, HCT are on target against the monthly trajectory of 48% for the month.
Chlamydia Screening (P30) – HCT completed 95 family planning clinic screens in February. HCT are currently 17 screens below trajectory
and marked amber. Additional screens held at young person’s clinics have yet to be verified by the HPA and upon inclusion in the year-end
total are expected to bring us back on target.
HPV Year 8 (P31) – HPV (P31) – HCT are above the Trajectory for February with 87% receiving dose 1 and 85% receiving dose 2
immunisations.
Children’s Continuing Care (P32) – The service reported 2,762 hours delivered against 2,997 hours allocated at a performance of 92%, of
the unused allocation, 101 hours were for reasons out of HCT Control. The main reasons were hours cancelled due to child in hospital (9),
hours cancelled due to holiday/family commitments (12) and alternative respite care (80). Therefore February’s hours have been adjusted to
reflect this, with a revised performance of 95% of hours delivered. The year to date average is 96% and on target.
Nascot Lawn – The occupancy for Nascot Lawn in February was 77.3%, giving a year to date occupancy of 86.3% and remaining on target.
Children’s community nursing training sessions offered – Two sessions were run in February and this is on schedule to achieve target.
External contracts – ADOs confirm all contracts with Children’s School and Families are meeting their specification according to feedback.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
24
WORKFORCE STANDARDS
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
25
WORKFORCE
Ref
Indicator
2010/11
Exec lead performance
Current Performance
RAG YTD Full year
Status
target YTD target
Trigger to be Trigger to be
established established
YTD
actual
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
9.0%
13.3%
10.4%
12.5%
11.4%
10.7%
11.1%
9.9%
9.2%
5.2%
8.2%
7.8%
3,043
2,462
120.8
80.5
5.5%
65.7%
2,992
2,336
241.8
116
4.6%
61.2%
2,995
2,316
153
117
4.6%
59.6%
2,947
2,347
191.6
84.3
3.4%
60.6%
2,947
2,346
169.2
126.7
5.1%
61.8%
2,939
2,329
112.9
161.7
6.4%
62.0%
2,948
2,342
121.3
165.0
6.6%
64.0%
2,972
2,367
83.0
173.7
4.5%
66.9%
2,990
2,349
139.9
96.9
4.9%
65.5%
2,998
2,398
131.5
95.5
5.0%
65.6%
3,007
2,427
131.2
80.5
4.3%
65.6%
3,043
2,462
120.8
80.5
5.5%
65.7%
45
76
41
42
48
52
48
37
48
48
24
45
W2
Total number of budgeted posts not filled by a substantive employee compared to total establishment.
DoF
14.9%
W2a
W2b
W2c
W2d
W3
W4
Headcount - No of staff
WTE in post
No of vacancies
WTE by bank/agency
Bank & Agency spend - percentage of bank and agency spend as percentage of total pay budget
% of eligible staff w ho have received mandatory fire training in the last 12 months
DoF
DoF
DoF
DoF
DoF
DoW
2,976
2,437
240
158
6.4%
61.9%
W5
The number of staff related incidents reported in month compared to last month
DQ
91 - average per
month
W6
% of staff w ho have received an appraisal in the last 12 months
DoW
69.5%
81.0%
70.4%
72.9%
72.9%
73.8%
72.3%
73.5%
73.0%
76.0%
78.0%
80.0%
81.0%
W7
Number of Employment tribunals cases per month
DoW
1
For information
0
1
1
1
1
1
0
0
0
0
0
0
W8
Number of staff grievance cases per month
DoW
6
For information
8
3
4
4
2
5
5
8
7
8
8
3
W9
Staff turnover
DoW
15.2%
A
12.0%
12.0%
12.7%
15.1%
15.2%
14.9%
14.8%
14.5%
14.6%
14.2%
14.0%
13.5%
12.7%
12.8%
W10
Absence Rate
DoW
4.26%
short-term 1.93%
long-term 2.33%
A
3.5%
3.5%
3.99%
short-term
1.63%
long-term
2.36%
4.15%
short-term
1.89%
long-term
2.26%
4.14%
short-term
1.84%
long-term
2.30%
4.10%
short-term
1.84%
long-term
2.26%
4.09%
short-term
1.82%
long-term
2.27%
4.16%
short-term
1.76%
long-term
2.40%
4.13%
short-term
1.76%
long-term
2.40%
4.09%
short-term
1.69%
long-term
2.40%
3.99%
short-term
1.63%
long-term
2.36%
3.93%
short-term
1.57%
long-term
2.35%
W11
No of Whistle blow ing events
DoW
N/A
0
0
0
0
G
R
4.5%
90%
4.4%
90%
Trigger to be Trigger to be
established established
R
90%
For information
90%
0
4.17%
4.15%
short-term short-term
1.81%
1.81%
long-term long-term
2.36%
2.34%
Feb-12
Workforce information relates to one month in arrears and this information is for January 2012.
Bank & Agency spend (W3) – In January Bank and Agency spend increased to 5.5% of total pay budget and is above the ceiling target of
4.5%.
Mandatory Fire Training (W4) – Fire training figures are still considerably below the 90% target, with 66.7% of eligible staff receiving fire
training in the last 12 months. The fire training requirements have been reviewed by the Health and Safety Group and changes made.
Corporate Services staff will require fire refreshers biannually and there is no requirement for face to face training. Staff in bases without beds
may now undertake e-learning two years out of three.
Staff related Incidents (W5) – Staff experiencing accidents, unrelated to moving and handling were the top sub-category for all staff-related
incidents (15 of 45, 33%). The number of staffing related incidents has increased since last month (10 compared to 8), but as a proportion of
all staff-related incidents has reduced (22% compared to 33%) and is the second highest sub-category. No staff-related incidents were
reported to the Health & Safety Executive as per RIDDOR regulations.
Appraisal rates (W6) – Appraisal rates increased slightly to 81% in January. All operational business units now have appraisal compliance
rates at 74% and above. As appraisal is included within the Business Unit performance reports, services have trajectories to meet agreed
targets for appraisals.
Employment Tribunals (W7) - There are no Employment Tribunal claims against the Trust at the current time.
Staff Grievances (W8) - There were a total of 3 grievances being dealt with in January.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
26
Business Unit Summary
Turnover - The turnover rate for January 2012 was 12.8%, a slight
increase from December. In the three Business Units with the highest
turnover, all improved in January with West Core Services decreasing from
15.8% in December to 15.6%, Core East & North decreased to 14.3% from
14.7% and Long Term Conditions decreased to 14.4% from 15.6% the
previous month. The turnover rate for Corporate Services also remains
high at 15.5%.
Of the 28 leavers in January 2012, the three top reasons staff gave for
leaving were Retirement (4), Relocation (4) and Lack of Opportunities (4).
There were 73 (59.54 wte) new starters in January.
Absence Rate – The absence rate in January 2012 was 3.93%, a reduction
from 3.99 % in December. Absence rates remain highest in the Core
Services Business Units although both continued the downward trend over
the last few months. East & North was 5.5% and West 5.1%. Within the
Business Units, the services with higher absence levels are the inpatient
units which is consistent with national trends. Managers and HR are working
together to manage absence and there has been a significant improvement
since the new attendance management policy was introduced which
highlights frequent short term absence.
Staffing
December spend was £40k less than the previous month. Presently Bank
and Agency spend for the trust stands at £442K which is higher than
December’s Bank & Agency Spend by £110K.
Notably Bank & Agency spend in the West has increased by £59K and Long
Term Conditions by £45K when comparing to December spend.
Jan-12
Business Unit
Adult Specialist
Adult Long Term Conditions
Core Community West
Core Community East
Childrens Universal Services
Childrens Specialist Services
Vacancies remain high in the West 51.4 WTE, Children’s Specialist 28.4
WTE and Adult Specialist 15.6 WTE.
Overall
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
Budgeted
staffing Actual
WTE
384.1
229.9
655.0
426.6
461.1
299.0
2455.7
367.3
202.8
569.8
401.9
449.5
269.5
2260.8
Variance
%
16.8
27.1
85.2
24.7
11.6
29.5
194.9
4.4%
11.8%
13.0%
5.8%
2.5%
9.9%
7.9%
Turnover Sickness Rate
11.0%
14.4%
15.6%
14.7%
8.8%
11.3%
12.8%
3.00%
4.00%
5.11%
5.67%
2.73%
2.85%
3.93%
27
FINANCE STANDARDS
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
28
FINANCE – KEY PERFORMANCE INDICATORS
Ref
F1
F2
F3
F4
F5
F6
F7
Indicator
Financial Risk Rating
Operating Surplus (£000)
Balance Sheet
Cashflow
Better Payment Practice
Code
Aged Debtors
Capital Plans
Exec
lead
DoF
DoF
DoF
DoF
Current Performance
2010/11
RAG YTD Full year
performance Status
target
G
2
3
G
£184
£1,000
G
>25 days
20
G
>20 days
A
YTD
actual
3
£1,004
43.1
G
Apr-11
2
-40.1
G
May-11
3
-41.7
G
Jun-11
3
-42.3
G
Jul-11
3
£1,207
42.9
G
Aug-11
3
£1,068
42.6
G
Sep-11
3
£1,315
43.0
G
Oct-11
3
£1,055
42.1
G
Nov-11
3
£1,026
43.0
G
Dec-11
3
£986
44.0
G
Jan-12
3
£961
42.3
G
Feb-12
3
£1,004
43.1
G
DoF
88%
G
95%
94%
94%
97%
96%
95%
95%
95%
94%
94%
95%
94%
94%
DoF
DoF
31%
100%
R
<5%
100%
33%
100%
11%
100%
26%
100%
41%
100%
52%
100%
49%
100%
39%
100%
44%
100%
45%
100%
32%
100%
32%
100%
33%
100%
G
Headlines
(a) Financial position year to date is on plan; the forecast is marginally below plan. Expenditure to year end is being monitored closely.
Individual service positions are reviewed at the monthly performance meetings with each Business Unit.
(b) Financial Risk rating remains at 3 overall. Income and Expenditure Margin has reduced from 3 to 2 due to impact of contract variation
(£4m) with NHS Hertfordshire.
.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
29
Financial Risk Rating
FINANCIAL RISK RATING 2011/12
Hertfordshire Community NHS Trust
Insert the Score (1 - 5) Achieved for each Criteria Per Month
Risk Ratings
Criteria
Indicator
Weight
5
4
3
2
1
Annual
Plan
2011/12
Apr
2011
May
2011
June
2011
Jul
2011
Aug
2011
Sept
2011
Oct
2011
Nov
2011
Mar
Dec
2011
Jan
2012
Feb
2012
Underlying
performance
EBITDA margin %
25%
11
9
5
1
<1
2
2
2
2
2
2
2
2
2
2
2
2
Achievement
of plan
EBITDA achieved %
10%
50 <50
5
2
5
5
5
5
5
5
5
5
5
5
Return on assets %
20%
6
5
3
-2
<-2
4
5
5
4
5
5
5
5
5
5
5
5
I&E surplus margin %
20%
3
2
1
-2
<-2
2
2
5
5
4
4
3
3
3
3
3
2
Liquid ratio days
25%
60
25
15
10 <10
4
4
4
4
4
4
4
4
4
4
4
4
Financial
efficiency
Liquidity
Average
Weighted Average
100%
70
3.4
3.1
4.0
3.8
3.8
3.8
3.6
3.6
3.6
3.6
3.6
3.4
Overriding rules
E
G
E
E
E
E
E
E
E
E
E
E
Final Overall rating
3
2
3
3
3
3
3
3
3
3
3
3
Overriding
rules
Overall
rating
100 85
Mar
2012
Comments on Performance in Month
HCT is planning to improve its working capital
0.0
Overriding Rules :
Max Rating
3
3
2
2
3
1
2
Rule
Plan not submitted on time
Plan not submitted complete and correct
PDC divident not paid in full
One Financial Crieterion at "1"
One Financial Crieterion at "2"
Two Financial Criteria at "1"
Two Financial Criteria at "2"
Ref.
A
B
C
D
E
F
G
Summary:
Overall the Trust continues to achieve a Financial Risk Rating of 3. Forecast is anticipated to be maintained at 3 overall.
I&E Surplus has dropped to a 2 due to the change in the Trust’s anticipated total income arising from a contract variation for anticipated
depreciation and capital charges for the whole year. Income has increased whilst forecast surplus remains constant. I&E margin has
consequently dropped to below the 1% trigger point.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
30
Financial Triggers
Hertfordshire Community NHS Trust
FINANCIAL RISK TRIGGERS 2011/12
Insert "Yes" / "No" Assessment for the Month
Actual - Year to date
Criteria
Apr
2011
May
2011
June
2011
Jul
2011
Aug
2011
Sept
2011
Oct
2011
NO
NO
NO
NO
NO
NO
NO
Dec
2011
Jan
2012
Feb
2012
Forecast
Mar
2012
NO
NO
NO
NO
NO
Nov
Mar
2011
Comments on Performance in Month
1
Unplanned decrease in EBITDA margin in two
consecutive quarters
2
Quarterly self-certification that the FRR may be less
than 3 in the next 12 months
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Assume the indicator is monthly
3
FRR 2 for any one quarter
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
This indicator has been amended to reflect the
calculation of Liquid Ratio Days in the FRR i.e.
to include an assumed working capital facility
4
Working capital facility (WCF) agreement includes
default clause
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Working Capital Facility not yet in place
Sufficient cash balance and no plans to utilise
working capital facility
5
Debtors > 90 days past due account for more than 5%
of total debtor balances
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Yes
Yes
HCT is actively working to improve debtors
6
Creditors > 90 days past due account for more than
5% of total creditor balances
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
7
Two or more changes in Finance Director in a twelve
month period
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
Since October 2010, there have been two
changes in Director of Finance
8
Interim Finance Director in place over more than one
quarter end
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Substantive appointment from December 2011
9
Quarter end cash balance <10 days of operating
expenses
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Assume this applies to the month in question
10
Capital expenditure < 75% of plan for the year to date
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
3
2
2
2
2
2
2
2
2
2
2
2
NB
Scoring: An answer of "YES" = 1.0
TOTAL
RAG RATING :
GREEN
= Score between 0 and 1
AMBER
= Score between 2 and 4
RED
= Score over 5
Summary
During February 2012, HCT scored 2 (Amber). The recent appointment to Director of Finance is expected to improve the score in future
months.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
31
Financial Summary
Annual
Budget
£000
Budget
£000
Turnover
£121,042
£110,673 £110,176
-£497
£124,582
less Operating expenses
£119,508
£109,184 £108,643
£541
£123,045
EBIDTA
less Depreciation
Surplus/(Deficit)
Year to Date
Actual Variance
£000
£000
Forecast
Actual
£000
£1,534
£1,489
£1,533
£44
£1,537
£530
£486
£522
-£36
£566
£1,004
£1,003
£1,011
£8
£971
EBIDTA = expenses before interest, depreciation, taxation and amortisation
Summary: YTD is on plan and forecast is anticipated to be marginally under the planned position of £1m by £30k.
Risks
(a) Estates expenditure is a pressure and action taken in recent months is showing a reducing run rate per month.
(b) Efficiency plans are overall on target but are presently reliant on staff turnover. Performance on individual schemes is being monitored
against delivery milestones as well as their financial performance.
(c) Forecast income and expenditure has increased by £4m for a contract variation from the PCT for charges for occupancy of buildings.
Financial impact is net nil but does marginally affect the financial risk rating.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
32
Balance Sheet
Balance Sheet as at 29th February 2012
At 1st Apr
11
£000's
FIXED ASSETS:
Intangible assets
Tangible assets
TOTAL FIXED ASSETS
CURRENT ASSETS:
Stocks and work in progress
Total Debtors
Cash at bank in GBS accounts
Other cash at bank and in hand
Total Cash at bank and in hand
TOTAL CURRENT ASSETS
CREDITORS:
Total amounts falling due within one year
NET CURRENT ASSETS/(LIABILITIES)
TOTAL ASSETS LESS CURRENT LIABILITIES
Provisions
Total provisions
PROVISION FOR LIABILITIES AND CHARGES
TOTAL ASSETS EMPLOYED
FINANCED BY TAXPAYERS EQUITY:
Public dividend capital
Other reserve
Income and expenditure reserve
TOTAL TAXPAYERS EQUITY
At 29th
Feb 12
£000's
At 31st
Mar 12
£000's
315
1,671
1,986
371
1,744
2,115
303
3,380
3,683
105
16,638
3,391
13
3,404
20,147
105
3,526
11,311
59
11,370
15,001
105
8,480
6,567
15
6,582
15,167
-16,976
3,171
5,157
-27
-27
0
5,130
-10,949
4,052
6,167
-27
-27
0
6,140
-12,749
2,418
6,101
0
0
0
6,101
0
4,946
184
5,130
0
4,946
1,194
6,140
0
4,946
1,155
6,101
Summary:
The balance sheet has remained constant compared to last month at a current ratio of 1.37. The forecast position is 1.18 (same as at 31
March 2011) due to the increased debtor and creditor positions as year-end approaches.
The balance sheet does not include the impact of the transfer of land and buildings approved by the Board, as the latest advice from the SHA
is that the Department of Health consider that this transfer is unlikely to now occur during 2011/12.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
33
Cashflow
Type
Opening Balance
Apr 11
May 11
Jun 11
Jul 11
Aug 11
Sep 11
Oct 11
Nov 11
Dec 11
Jan 12
Feb 12
Mar 12
£000's
£000's
£000's
£000's
£000's
£000's
£000's
£000's
£000's
£000's
£000's
£000's
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Plan
3,391
7,608
12,819
12,977
15,272
9,981
12,042
12,016
9,513
10,593
10,636
11,311
SLA Patient Income
8,625
8,877
9,126
8,876
8,876
8,876
8,876
8,876
8,876
8,476
7,750
6,163
Other Healthcare Income
1,343
11,195
689
2,881
1,660
2,208
1,888
2,496
1,209
1,590
2,984
2,297
15
15
20
15
15
20
126
5
32
35
Capital Funding
Interest Receivable
Other Credits
Total receipts
Creditors - Revenue
Creditors - Capital
Staff Salaries
9,983
20,087
9,835
11,772
10,551
11,104
10,890
2
2
0
47
11,374
10,134
1
10,071
10,766
8,496
1,331
6,866
2,294
2,179
8,591
1,739
3,519
6,539
1,575
2,496
2,303
2,340
36
772
223
106
35
19
151
39
127
125
337
545
4,399
Tax.NI,Super
4,426
4,425
4,429
4,441
4,468
4,508
4,524
4,571
2,812
2,735
2,763
2,775
2,741
2,738
2,775
2,781
Annual TDR Dividends
4,621
4,645
4,650
2,786
2,806
5,680
76
25
Loan Repayments
Total payments
5,766
14,876
9,677
9,477
15,842
9,043
10,916
13,877
9,054
10,028
10,091
13,240
Closing Cash Balance
7,608
12,819
12,977
15,272
9,981
12,042
12,016
9,513
10,593
10,636
11,311
6,567
Summary:
The February cash position is £45k below the planned position for the month. Cash Balance remains in excess of 20 days of monthly
expenditure.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
34
Better Payment Practice Code
Capital Expenditure
Capital Projects
Plan £000's
Mobile Working
E-Rostering
IT Equipment
Medical Equipment
SLR/Business Intelligence
Telecoms
Capitalisation Staff Time
Website
QVM Refurbishment
Heating / Roofing / Room upgrades
Eliminating Mixed Sex Accommodation
Fire Alarm Systems
Uncommitted
Total
261
69
206
117
30
5
250
17
172
573
133
95
353
2,281
YTD £000's FOT £000's
238
60
195
19
29
5
178
17
44
121
41
56
0
1,002
FOT Var
£000's
261
60
532
71
84
0
364
17
180
522
130
60
2,281
0
-9
326
-46
54
-5
114
0
8
-51
-3
-35
-353
-1
Better Payment Practice Code: Performance against the Better Payment Policy code target of 95% of invoices paid within 30 days for
February is 94%.
Capital Expenditure - Capital expenditure is on plan. The previously uncommitted funds will be used to replace outdated IT equipment.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
35
Aged Debtors
Aged Debtors by Value (£000)
0-30 days
31-60 days
61-90 days
>90 days
April
£8,831
£3,937
£1,494
£1,845
May
£1,309
£2,296
£902
£1,580
June
£663
£729
£2,226
£2,466
July
£2,092
£372
£70
£2,781
Aug
£678
£1,441
£329
£2,332
Sept
£1,532
£447
£597
£1,630
Oct
£1,882
£424
£52
£1,900
Nov
£829
£545
£31
£1,159
Dec
£1,034
£565
£374
£937
Jan
£2,048
£357
£180
£1,204
Feb
£1,037
£970
£147
£1,054
£16,107
£6,087
£6,084
£5,315
£4,780
£4,206
£4,258
£2,564
£2,910
£3,789
£3,208
Mar
Summary - Overall level of debt has reduced from last month by £581k. Debt > 90 days has reduced from last month. The Director of
Finance is meeting with Barnet and Chase Farm Hospital concerning its level of aged debt.
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
36
APPENDIX ONE
PERFORMANCE BY CONTRACT
TYPE
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
37
National Indicators
Performance
Ref
Indicator
P1
18 Weeks - non-admitted patients % of patients being treated w ithin
18 w eeks for HCT consultant led
services
P2
GUM - percentage of patients
offered w ithin 48 hours
P3
GUM - percentage of patients seen
w ithin 48 hours
P4
P5
P6
P7
S28
West Herts New born Hearing
Screening - % of babies screening
w ithin 4 w eeks of birth
Retinal screening - % of diabetic
cohort that has been offered an
annual screen
Retinal screening - % of diabetic
cohort that has been screened in
2011/2012
Minor Injuries Unit - Herts and Essex
hospital - patients to be seen
treated and discharged w ith 4
hours
NHS Litigation authority (NHSLA)
clinical negligence level
Contract ref
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
Exec
lead
2010/11
performance
RAG YTD
Status
Full year
target
YTD target
YTD actual
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
DO
100.0%
G
95%
95%
99.9%
100.0%
100.0%
100.0%
99.9%
100.0%
99.8%
99.9%
100.0%
100.0%
100.0%
99.9%
T100%
DO
100.0%
G
98%
98%
99.4%
100.0%
100.0%
99.5%
99.6%
99.4%
98.9%
98.7%
99.3%
99.2%
100.0%
99.0%
T100%
DO
99.9%
G
85%
85%
99.4%
100.0%
100.0%
99.5%
99.6%
99.4%
98.9%
98.7%
99.3%
99.2%
100.0%
98.9%
T100%
99%
3 month
screens
95%
97%
DO
98%
G
95%
95%
97%
99%
3 month
screens
DO
100.0%
G
100%
94.2%
100.0%
8.5%
21.7%
35.8%
49.6%
60.7%
72.0%
84.2%
96.5%
100.0%
100.0%
100.0%
T100%
DO
81.9%
G
80%
81.0%
82.3%
4.9%
12.8%
21.8%
31.5%
39.8%
47.5%
54.9%
62.1%
67.4%
75.2%
82.3%
T81%
DO
100.0%
G
95%
95.0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
G
N/A
Level 1
Level 1
Level 0
Level 0
Level 1
Level 1
Level 1
Level 1
T level 1
YTD target
YTD actual
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
99.9%
99.6%
99.8%
99.9%
99.9%
99.9%
99.8%
99.8%
99.9%
100%
100%
100%
T100%
DQ
98%
96%
T95%
SHA Indicators
Ref
Indicator
Contract ref
Exec
lead
2010/11
performance
Performance
RAG YTD
Full year
Status
target
P9
18 Weeks - non-admitted patients % of patients being treated w ithin
18 w eeks for HCT non consultant
led services
NHS Hertfordshire
Contract
DO
99.6%
G
98%
98%
P11
Urgent District Nurse response
w ithin 24 hours
NHS Hertfordshire
Contract
DO
100%
G
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
P12
Non urgent district nurse response
w ithin 48 hours
NHS Hertfordshire
Contract
DO
95%
G
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
38
CQC
Performance
Exec
lead
2010/11
performance
RAG YTD
Status
Full year
target
YTD target
YTD actual
S3
CQC
Compliance w ith Hand hygiene in all
NHS Hertfordshire
Community Hospitals w ill be > 95%
Contract
DQ
99%
G
95%
95%
99%
100%
99%
99%
T95%
S4
Compliance w ith Commode Audit in
all Community Hospitals w ill be >
95%
DQ
98%
G
95%
95%
97%
100%
97%
95%
T95%
DQ
99%
G
95%
95%
100%
100%
100%
100%
T99%
DQ
March 2011
16
For information
For information
48
23
21
26
31
43
46
52
42
48
53
50
DQ
Average 2010/11
220
R
Average
337
per month
272
313
356
300
334
336
308
363
374
331
422
DQ
0
G
0
0
0
0
0
0
T0
DQ
4
R
0
0
1
0
1
0
T0
MD
207
For information
For information
199
accumulative
20
14
24
17
16
22
19
16
25
12
14
MD
9
For information
For information
0
0
0
0
0
0
0
0
0
0
0
0
DQ
100%
A
90%
90%
89%
93%
99%
89%
96%
90%
93%
88%
90%
89%
87%
89%
T90
DQ
87%
A
90%
90%
84%
81%
94%
88%
89%
84%
99%
92%
90%
80%
80%
84%
T90
DQ
96%
G
80%
80%
95%
98%
DQ
88%
G
80%
80%
81%
88%
Ref
S7
S10
Indicator
Contract ref
CQC
Compliance w ith Essential steps
urinary catheter care and ongoing
CQC
care w ill be > 95% in all community
hospitals
The number of SI's that remain open NHS Hertfordshire
Contract
to HCT
CQC
Number of patient-related incidents CQC
reported in month
S14
Number of patient-related incidents
S16
Number of medicine adverse
incidents reported
Number of relevant medicine safety
S20 alerts not managed appropriately or
w ithin timescales
Staff accessing safeguarding
S21
training level 1
All staff w orking directly w ith
S22 children have received level 2
training.
Eligible HV & School Nursing staff
S23a w orking w ith children have clinical
supervision (3 times a year)
Eligible AHP Nursing staff w orking
S23b w ith children have clinical
supervision (2 times a year)
S19
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
T211-324
CQC
S15 reported in quarter that resulted in
severe harm or death
Number of incidents in quarter
w hich allege abuse of patients
w ithin our care w hich have been
reported via incident reporting (and
to police and/or ACS or CSF)
Monthly
incidents
Monthly incidents
reported
reported betw een
betw een 211211-334
334
Apr-11
CQC
CQC
CQC
CQC
CQC
CQC
95%
100%
CQC
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
92%
81%
39
NHS Hertfordshire Contract
Performance
Ref
Indicator
P1
18 Weeks - non-admitted patients % of patients being treated w ithin
18 w eeks for HCT consultant led
services
P2
GUM - percentage of patients
offered w ithin 48 hours
P3
GUM - percentage of patients seen
w ithin 48 hours
P4
P5
P6
P7
P9
West Herts New born Hearing
Screening - % of babies screening
w ithin 4 w eeks of birth
Retinal screening - % of diabetic
cohort that has been offered an
annual screen
Retinal screening - % of diabetic
cohort that has been screened in
2011/2012
Minor Injuries Unit - Herts and Essex
hospital - patients to be seen
treated and discharged w ith 4
hours
18 Weeks - non-admitted patients % of patients being treated w ithin
18 w eeks for HCT non consultant
led services
Contract ref
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
NHS Hertfordshire
Contract
National Indicator
Exec
lead
2010/11
performance
RAG YTD
Status
Full year
target
YTD target
YTD actual
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
DO
100.0%
G
95%
95%
99.9%
100.0%
100.0%
100.0%
99.9%
100.0%
99.8%
99.9%
100.0%
100.0%
100.0%
99.9%
T100%
DO
100.0%
G
98%
98%
99.4%
100.0%
100.0%
99.5%
99.6%
99.4%
98.9%
98.7%
99.3%
99.2%
100.0%
99.0%
T100%
DO
99.9%
G
85%
85%
99.4%
100.0%
100.0%
99.5%
99.6%
99.4%
98.9%
98.7%
99.3%
99.2%
100.0%
98.9%
T100%
99%
3 month
screens
95%
97%
DO
98%
G
95%
95%
97%
99%
3 month
screens
DO
100.0%
G
100%
94.2%
100.0%
8.5%
21.7%
35.8%
49.6%
60.7%
72.0%
84.2%
96.5%
100.0%
100.0%
100.0%
T100%
DO
81.9%
G
80%
81.0%
82.3%
4.9%
12.8%
21.8%
31.5%
39.8%
47.5%
54.9%
62.1%
67.4%
75.2%
82.3%
T81%
NHS Hertfordshire
Contract
National Indicator
DO
100.0%
G
95%
95.0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
NHS Hertfordshire
Contract
DO
99.6%
G
98%
98%
99.9%
99.6%
99.8%
99.9%
99.9%
99.9%
99.8%
99.8%
99.9%
100%
100%
100%
T100%
98%
96%
T95%
P11
Urgent District Nurse response
w ithin 24 hours
NHS Hertfordshire
Contract
DO
100%
G
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
P12
Non urgent district nurse response
w ithin 48 hours
NHS Hertfordshire
Contract
DO
95%
G
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
T100%
P13
Community Hospitals - Number of
patients per w eek w hose discharge
or transfer from community hospital
is delayed due to NHS delay
NHS Hertfordshire
Contract
DO
15.4 per w eek
average for April to
Mar
A
10.6 per
w eek
average
11.3 per
w eek
average
T10
P25
Health Visiting - % of babies w ho
have had a face to face contact
w ith health visitor w ithin 14 days of
birth
NHS Hertfordshire
Contract
DO
Not collected
G
90%
90%
91%
Average
P26
Health Visiting - % of children under
1 w ho transfer into area from other
counties have face to face contact
w ith Health Visiting service w ithin 5
days of notification
NHS Hertfordshire
Contract
DO
Not collected
R
98%
98%
65%
Average
P27
Health Visiting - %vacancy rates in
Health visiting service
NHS Hertfordshire
Contract
DO
6.9%
G
8%
8%
5.6%
5.8%
5.1%
5.5%
P28
Health Visiting - average caseload
size
NHS Hertfordshire
Contract
DO
520
R
<500
<500
635
528
528
525
P29
School Nursing - % of children w ho
have had height and w eight
monitored in reception and year 6
NHS Hertfordshire
Contract
DO
Reception Year
93.6%
Year 6
89.6%
G
87%
48%
51%
Q2
Proportion of complaints resolved
w ithin timescale agreed w ith
complainant (reported monthly)
NHS Hertfordshire
Contract
DQ
March 2011
73%
G
80%
80%
88%
Q5
EMSA breaches reported in quarter
DQ
0
G
0
0
0
Q6
NHS Hertfordshire
Contract
% of patients reporting positively
NHS Hertfordshire
about cleanliness of environment in
Contract
a community hospital
DQ
99%
10 across Herts 10 across Herts
per w eek
per w eek
Triggers to be
Triggers to be
established
established
follow ing
follow ing baseline
baseline data
data collection
collection
12.6 per w eek
average
97%
13.5 per
w eek
average
71%
12.3 per w eek
average
69%
16.8 per
w eek
average
18.5 per
w eek
average
92%
91%
92%
12.8 per w eek 8.8 per w eek
average
average
84%
100%
12.3 per w eek 6.5 per w eek
average
average
91%
91%
92.0%
90.0%
92.0%
91.0%
83%
Provisional
T90%
45%
51%
56%
57%
78%
81%
86%
T98%
7.0%
7.8%
3.9%
3.4%
5.2%
6.2%
6.4%
5.5%
T4%
525
525
525
525
635
635
635
635
T510
5%
15%
24%
37%
51%
T63%
89%
88%
100%
88%
100%
T80%
95%
96%
87%
94%
0
100%
12.4 per
w eek
average
94%
0
100%
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
100%
97%
0
100%
100%
98%
40
NHS Hertfordshire Contract
Performance
Ref
P14
P16
P16a
P16b
P17
Indicator
Community Hospitals - % of bed
days lost due to delayed transf ers
of care
Community Hospitals - Average
length of stay in HCT community
hospital - TOTAL
Community Hospitals - Average
length of stay in HCT community
hospital - Stroke
Community Hospitals - Average
length of stay in HCT community
hospital - Non Stroke
Community Hospitals - Readmission
rates w ithin 28 days
Exec
lead
2010/11
performance
NHS Hertf ordshire
Contract
DO
Average
Total 9.4%
(NHS 5.2%
HCS 4.2%
Both 0.0%)
NHS Hertf ordshire
Contract
DO
32.3 days
Contract ref
RAG YTD
Status
Full year
target
YTD target
YTD actual
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
G
6%
f or NHS delays
6%
f or NHS delays
Total 8.7%
(NHS 4.7%
HCS 3.9%
Both 0.1%)
Total 10.5%
(NHS 5.7%
HCS 4.6%
Both 0.2%)
Total 7.6%
(NHS 4.3%
HCS 3.2%
Both 0.1%)
Total 8.3%
(NHS 6.1%
HCS 2.2%
Both 0.0%)
Total 10.2%
(NHS 6.4%
HCS 3.8%
Both 0.0%)
Total 9.9%
(NHS 4.9%
HCS 4.9%
Both 0.1%)
Total 8.3%
(NHS 3.9%
HCS 4.2%
Both 0..2%)
Total 8.7%
(NHS 5.2%
HCS 3.4%
Both 0..1%)
Total 9.0%
(NHS 4.7%
HCS 4.1%
Both 0..2%)
Total 6.3%
(NHS 2.7%
HCS 3.5%
Both 0.1%)
Total 9.8%
(NHS 4.6%
HCS 5.2%
Both 0.0%)
Total 7.5%
(NHS 3.6%
HCS 3.9%
Both 0.0%)
Non stroke 21
days, Stroke 42
days
Non stroke 21
days, Stroke 42
days
33.9 days
35.6 days
38 days
34.6 days
34.7 days
31.1 days
29.4 days
36.4 days
40.3 days
35.5 days
41.9 days
34.8 days
39.2 days
38.4 days
40.1 days
30.8 days
28.7 days
27.2 days
27.3 days
29.5 days
28.2 days
27.0 days
29.7 days
Mar-12
NHS Hertf ordshire
Contract
DO
G
42 days
42 days
Average
38..0 days
NHS Hertf ordshire
Contract
DO
R
21 days
21 days
Average
28.6 days
NHS Hertf ordshire
Contract
DO
1.2%
G
<2%
<2%
0.8%
1.0%
1.0%
0.7%
0.8%
1.0%
0.5%
0.5%
0.8%
0.7%
1.1%
0.5%
DO
Annual Total 399
Ave per month 33
375
302
accumulative
27 Average per
month
22
12
19
38
46
22
12
18
33
37
43
1019
accumulative
92 Average per
month
83
85
108
88
80
84
102
93
92
105
99
492
accumulative
44 per month
Average
8
44
54
45
20
38
76
60
20
71
56
492
accumulative
44 per month
Average
8
44
54
45
20
38
76
60
20
71
56
122
accumulative
12 per month
Average
38
14
7
12
7
0
23
0
15
6
8
122
accumulative
12 per month
Average
38
14
7
12
7
0
23
0
15
6
8
92%
91%
91%
91%
92.0%
90.0%
92.0%
91.0%
83%
Provisional
T90%
45%
51%
56%
57%
78%
81%
80%
T98%
T<2%
P18
Intermediate care - Number of
patients transf erred f rom acute
hospital/AAU in West Herts
P22
Community Matrons - Number of
patients w ho have been prevented
f rom admission/emergency
attendance
NHS Hertf ordshire
Contract
DO
Annual 1419
Ave Month 118
Triggers to be
established
f ollow ing baseline
data collection
P23a
Diabetes -Number of patients
attending structured education
sessions
NHS Hertf ordshire
Contract
DO
Annual Total 600
Ave per month 50
Triggers to be
established
f ollow ing baseline
data collection
P24a
Diabetes - Number of patients
completing a personal health plan
f ollow ing a patient education
programme
NHS Hertf ordshire
Contract
DO
Annual Total 600
Ave per month 50
Triggers to be
established
f ollow ing baseline
data collection
P23b
Respiratory -Number of patients
completing structured group
education sessions
NHS Hertf ordshire
Contract
DO
Annual Total 295
Ave per month 25
Triggers to be
established
f ollow ing baseline
data collection
P24b
Respiratory -Number of patients
completing a personal health plan
f ollow ing a patient education
programme
NHS Hertf ordshire
Contract
DO
Annual Total 295
Ave per month 25
Triggers to be
established
f ollow ing baseline
data collection
P25
Health Visiting - % of babies w ho
have had a f ace to f ace contact
w ith health visitor w ithin 14 days of
birth
NHS Hertf ordshire
Contract
DO
Not collected
G
90%
90%
91%
Average
P26
Health Visiting - % of children under
1 w ho transf er into area f rom other
counties have f ace to f ace contact
w ith Health Visiting service w ithin 5
days of notif ication
NHS Hertf ordshire
Contract
DO
Not collected
R
98%
98%
64%
Average
P27
Health Visiting - %vacancy rates in
Health visiting service
NHS Hertf ordshire
Contract
DO
6.9%
G
8%
8%
5.6%
5.8%
5.1%
5.5%
7.0%
7.8%
3.9%
3.4%
5.2%
6.2%
6.4%
5.5%
T4%
P28
Health Visiting - average caseload
size
NHS Hertf ordshire
Contract
DO
520
R
<500
<500
635
528
528
525
525
525
525
525
635
635
635
635
T510
P29
School Nursing - % of children w ho
have had height and w eight
monitored in reception and year 6
NHS Hertf ordshire
Contract
DO
Reception Year
93.6%
Year 6
89.6%
G
87%
48%
51%
5%
15%
24%
37%
51%
T63%
P30
Chlamydia screening - assist PCT in
reaching its target by screening
patients in f amily planning service
NHS Hertf ordshire
Contract
DO
2259
90% of Target
A
1420
1301
1284
Year 8
87% dose 1
87% dose 2
85% dose 3
G
Year 8
85% dose 1
85% dose 2
85% dose 3
Year 8
T75% dose 1
T65% dose 2
T0% dose 3
Year 8
87% dose 1
85% dose 2
0% dose 3
NHS Hertf ordshire
Contract
A
410
Triggers to be
established
f ollow ing
baseline data
collection
Triggers to be
established
f ollow ing
baseline data
collection
Triggers to be
established
f ollow ing
baseline data
collection
Triggers to be
established
f ollow ing
baseline data
collection
Triggers to be
established
f ollow ing
baseline data
collection
83
107
130
145
134
192
102
90
101
105
95
Year 8
73% dose 1
3% dose 2
0% dose 3
Year 8
87% dose 1
69% dose 2
0% dose 3
Year 8
87% dose 1
79% dose 2
0% dose 3
Year 8
87% dose 1
85% dose 2
0% dose 3
Year 8
87% dose 1
85% dose 2
0% dose 3
Year 8
T85% dose 1
T75% dose 2
T20% dose 3
P31
HPV - % of eligible children
immunised
NHS Hertf ordshire
Contract
DO
P32
Children's Continuing Care - 95% of
allocated hours are delivered
NHS Hertf ordshire
Contract
KT
94%
G
95%
95%
96%
97%
96%
94%
95%
95%
98%
93%
99%
97%
92%
95%
T95%
P33
Children's inpatient unit - Nascot
Law n - Bed occupancy
NHS Hertf ordshire
Contract
KT
88.1%
G
90%
>85%
86.3%
87.2%
81.4%
87.1%
83.9%
85.3%
82.0%
94.0%
93.6%
91.3%
84.6%
77.3%
T85%
P34
Children's Community Nursing number of training sessions of f ered
in year to groups of carers to
support Aiming High agenda
NHS Hertf ordshire
Contract
DO
24
G
24
20
20
2
2
2
3
0
2
3
2
2
2
2
T2
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
41
External Contract
Ref
P35
P35b
P36
P37
Indicator
Are HCT meeting the specification
for Sure Start (Saw bridgew orth)
Are HCT meeting the specification
for Sure Start (St Albans)
Are HCT meeting the specification
for CSF Speech and Language
Therapy
Are HCT meeting the specification
for Step 2
Contract ref
Exec
lead
2010/11
performance
Meeting
specification
Meeting
specification
Performance
RAG YTD
Full year
Status
target
YTD target
YTD actual
Meeting
specification
Meeting
specification
Meeting
specification
Meeting
specification
Meeting
specification
Meeting
specification
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Meeting
specification
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Meeting
specification
Meeting
specification
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Full year
target
YTD target
YTD actual
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
R
0
0
2
0
0
2
T0
R
0
0
1
0
0
1
T0
CSF
DO
G
CSF
DO
CSF
DO
Meeting
specification
G
Meeting
specification
Meeting
specification
CSF
DO
Meeting
specification
G
Meeting
specification
Exec
lead
2010/11
performance
RAG YTD
Status
DQ
3/0
DQ
3/0
G
Patient Experience Data Set
Performance
Ref
Indicator
Number of clinical negligence claims
S13
received in quarter
Number of clinical negligence claims
S13b
closed in the quarter
Contract ref
Patient Experience
Data Set
Patient Experience
Data Set
Q3
Number of PALS enquiries (for HCT
services) reported monthly
Patient Experience
Data Set
DQ
Annual Total 445
Ave per month
37
Q4
Number of compliments received in
quarter
Patient Experience
Data Set
DQ
Annual Total 449
Ave per month
37
Q7
Number of in patient survey returns
received and % rating care
received as good or better than
good
Patient Experience
Data Set
DQ
Annual Total 455
Ave per month
38 returns
97%
Triggers to be
established
follow ing
374 accumulative
baseline data
collection
Triggers to be
Triggers to be
established
established
1028
follow ing
follow ing baseline
accumulative
baseline data
data collection
collection
Triggers to be
Triggers to be
established
established
660 returns
follow ing
follow ing baseline
98%
baseline data
data collection
collection
Triggers to be
established
follow ing baseline
data collection
41
27
33
25
23
182
47 returns
100%
61 returns
98%
67 returns
100%
45
52
44
502
60 returns
99%
Hertfordshire Community NHS Trust – Safety, Quality, Performance, Workforce & Finance Report –
February 2012 Final
40 returns
100%
58 returns
98%
17
30
37
74 returns
96%
56 returns
98%
344
72 returns
99%
60 returns
97%
65 returns
96%
42