Archived: North Somerset Community Partnership Community Interest Company

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

Letter from the Chief Inspector of Hospitals

We undertook a planned announced inspection as part of our comprehensive community health services inspection programme on 29 & 30 November and 1, 2 December 2016. We also carried out an unannounced visit on 12,13 and 14 December 2016 and inspected the following core services:

• Community health services for adults

• Community health services for children, young people and families

• Community mental health services for people with learning disabilities or autism

• Urgent care services

• End of life services

We did not inspect the inpatient ward at Clevedon Community Hospital as it was closed for refurbishment at the time of our inspection.

We rated North Somerset Partnership Community CIC and the five core services inspected as good overall. Safety in the community adults service and community services for children, young people and families was rated as requires improvement.

Our key findings were as follows:

Safe:

• There was a good incident reporting culture and evidence of thorough investigation leading to learning from incidents across the organisation.

• Staff understood the importance of being open and honest and we saw evidence that Duty of Candour was applied when things went wrong.

• Staff were knowledgeable about safeguarding which was embedded in practices although not all staff had received training to the level required for their role and contact with children.

• There were business continuity plans in place to respond to emergencies and other major incidents.

However

• There was a lack of auditing compliance with assessing risks to patients such as assessment for nutrition and falls assessments.

• The use of both paper and electronic records led to risk of staff being unable to access patient information in a timely manner due to issues with connectivity of mobile devices. This meant staff did not always complete contemporaneous electronic patient records. These issues had been recognised and were noted on the risk register.

• The organisation did not have an effective process for flagging to managers when compliance with training was low.

• There were challenges in maintaining levels of staffing with an inequality of the capacity and the size of the caseload across the localities for community adults services. Similarly in the services for children, young people and families some staff had very high caseloads and funding for health visitors had reduced.

  Effective:

• Staff followed care and treatment guidelines and pathways based on current best evidence.

• Staff had the right qualifications to carry out their roles, supported by competency assessment framework.

• There was effective multidisciplinary working across the organisation and staff had good working relationships with GPs across North Somerset.

• Staff were knowledgeable about mental capacity assessment and deprivation of liberty legislation and obtaining consent for treatment and care interventions.

• Service users had access to psychologists in the team provided by another provider. This allowed them access to therapies recommended by the National Institute for Health and Care Excellence.

• Patients had care from staff who had specialist training in end of life patient care.

However:

• Not all services consistently collect data to measure patient outcomes and they did not participate in national audits to benchmark their treatment and care.

• Health visiting teams provided care as agreed with commissioners. However, this did not always follow national guidance and  could have an impact on the health outcomes for children and young people.

• The inadequate mobile working arrangements meant that staff did not always have access to information about the patient.

Caring:

• Patients and their carer’s (when appropriate) were routinely involved in planning and making decisions about their care and treatment.

• Staff communicated effectively with patients and took time to answer questions.

• Patients received care from nurses and support staff that treated them with dignity and respect in the minor injury unit (MIU) and they were always listened to and felt able to raise concerns.

• 98.3% of patients in between July and September 2016 said they would recommend the MIU service to others.

• Staff providing end of life care were highly regarded by relatives of deceased patients for their kindness, caring and compassionate attitude.

• Children and families were offered support and staff used caring approaches to help people who found difficulty in expressing their concerns.

• Children and families were offered privacy when it was needed and confidentiality was respected.

Responsive:

• The organisation worked within the contract of the clinical commissioning group to ensure the services met the needs of the local population as far as possible.

• Clinics were scheduled to meet the needs of individuals as far as possible and many patients benefitted from clinics in locations close to their homes.

• The service provided patient group activities, which enabled patients to gain social interaction as well as access to advice, education and support.

• The service received few complaints, but responded to and handled complaints in a timely manner.

• Care was provided 24 hours a day, seven days per week and there was access to end of life and palliative care advice at any time of the day or night.

• The minor injury service (MIU) was planned to meet the needs of all patients, including those who were vulnerable or who had complex needs.

• The average time to treatment in the minor injuries unit was 47 minutes.Waiting times were constantly monitored in real-time by clinical staff and 99% of patients were treated, discharged or transferred within four hours in the last 12 months.

• In services for children and young people the leads were working with public health and commissioners to identify the priorities for the local population. Staff were encouraged to develop services that worked towards these priorities.

However,

• The waiting time from referral to treatment at times exceeded 19 weeks in the outpatient physiotherapy services.

• Patients were not routinely screened for dementia or referred for further assessment.

• School nursing services had a four month waiting list for children and families who needed routine support.

Well led:

• Staff were proud to work for the organisation and liked their roles. They felt they could feed issues up to senior managers and executives and they were listened to at board level.

• The challenges of changes at executive level were recognised and much work was underway to ensure a cohesive team which was visible and accessible.

• Public opinions were sought in a variety of ways which was suitable for the service they offered and where possible, changes were made in response to comments.

• Staff were keen to improve services and acted on ideas for improvement.

• Staff engagement was recognised as key in the employee owned organisation with the staff council being at the heart of plans going forward.

  We saw several areas of outstanding practice including:

• The community outreach team had adopted an effective approach to reach out to people and improve their access to health care. They set up ten weekly clinics in Weston-Super-Mare for ‘hard to reach’ groups such as people with substance misuse, homelessness and social isolation. The service provided interventions on a range of public health lifestyle issues such as weight management, healthy eating, reducing substance misuse including alcohol, Between October 2015 and January 2016 the service received 103 new referrals and assisted 11 people to find accommodation.

• Some patients relatives were enabled to give care to relatives after assessment and training by end of life care coordination centre team.

• The end of life care coordination centre had established a library of books in each of the eight teams (for example learning disability, community nurses). This had been enabled by money raised by friends of a patient. They covered all children’s age ranges who might be affected by a death in their life.

• The end of life care coordination centre were providing staff with ‘shadowing’ opportunities so that they could work alongside experienced workers in end of life care.This approach was intended to ensure that workers recruited knew what the role entailed and had the right qualities to work in end of life care.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that staff working in the community adults service have access to a system that enables them to complete all care records contemporaneously.

• Ensure that paper and electronic records for patients contain relevant information and are available to all staff at the time needed to ensure the delivery of safe and effective care.

• Ensure that staff working in the community adults service and the end of life care service are compliant with mandatory training in line with the organisations targets.

• In the community adults service, ensure that patient risk assessments are completed in a timely way.

• In the community adults service, ensure that processes are in place to monitor staff compliance with the completion of patient risk assessments.

• In the community adults service, ensure that processes are in place to monitor staff compliance with the completion of audits.

• In the community adults service, ensure that areas where sterile dressings are prepared are regularly cleaned.

• Ensure there are sufficient numbers of staff to meet the needs of children, young people and families in all areas of North Somerset.

Professor Sir Mike RichardsChief Inspector of Hospitals

We rated adult community health services as good because;

• Staff reported incidents and there was evidence of thorough investigation leading to learning from incidents across the organisation.
• Staff were knowledgeable about safeguarding, mental capacity assessment and deprivation of liberties safeguards legislation and obtained consent for treatment and care interventions. This was embedded in the way staff worked.
• Staff had the right qualifications to carry out their jobs, there was a robust competence assessment framework and staff were encouraged and supported to enhance their qualifications.
• There was effective multidisciplinary working across the organisation and staff had good working relationships with GP across North Somerset.
• Staff had built positive relationships with patients and their relatives/carers and treated patients with dignity, respect and compassion.
• Staff involved patients and their carer in planning and making decisions about their care and treatment.
• There was an effective governance framework with evidence of learning from incidents across the service.
• Staff felt valued and team working was strong.

However:

• Staff compliance across the four localities and in the urgent and specialist care team with some mandatory training was low.
• There was a lack of auditing compliance with assessing risks to patients such as completion of Waterlow score, malnutrition universal screening tool and falls assessments. Waterlow score is an assessment that identifies the level of risk for a patient of developing pressure sore.
• There was not a consistent approach to obtaining patients’ vital signs when patients were admitted to the caseload, which meant it was difficult to judge deterioration in a patient’s condition.
• The infection control risk assessment for the leg club did not identify that the area for the preparation of the trolley should be cleaned before use.
• Staff did not consistently carry out assessment of pain using a recognised pain assessment tool.
• Staff did not always assess patients’ nutritional risk assessment and take appropriate actions when a risk was identified.

Overall rating for this core service

We rated services for children, young people and families as good because:

• Senior managers were aware of the challenges the children’s service faced and were taking steps to plan services in a way that would reduce risk to children and their families. They were using available information about the needs of families in their locality to plan services within financial limits.

• Staff were encouraged to contribute their ideas in how support was offered to families. This had resulted in different ways of working in order to engage vulnerable families.

• Most staff were trained appropriately and qualified for their role. They were knowledgeable about safeguarding procedures and received support to ensure their practice was current although a few unregistered support staff were not trained to the appropriate level for safeguarding children.

• There had been no reportable incidents requiring investigation within the previous 12 months. Staff followed the organisation’s protocols for reporting incidents and were keen to learn and improve their practice. They assessed risk for children and their families and took appropriate action to minimise that risk.

• Multi disciplinary working was good and Staff worked with external agencies and disciplines within their organisation to support children and families and promote improved health outcomes.

• Care was provided using nationally recognised guidelines and standards. Activity and health outcomes were measured and results were shared with staff.

• Staff showed compassion and respect for children of all ages and their families and ensured their dignity was protected. Children and families were treated with sensitivity and supported to access health care. Some people needed additional support and staff provided this. Interpreters supported people whose first language was not English.

• Staff were aware of their responsibilities around consent and when to share information to benefit children, young people and their families.

• A reduction in funding for the Children’s Service had created a risk of the organisation failing to meet performance indicators in delivering care to children and families. Managers had escalated this risk to the executive team and were working with commissioners and public health colleagues to identify the needs of the population. This would allow them to prioritise where care was needed most.

• Staff were encouraged to take opportunities for professional development and put learning into practice. Managers supported staff to analyse how they could work differently to make the service more efficient.

However:

• Some staff had very high caseloads of families with enhanced needs and regularly worked beyond their contracted hours to deliver a safe service.

• The school nursing service prioritised referrals to their service and non urgent referrals who wanted to see a school nurse had a four month wait.

• Themes from audits carried out in localities were not always clearly shared with staff.

• Record keeping systems caused duplication for staff who needed to use electronic and paper records together to make a complete patient record.

• Administration staff working in the No Worries service who had face to face contact with young people were trained at level 1 safeguarding. National guidance advises this should be at level 2

• The No Worries sexual health service was vulnerable due to lack of formal service agreements. There were no formal agreements with estates department for the use of clinic areas or with a local GP practice that supported a weekly clinic. There was also no formal agreement for the provision of clinical supervision for the lead nurse which was provided by a clinician from another service.

• The No Worries service did not have a formal strategy for the development of the service over the term of the newly acquired contract.

• The identified risks within the No Worries service were not recorded on any form of risk register. There were clear lines of accountability and staff were clear about the reporting and management structures. However there was no indication that risks and service developments around the service were discussed at a senior or board level.

Overall rating for this core service

GOOD

We have rated the minor injury service (MIU) as good overall because:

• People were protected from avoidable harm. There were systems in place to report concerns or incidents and learn from them.

• There were reliable systems, practices and processes in place to keep adults and children safe and safeguard them from abuse, which were embedded in practice.

• The MIU was clean and well equipped and equipment was maintained and fit for purpose.

• Risks to people who used minor injury service were assessed, monitored and managed on a daily basis and incorporated relevant and current evidence based practice guidance and standards.

• New procedures or treatments were researched and reviewed by the relevant clinical governance forum (which oversaw the minor injury service) prior to being implemented in MIU.

• Training was provided for all staff to ensure they were competent and effective in their roles.

• Competency frameworks, peer review and clinical supervision arrangements were robust and ensured Emergency Nurse Practitioners and support staff were fit to practice on an ongoing basis.

• We received positive feedback about the staff and the minor injury service from all the patients we spoke with. Patients told us they were treated with kindness and respect and were always kept informed about their treatment and care.

• People told us they had timely access to the minor injury service and said waiting times were considerably less than attending the emergency department in nearby acute hospitals.

• Practitioners worked collaboratively with multidisciplinary teams across community services and had strong links with specialist services in local acute hospitals.

• Clinical leaders were respected by staff and they were knowledgeable about quality issues and understood the priorities of the minor injury service.

• There was a strong sense of team working in MIU and there were shared values to ensure the delivery of high quality patient care.

• The MIU had developed an innovative approach to the management of pain in children.

Overall rating for this core service GOOD

We rated end of life care provided by North Somerset Community partnership as good because.

• Comprehensive patient safety information was discussed in nurse meetings which included patients who might be at risk of pressure ulcers and other health risks.

• Patients had care from staff who had specialist training in end of life patient care.

• Risk was assessed and managed positively enabling patients to stay in own homes. Staff ensured they responded to patients with increased needs.

• Equipment and care packages to support patients at home and discharge from hospital were put in place promptly through a ‘fast track’ (Continuing Health Care) system for end of life patients. Records showed assessments and action plans were completed quickly and promptly passed to the care coordination centre.

• Staff we spoke with understoodconsent and decision-making requirements of the Mental Capacity Act (2005) code of practice. Patients who did lack mental capacity for decision-making were supported by staff in making best interest decisions in accordance with legislation.

• Pain and symptom relief was prioritised for patients receiving end of life treatment and care. Anticipatory or ‘just in case’ medicines to manage symptoms such as pain and nausea were prescribed and stored in patients’ homes so they were readily available when required.

• Patients and relatives we met with spoke positively about the care they received. We observed respectful, dignified and compassionate communication between staff, patients and relatives.

• Staff providing end of life care were highly regarded by relatives of deceased patients for their kindness, caring and compassionate attitude.

• The care coordination centre and community services planned and delivered services to meet needs. There was coordination with other local end of life care services including hospices, acute trusts and a national provider of cancer nurse services. The organisation worked with the clinical commissioning group to ensure the services met the needs of the local population as far as possible.

• Priority was always given to patient’s receiving treatment and care at end of life. We observed during shift handovers how staff worked flexibly to prioritise patients whose needs became urgent. Care was provided 24 hours a day, seven days per week and there was access to end of life and palliative care advice at any time of the day or night.

• Staff listened to complaints and concerns and improved the service.

• The end of life and palliative care planned and action plans were based on the six national ambitions published by the National Palliative and End of Life Care Partnership, (2015). The outcomes were also based on achieving the five priorities of good end of life care (Leadership Alliance for the Care of Dying People, 2014)

• Staff we spoke with were clear about their roles and they understood what they were accountable for.

However:

• There was variable compliance in assessing and recording risks for patients in their last year of life.

• The programme of clinical and internal audit for end of life and palliative care was not yet embedded.

We rated community mental health services for people with learning disabilities as good because:

• There was an integrated team, and although there were vacancies, the provider was holding interviews for the posts shortly after the inspection. The variety of staff meant that service users had access to psychological therapies recommended by the National Institute for Health and Care Excellence. Staff ensured that any safeguarding concerns were passed to appropriate bodies.

• Staff working in the community used safe lone working procedures and there had been no serious incidents in the year before this inspection. They also had access to hand cleaning kits for visits. Staff attempted to rebook missed appointments.

• Staff held a range of meetings to allow them to seek supervision from colleagues in the team, as well as in their professional groups. Staff used these meetings to discuss learning from incidents and complaints, discuss the risks on their caseload as well as for informal supervision. The team also had good links with other local services.

• Overall, people that we spoke with who were either service users, or cared for service users (including other professionals) spoke highly of the service. One carer out of six that we spoke with felt the team could have done more to support them. We saw that staff provided high quality care on the two visits we accompanied them on. These echoed the provider’s values that had been developed by staff. The staff we spoke with were aware of the provider’s values. We saw that these values had translated into staff providing comprehensive care plans that had been developed with the person using the service.

• Staff had access to information leaflets and were developing more easy read information. Service users could access an easy to read website and staff could access translators for service users who did not speak English as a first language.

• Staff had waiting time targets and although they had identified waiting times as a risk, they had put measures in place to help meet them. In the majority of cases they were meeting their targets. The team’s performance was measured against key performance indicators to help ensure staff performed well, and governance systems helped to support them to reach these targets.

• Staff had planned to hold feedback groups for service users because they found that they did not return the questionnaires staff sent. There had been no formal complaints about this team in the 12 months before this inspection. Staff knew how to report complaints.

• There was strong leadership within the team and morale was high. The team were focused on improving the tools that they used and they were in the process of rolling out new information for service users.

However,

• Staff stored clinical information on different systems which meant that information might not be available to staff who need it. The provider was moving to a new record system in the three months after this inspection. This system would allow staff to access both health and social care records.

• The team had service users who were detained out of county under the Mental Health Act. The provider was advertising for a mental health liaison nurse to work with service users detained in other services out of county and was due to interview the week after the inspection.
• Mental Health Act training was not mandatory for staff which meant that staff may not have the knowledge to deal with services users with mental health problems if needed.