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Patient safety and experience

The Director of Nursing and Quality is supported by 3 deputies; the Deputy Director of Nursing and Quality, Deputy Director of Continuing Healthcare and Deputy Director of System Resilience.

Our Nursing and Quality team have three main functions:

Patient Safety

Infection, Prevention and Control (IPC)
Serious Incidents (SI)

Patient Experience

Freedom of Information (FOI)

Quality Monitoring

Quality Assurance Visits (QAV)
Quality Review Meetings (QRM)
Care Home Improvement Team (CHIT)


Quality Impact Initial Assessment

Please find attached here the latest Quality Impact Initial Assessment document.

Patient Safety

Infection, Prevention and Control

The Head of Infection Prevention and Control (IPC) provide strategic leadership and direction from a commissioning perspective in relation all aspects of preventing and managing infections in healthcare environments in Hertfordshire. She works closely with all partners, providers and stakeholders to ensure high standards of IPC within the county (on behalf of both HVCCG and ENHCCG) and is the expert advisor for strategic and clinical planning processes to ensure effective implementation of infection control standards and clinical practice across the health system.

Key duties include:

  • Performing quality assurance visits to clinical areas in order to assess standards of practice in relation to IPC
  • Maintaining oversight of provider compliance with IPC standards and best practice and ensuring appropriate internal assurance processes are in place to monitor these
  • Ensuring key aspects of IPC are included in contractual arrangements with healthcare providers in Hertfordshire
  • Maintaining oversight of outbreak management in local healthcare environments
  • Encouraging a health economy approach to IPC, through the promotion of collaborative partnership working across organisational boundaries
  • Hosting of a multi-agency forum for sharing good practice and learning related to IPC in Hertfordshire
  • Providing professional support and advice to healthcare providers in Hertfordshire in relation to IPC
  • Reviewing local healthcare associated infection (HCAI) data to identify themes and trends, and identify any associated learning
  • Establishing time limited working groups to focus on and address relevant IPC issues across the health system
  • Identifying clinical and non-clinical issues that impact on standards of IPC within individual organisations
  • Setting IPC priorities for the forthcoming year
  • Advising the CCG Boards and Quality Committees of IPC issues and any significant risks that may impact on the Hertfordshire health system, and making recommendations to mitigate these risks
  • Providing challenge where standards of IPC need to improve
  • Promoting the evidence base for IPC practice across Hertfordshire

Current local priorities include:

  • The reduction of gram negative blood stream infections across the health system (Eschericia coli, Klebsiella, Pseudomonas)
  • Prevention of urinary tract infections
  • Improvements in diagnosis of urinary tract infections
  • Continued improvements in antibiotic prescribing to help address the issue of antibiotic resistance

Serious Incidents

The CCG is committed to ensuring that we commission services that provide high quality care with patient safety as one of its fundamental principles. It is therefore essential that the CCG and all of our providers have effective processes in place to allow staff to report incidents when patients have, or could be harmed.

There is no definitive list of events/incidents that would constitute a Serious Incident and every incident is therefore considered on a case-by-case basis using the definitions detailed below:

  • Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in:
    • Unexpected or avoidable death of one or more people. This includes;
      • suicide/self-inflicted death; and
      • homicide by a person in receipt of mental health care within the recent past
    • Unexpected or avoidable injury to one or more people that has resulted in serious harm
    • Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent;
    • the death of the service user; or
      • serious harm
    • Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery where;
      • healthcare did not take appropriate action/intervention to safeguarding against such abuse occurring or
      • where abuse occurred during the provision of NHS-funded care
  • An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following:
    • Failures in the security, integrity, accuracy or availability of information often described as data loss and/or information governance related issues, including cyber security (See Section 5.1.8)
    • Property damage
    • Serious breach/concern
    • Incidents in population-wide healthcare activities like screening and immunisation programmes where the potential for harm may extend to a large population.
    • Inappropriate enforcement/care under the Mental Health Act (1983) and the Mental Capacity Act (2005) including Mental Capacity Act Deprivation of Liberty Safeguards (MCA DOLS)
    • Systematic failure to provide an acceptable standard of safe care (this may include incidents, or series of incidents, which necessitate ward/unit closure or suspension of services)
    • Activation of Major Incident Plan (by provider, commissioner of relevant agency)
  • Major loss in confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation.

Through investigation of incidents and analysing the root cause, there is an opportunity for the CCG and/or our providers to learn lessons and implement actions to reduce the risk of an incident recurring and ultimately improving patient outcomes.

The reporting of incidents, and the subsequent learning, is therefore regarded as positive by all staff, including those employed by provider organisations, and NHS England has provided a clear framework about the declaration and management of Serious Incidents.

The CCG’s SI processes for reporting and managing SIs relates to all services commissioned by the CCG and staff employed directly, and working on behalf of the CCG. We therefore expects all commissioned organisations that provide NHS funded healthcare to incorporate the requirements of the CCG’s SI policy into their own organisational policies, as per the requirement within the NHS Standard Contract.

Should you have any concerns about an incident that you are a family member / friend has been involved in, that you feel it not be treated appropriately, you can raise these directly with the providers patient service/complaints department, such as PALS for example.


The aim of the safeguarding professionals is to ensure that commissioned services promote and protect individual rights, independence and well-being and secure assurance that the child or adult thought to be at risk are effectively safeguarded against abuse, neglect, discrimination, embarrassment or poor treatment.

All NHS commissioned services have a key role to play in safeguarding and promoting the welfare of children and adults at risk of harm, as safeguarding is everybody’s business.  Safeguarding children is a statutory duty under section 11 of the Children Act 2004 and in accordance with government guidance in ‘Working Together to Safeguard Children 2018’. The statutory framework for Adult Safeguarding was set out in the Care Act in 2014 which came into effect in April 2015.

Read more about Safeguarding Children

Read more about Safeguarding Adults

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