Medway Community Healthcare C.I.C

Updated 7 October 2022

Medway Community Healthcare is a community interest company (CIC) and provider of NHS funded adult and children’s community healthcare in Medway and Swale. Their services include community health services for adults, children and young people, a care home and hospice services, adult inpatient services, specialist dental and urgent care. Medway Community Healthcare (MCH) was established in 2011 and is a not-for-profit social enterprise committed to serving its communities and funded by the NHS and local authorities. MCH employs over 1300 staff. All staff have the option to become shareholders and any surplus money is re-invested back into the community.

Services span across all ages from birth to end of life and range from preventative and pro-active support to keep people as well and independent as possible through to complex care and support in individuals’ own homes to prevent admission to hospital or to support people following discharge. MCH provides 40 different services across 31 different locations as well as in individual’s homes and in schools.

MCH provide the following core services:

• Community health services for adults
• Community health inpatient services
• Community health services for children, young people and families
• Urgent care services
• Community dental services
• Hospice services
• Care home

MCH are registered for the following regulated activities:

• Diagnostic and screening procedures
• Family planning
• Maternity and midwifery services
• Nursing care
• Personal care
• Surgical procedures
• Transport services, triage and medical advice provided remotely
• Treatment of disease, disorder or injury
• Accommodation for persons who require nursing or personal care

We carried out inspections of four core services provided by Medway Community Healthcare C.I.C. followed by a well led inspection.

We inspected the community health services for adults, community health services for children, young people and families and community health services for inpatients core services. We also inspected the community dental service, and the findings are included in this report, however we do not rate this core service.

The community health services for adults and the community health services for children and young people were last inspected in March 2017 and both had a rating of good. The urgent care core service was inspected separately in February 2022 as part of an inspection of the urgent care pathway in Kent and Medway and was rated requires improvement.

We did not inspect the Wisdom Hospice or Darland House care home. The Wisdom Hospice was inspected in August 2021 and is rated Good. Darland House care home was inspected in February 2021 and has a rating of good.

This was the first time we had undertaken a well led inspection of this provider.

Although Medway Community Healthcare is not an NHS trust, the word trust is used erroneously in several places in the report as the word cannot be removed from the standardised inspection report template.

We rated Medway Community Healthcare as good because:

• We rated safe as requires improvement, responsive as good, caring as good, and effective as good. We rated well-led for Medway Community Healthcare as good.
• We rated three of the four MCH core services we inspected as good. We do not rate community dental services. In rating the trust overall, we included the existing ratings of the three previously inspected services.
• The non-executive directors provided high quality, effective leadership and delivered appropriate challenge to the senior executives. They all had experience as senior leaders in a range of organisations and brought skills from other sectors including NHS acute care, health organisation directorships, social care, education and local government.
• The board was well supported by five sub-board committees which met every six weeks: audit and risk committee, integrated quality and performance committee, remuneration committee, finance committee and people committee. Each sub-committee was chaired by a non-executive director and also had an executive lead.
• The MCH senior leadership team demonstrated a high level of awareness of the priorities and challenges facing the organisation and the local health environment, and how they could address these and influence change in the system. The senior leaders had demonstrated an ability to adapt at a fast-changing pace during the COVID-19 pandemic.
• The organisation had a clear vision and a set of values which staff understood. These were underpinned by a set of clear strategic priorities running from 2019-2025 and progress was regularly reviewed. Leaders were well sighted on the ambition of the strategy and there was a focus on aligning the strategy with both local priorities in the Medway and Swale primary care networks and within the emerging Kent and Medway integrated care system.
• Staff described an open, transparent and supportive culture that centred on what was best for patients and the wider healthcare system. Staff across the organisation worked hand in hand with partners working in the wider healthcare system, with other providers and with external agencies including the voluntary sector.
• The provider’s governance system effectively provided assurance and helped keep patients safe. It helped the organisation deliver its key transformation programmes and priorities outlined in the annual business plan.
• During the core services inspections we saw that staff treated people with compassion and kindness, respected their privacy and dignity and understood people’s individual needs. Services were inclusive, took account of patients’ preferences and their individual needs. People had their communication needs met and information was shared in a way that could be understood.
• The provider was a research active organisation and had a research team of 2.4 full time staff and a research strategy. We saw that awareness of research, and its value to staff and patients, was embedded in the operational teams during the core services inspection. Research was part of the organisational culture and research activities were beyond what could be expected in an organisation of this size.

However:

• The provider needed to strengthen its work on Equality, Diversity and Human Rights (EDHR). The provider had produced a Staff Equalities Action Plan in 2021 and had an up to date Workforce Racial Equality Standard (WRES) report. It was clear that the experience of staff with disability, black and minority ethnic staff and the gender pay gap was being considered by the organisation. However, the responses in relation to targeting actions and delivering improvements were not fully formed in any substantial detail across all the groups with protected characteristics.
• Whilst the role and remit of the elected members forum (EMF) was well described, it was not evident from the inspection that the forum was playing the central role envisaged in conveying the views of the shareholders to the board and playing an active part in the development of the organisation’s strategy and governance.
• The scale of the organisation meant that succession planning and ensuring that skilled leaders were being developed presented a risk as the departure of key people could have a larger impact on service delivery. Senior leaders recognised that succession planning was an issue that presented a challenge to the organisation.
• Within the community adults core service the process around maintaining and reviewing patient risk assessments needed improving. The provider also needed to strengthen the palliative care pathway so that staff could effectively escalate the needs of deteriorating patients and ensure communication pathways were effective at these times.
• Within the community inpatients core service we told the provider that it must deploy the right number of staff with the right skills on every shift. The provider also needed to ensure that equipment needed to care for patients is available, fit for purpose and stored appropriately.

How we carried out the inspection

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

Before the inspection visit, we reviewed information that we held about the services and reviewed a range of information. During the inspection visit to Medway Community Healthcare services, the inspection team:

Community Health Services for adults

• visited two Medway Community Healthcare CIC bases and three satellite clinic locations
• spoke with 16 senior leaders including heads of service, operational and clinical leads
• spoke with 46 other members of staff including advanced practitioner physiotherapists, physio assistants, dieticians, speech and language therapists, podiatrists, phlebotomists, registered nurses, nursing assistants, tissue viability nurses, occupational therapists, an induction facilitator and administrative staff
• spoke with 19 patients and families who were using services or their carers/relatives
• reviewed 18 patient care and treatment records
• observed three shift handover meetings for community nursing teams
• observed five schedules of care in patients’ homes
• observed staff providing care to patients in clinic settings
• held six focus groups to capture staff who were unavailable on the days of the inspection
• looked at a range of policies, procedures and other documents related to the running of the services.

Community health services for children, young people and families

• visited the main base of the service and two other locations to observe clinics and reviews
• looked at the quality of the service environment
• observed a number of clinics, assessments and reviews, such as well-baby clinics, developmental reviews, health and continence assessments
• observed three home visits
• observed a virtual multidisciplinary team meeting
• observed a virtual meeting between staff members and a special educational needs coordinator
• spoke with 25 parents who were using the service; we spoke to 18 of these parents remotely following the inspection
• spoke with five team managers, two medical staff and 17 other staff including nurses, health visitors, admin staff and therapy staff
• we ran three focus groups virtually for additional staff to join and give feedback on the service
• looked at 18 patient records
• reviewed a range of documents relating to the running of the service
• looked at medicines management.

Community health inpatient services

• visited Amherst Court, Britannia and Endeavour wards on 17 May
• visited Harmony House on 28 May. This visit was delayed due to COVID-19 within the inspection team
• toured all the wards and had an introduction by staff
• observed clinic rooms and medical equipment
• attended a MDT meeting
• spoke with sixteen patients and two relatives face to face
• spoke with 16 staff face to face and six more via an online focus group, and four senior leaders
• looked at seven patient care records and prescription charts
• observed care in communal areas and therapy groups
• looked at charts recording food and hydration intake for eight patients
• looked at records including complaint records and incident reports, workforce data and training information

Community dental services

• toured the unit at Lordswood Healthy living centre
• looked at systems and processes such as observation of the decontamination process
• spoke with four members of staff, 1 dentist, two nurses and the receptionist
• looked at maintenance documents and schedules for the decontamination and radiography equipment
• looked at policies, recruitment processes, complaints, risk policies, and safeguarding
• checked that clinical staff had a current registration with the general dental council and were up to date with their mandatory continuing professional development
• checked the processes, equipment maintenance, training of staff and medicines management with regard to the provision of inhalation sedation
• looked at auditing processes for infection prevention and control, radiographic image quality, disability access, patient records, appointment waiting times and antimicrobial prescribing
• looked at the process for consent, how capacity assessments were carried out and what these entailed.

The well led inspection team comprised one executive reviewer who was an executive of an NHS community health provider, two specialist advisors with professional experience in board-level governance, one CQC head of hospital inspection, one CQC inspection manager and two CQC inspectors.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 7 October 2022

Updated 7 October 2022

Updated 7 October 2022

Updated 7 October 2022

Updated 22 June 2022

Medway on Call Care (MedOCC) provides urgent care services in three sites across Medway and Swale. Staff at urgent treatment centres see and treat people who require medical attention, where their condition is not life threatening.

We rated the service overall as requires improvement and safe as inadequate because:

• The service did not ensure patients were clinically assessed within the required timeframes in line with NHS England’s standards. Staff were not continually monitoring patients to mitigate against the risk of their condition deteriorating while they waited. Patients who were too unwell to be seen at the urgent treatment centre (UTC) were kept waiting for long periods before they were sent to the A&E department.
• The environment was not cleaned to a high standard and toilets were dirty. This could expose staff and patients to risks of infection.
• The security arrangement in terms of who could enter the department were insufficiently robust to keep staff and patients safe. Staff were not always aware of who came into the department. The CCTVs monitoring people in the department were not in operation at the time of our inspection.
• Managers did not ensure all staff had regular clinical supervision and appraisal.
• Staff were not completing face to face mandatory training in line with the providers’ target. Managers did not always ensure that staff accessed specialist training where appropriate.
• Staff did not always record consent to treatment for patients.
• The service leaders did not ensure that the safeguarding alert system worked effectively and that all staff were aware of how the system worked.
• Staff did not always ensure medicines were stored correctly. Injectable medicines were not in their original container and different strengths were mixed.
• The service did not ensure that records were completed thoroughly and kept up to date.
• The service did not ensure that there was enough information including self-help and health promotion materials readily available to patients and families.
• The service did not ensure all aspect of its governance processes were robust and effective. For example, although service level risk was being monitored, there were no clear actions to address any improvements that were needed. In addition, managers did not ensure employee records were up to date.

However:

• Staff were kind and caring. Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service had enough staff to care for patients and keep them safe.
• The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983.
• The service planned care to meet the needs of local people and took account of patients’ individual needs.
• Staff worked across health care disciplines and with other agencies when required to care for patients.
• Leaders had the skills and experience to lead the service. Staff spoke highly of their leaders. There was an open culture and staff felt managers listened to them.

A summary of CQC findings on urgent and emergency care services in Kent and Medway.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Kent and Medway below:

Kent and Medway

The health and care system in this area is made up of many health and social care providers and is supported by stakeholders, commissioners and the local authority. We found front line staff working across all services were doing their best in very challenging circumstances and had continued to do so throughout the COVID-19 pandemic.

Increased system wide collaboration, particularly between health and social care was needed to alleviate the pressure and risks to patient safety identified in some services we inspected. However, we did find some good collaborative working; for example, staff in acute and ambulance services had been working together to reduce handover delays, and primary and community services worked together to reduce attendances in Emergency Departments.

We found some access issues in primary care and some GP practices were not allowing patients to enter the building without staff permission; since our inspections, action has been taken to ensure patients can access their GP Practice freely. We did find examples of innovative practice including employing a variety of different healthcare professionals in GP Practices and across Primary Care Networks to better meet the needs of their patients ensuring people receive the right care at the right time. There was also funding available to provide interpreting and translation services to support people from diverse communities and to support people arriving in the UK from Ukraine.

Primary Care Networks were working well with community services to alleviate the pressure on ambulance and acute services where possible, particularly in out of hours services. In addition, technology was being utilised to improve services and provide timely access to patient information, especially for staff providing out of hours care.

Staffing issues and high levels of absence due to COVID-19 had impacted on services across Kent and Medway. GP Practices in this area had a larger number of patients per GP and demand had increased; however, in many cases this was well managed. The NHS111 service had experienced staffing issues as well as increased demand; this had resulted in significant delays in call answering times for people trying to seek advice.

Ambulance response times had also been poor across Kent and Medway. Whilst operational staff had done all they could to maintain response times to serious and life-threatening calls, response times to less serious calls were unacceptable, and performance had continued to be poor for a long time. This had widespread impact on people in Kent and Medway, and particularly on people living in care homes. Social care staff had to provide long periods of enhanced care to people waiting for an ambulance response whilst also caring for other residents.

There continued to be long ambulance handover delays at hospitals in Kent and Medway; however acute and ambulance services had worked well together to reduce these delays and improve handover processes.

Emergency departments inspected in Kent and Medway continued to be under significant pressure. However, we found some improvements since previous inspections, including improvements in leadership and the culture within the departments. Staff worked hard to meet current demands and felt positive about the improvements they had seen. Some social care services had raised concerns in relation to the care provided to people with dementia and autism in emergency departments. Where specific concerns were raised, these were being investigated.

There were delays in patients receiving care and treatment caused by poor patient flow across urgent and emergency care pathways. There were many urgent and emergency care pathways available within hospitals in Kent and Medway, however staff acknowledged these were not all working well or being fully utilised. Referral pathways between emergency department and urgent treatment centres aimed to meet people's needs and reduce pressure on acute services. However, we identified issues with inappropriate referrals, long waiting times and inconsistent risk assessments putting people at risk of harm. Patients also reported delays in their treatment due to inappropriate referrals. System partners were aware of issues with UEC pathways and had an action plan in place to address them.

We also found delays in patient discharge from hospitals and a shortage of social care capacity to enable people to leave hospital in a safe and timely way. In addition, social care services reported concerns about poor discharge processes. Examples included insufficient information about changes to medicines or people discharged into care homes who required a level of care for which staff were not trained to provide.

Staff working across Kent and Medway require additional support to manage the continued pressure on services. We also identified opportunities to upskill staff, for example, training additional social care staff in areas such as detecting early signs of deterioration in health. Increased collaboration between health and social care services and stakeholders is needed to address issues with patient flow across urgent and emergency care pathways. These pathways also require evaluation to ensure they are as efficient and effective as possible to meet the needs of people in Kent and Medway.

Background to inspection

Medway On Call Care (MedOCC) is run by Medway Community Healthcare CIC, which is an independent Community Interest Company, co-owned and has 1,359 staff. As a social enterprise they are not for profit organisation and reinvest any surplus back into health and care services and the local community.

MedOCC provides urgent care services in three sites across Medway and Swale.

The urgent treatment centre (UTC) at Medway Maritime Hospital operates a 24 hour service where the teams see patients who were referred via the NHS111 service or streamed from the acute trust. The UTC front door is operated by staff from the acute trust who are responsible for the initial clinical contact of patients presenting to the department. The streaming to MedOCC takes place at the UTC front door by the acute trust clinical staff.”

The urgent treatment centre (UTC) at Medway Maritime Hospital operates a 24 hour service where the teams see patients who were referred via the NHS111 service or the accident and emergency department. The service does not accept walk-in patients.

The urgent treatment centre at Sheppey Community Hospital is shared with Kent Community Health NHS Foundation trust who provides urgent treatment in hours, while the MedOCC provides urgent care service on weekends and out of hours on Mondays.

The UTC at Sittingbourne Hospital is currently closed.

MedOCC UTC is also commissioned to assess and manage patients with symptoms of cellulitis or deep vein thrombosis. The service acts as a communication hub for messages to district nurses, rapid response teams and other community and specialist teams.

The service is registered to provide the following regulated activities: Treatment of diseases, disorder or injury and Transport services, triage and medical advice provided remotely.

There are two registered managers.

MedOCC has previously been inspected as an out of hours service under the name MedOCC -Quayside in November 2014.

What people who use the service say

Feedback from patients was generally positive. The service had received a lot of compliments from people who used the service. Patients, families and carers felt that staff were generally kind and caring.

People who used the service felt it was accessible for them especially as there were not enough GPs in the area, and it was often very difficult for them to get an appointment with their GPs.

Patients felt they always had a good outcome following their visit. However, they felt service could improve on the very long waiting time, triaging process, and communication could be better.

How we carried out this inspection

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• are services safe?

• are services effective?

• are services caring?

• are services responsive?

• are services well-led?

Before the inspection visit, we reviewed information that we held about the location.

During the inspection visit, the inspection team:

• looked at the quality of the environment and observed how staff were caring for clients

• spoke with nine patients and carers

• spoke with the head of service

• spoke with the medical director

• spoke with 15 other staff members: including managers, doctors, pharmacists, nurses, clinicians, reception, and admin staff

• observed patient consultation with clinicians

• looked at 14 care and treatment records

• looked at a range of policies, procedures and other documents relating to the running of the service.

You can find information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.