Archived: Liverpool Community Health NHS Trust

Updated 8 July 2016

We found that the provider was performing at a level which led to a judgement of requires improvement.

We judged the majority of services to be safe; however there was a risk to patient safety from reduced community staffing levels, most notably in children’s and family services, and from the acuity of patients being admitted to the intermediate care wards. Staff reported incidents and the majority felt confident to do so; however learning tended to take place within local teams. Staff levels and caseloads varied in risk across the organisation; community services carried the greatest risk, though action had been taken to improve staffing levels in district nursing services. The acuity of patients on inpatient wards had resulted in a lack of rehabilitation.

Staff were able to describe how to use pathways of care and treatment that are based on nationally agreed best practice. There was multidisciplinary team work taking place. Training had improved recently and staff welcomed the block training approach that offered them better opportunities to attend. The trust took part in national audits; local audits were also carried out. Learning tended to remain local within teams.

Most patients commented on the caring and compassionate approach of staff across the organisation. We saw staff treating patients with respect. Patient surveys carried out by the trust showed good levels of patient satisfaction. Patients were involved in care decisions in the majority of services. However some patients were concerned about shared waiting areas in the walk in centres. There were some concerns regarding care within intermediate care wards which didn’t demonstrate patient involvement in their care and assessment.

The majority of services we reviewed were responsive to the needs of the patients. There was good triage in the walk-in centres. Multidisciplinary teams were working to make sure patients were discharged smoothly and the children’s care services were centred on the needs of families. Concerns were identified with access to some services; although staff had taken a range of action to improve the service, there remained long waiting times for access to wheel chair assessments for adults. Some elements of the healthy child programme were not being met due to staffing arrangements and a prioritisation of vaccination and immunisation clinics. Response times at the single point of contact were adversely impacting on access to some services.

The trust had a vision and values in place, but these were not well known by all staff, and staff had not been engaged with effectively in some service reconfigurations. Governance structures had developed since a warning notice was issued in January 2014 but trend analysis required further development and systems to share and develop learning needed to be embedded across the trust. There had been recent changes amongst executive staff at the trust and staff we interviewed welcomed the changes. Staff told us they felt there had been improvements in the culture of the organisation and some more punitive processes had been changed. Patient engagement was good with evidence of service development as a result of patient stories shared with the trusts board.

The trust had been served with two warning notices in January 2014. The provider was served with a warning notice for outcome 16 (regulation 10, assessing and monitoring the quality of service provision) and ward 35 intermediate care unit was served with a warning notice for outcome 14 (regulation 23 supporting workers). The trust was told to ensure they were compliant with these regulations by 1 April 2014.

During our inspection in May 2014 we judged that the provider had met the requirements of regulation 10 and had demonstrated suitable improvements to its systems for assessing and monitoring the quality of service provision. With regard to the warning notice served on ward 35 intermediate care unit, we judged that the provider had met the requirements of regulation 23 supporting workers.

In addition to this compliance actions were served on both the provider, ward 35 intermediate care unit and Alexandra Wing, Broadgreen Hospital. At the provider level, these were outcome 4 (regulation 9 care and welfare of service users), outcome 11 (regulation 16 safety, availability and suitability of equipment), outcome 13 (regulation 22 staffing) and outcome 14 (regulation 23 supporting workers).

At ward 35 intermediate care unit these were outcome 4 (regulation 9 care and welfare of service users), outcome 9 (regulation 13 management of medicines), outcome 13 (regulation 22 staffing), and outcome 14 (regulation 23 supporting workers).

At Alexandra Wing, Broadgreen Hospital these were outcome 9 (regulation 13 management of medicines) and outcome 14 (regulation 23 supporting workers).

Whilst trusts are told the date by which they are to be complaint when served with a warning notice; trusts inform CQC when they expect to be compliant when served with a compliance action. At the time of this inspection (12 May 2014), the dates for compliance (against the compliance actions served above) were;

• Outcome 4 (regulation 9) – June 2014
• Outcome 9 (regulation 13) – March 2014
• Outcome 11 (regulation 16) – July 2014
• Outcome 13 (regulation 22) – June 2014
• Outcome 14 (regulation 23) – June 2014

As a result of this, whilst we reviewed evidence against these outcomes, with the exception of outcome 9 (regulation 13) further inspection will be required to judge compliance against these outcomes during the coming months. During the inspection in May 2014 we assessed and judged the trust compliant with outcome 9 (regulation 13).

Updated 8 July 2016

At the last inspection we found improvements were required in relation to waiting times, learning from incidents and staffing, and the trust still had some outstanding actions to meet regulatory breaches previously identified in regards to staffing and governance.

At this inspection we rated community health services for adults as ‘Requires Improvement’ overall because;

• We found that there was a need for further work to identify, provide and monitor safe staffing levels for individual core services.

• Although the trust had identified waiting times as a concern on the risk register and remedial plans were in place, we were still concerned about the pace of progress as there were lengthy waits for some patients. Some of the services provided by the trust had not met their waiting time targets in the 12 months prior to the inspection.

• Systems for governance, risk management and quality monitoring were in place through the locality structures. However, we found further work was required to embed these systems to ensure that learning and communication was cascaded across the wider geographical area and localities.

• The role of clinical leads and locality teams were new to staff; this needed time to mature whilst ensuring that centrally hosted services are engaged appropriately and the issues across localities are linked throughout the trust.

However;

• The majority of staff were positive about the progress made by the trust and told us the trust felt more open and staff appreciated the changes that had been made. There were however still areas of concern where staff felt that the senior management attention had been concentrated on the high risk areas to the detriment of their own services. The trust management acknowledged the improvement and the need to be more visible and supportive of all the adult community services.

• There were examples of good local leadership across the individual services.

• The inspection team were mindful of the complexity of different commissioners and acute providers in service planning and delivery of services. However, the trust needs to ensure that they fulfil their responsibilities to engage with the public as part of the reshaping of services.

Updated 8 July 2016

Overall, we have judged that the community service provided to children, young people and their families "Requires Improvement". This is because;

• Safeguarding children policies and procedures did not reflect the most up to date best practice guidance.

• Some staff had inherited caseloads on day one of their employment despite still being in their preceptorship period.

• There were high levels of sickness in some health visiting and school nursing teams.

• Whilst there had been significant improvements in the delivery of services since the last inspection in May 2014, the trust was still not meeting some key aspects of the Healthy Child Programme.

• The numbers of staff who has received an appraisal was lower than the trust’s target. Though transition processes were in place, the trust did not have a policy detailing the process of children transitioning either internally across the trust or into Adult Health services.

• Improvements were needed in the way that the service responded to the needs of the children and young people it served. In some parts of the service, there were unacceptable delays in the referral pathways to allied health professionals such as speech and language therapies and dietetics.

• Some risks weren’t mitigated in a timely way and some services didn’t have clear action plans to improve performance.

However;

• The trust had done a lot of work to improve the culture and the majority of staff stated that the organisation was a very different place to work than it had been, although not all staff felt fully informed and engaged.

• The trust has responded to the risks associated with lone working. The introduction of more training and the use of IT and communication systems has meant that staff working in the community could be more closely monitored and supported.

• Safeguarding concerns were given the highest priority and were taking up more and more of the clinician’s time. As a consequence, not as much health promotion work was being undertaken in schools.

• Incident reporting had improved and lessons were being learned. Medicines were being well managed; this included the preservation of the ‘cold chain’ for vaccines.

• People we spoke with who used the service were positive about the way they were treated by staff. Children, young people and their families said they were treated with compassion and respect. We saw staff ensuring that people’s dignity and privacy was upheld.

• In terms of leadership, staff generally spoke positively about the recent changes. Clinician’s felt that they now had a voice that was more likely to be heard by senior managers within the trust. The move to localities was welcomed and whilst the organisation was still going through change and transformation very few staff raised this as an issue.

Updated 8 July 2016

At the last inspection in May 2014, we found improvements were required relating to care and welfare, medicines, staffing, supporting staff and quality assurance processes. Staff also raised serious concerns regarding the trust’s culture.

At this inspection we rated community inpatient services as ‘Good’ overall because;

• We found that the culture and procedures relating to patient care, safety, medicines, supporting staff and reporting incidents, had improved.

• Staff said that they now had access to recent incidents and that they now felt supported by the trust.

• The trust had systems and processes in place for governance and risk management.

• We found that patients had been admitted with needs more complex than was set out in the ward admission criteria. However we found that this had no impacted on staffing levels and the ability of staff to do their job.

• We spoke with 11 patients and relatives of six people who are current patients during this inspection. Most of the patients and relatives spoke positively about the care they had received.

• Patients were fully protected against the risks associated with medicines because the provider had made appropriate arrangements to safely manage them.

Updated 4 August 2014

The Walk-in centres were managed through the ambulatory care directorate. The centres had both clinical and service manager leadership.

There were effective systems and processes to provide safe care and support for patients. Patient safety was monitored and incidents were investigated to help learning and improvement. There was not always enough staff to make sure that patients referred to the services could be seen promptly. This may impact on the quality of care delivered by the service.

Systems were in place to support vulnerable patients. Patients and their relatives spoke positively about their care and treatment.

Staff followed national guidelines and had clinical procedures in place based on national and regional guidance. The trust took part in local clinical audits but did not have a clear audit calendar. Changes to the service information system did not facilitate the services ability to communicate with external partners such as GPs in a timely fashion. The clinical managers told us that previously they had been able to carry out systematic peer reviews to ensure that practitioners were clinically effective and adhering to best practice guidance. The changes to the information system in 2010 meant that this was not possible. We were told that the service was about to start procurement for a new Information system.

Staff told us and records showed that they had been appropriately supported with training and supervision, and encouraged to learn from mistakes. We found that the staff were hard working and caring. The team felt supported locally but did not have regular staff meetings due to pressure on staffing and staff were not aware of the trust visions and strategies.

Updated 2 July 2014

There were a number of measures in place to monitor patient safety and reduce the risk of harm to patients. There was evidence of dissemination of learning from incidents and complaints. In the patient records reviewed there was no evidence of risk assessments being completed, which related to issues around staff safety or the patients general living environment. The team relied on risk assessments being completed by community nursing.

The team had procedures based on other national and regional guidelines. The staff within the team followed guidelines from other organisations, such as the Macmillan Cancer Support and Marie Curie Cancer Care. There was effective communication and multidisciplinary team working. The staff within the team were highly trained and had a good understanding of existing end of life care guidelines and implemented these effectively.

Services were delivered by a hardworking, caring and compassionate staff. We observed that staff treated patients with dignity and respect and planned and delivered care in a way that took into account the wishes of the patients.

Staff had a good understanding of the needs of the local population and worked as part of multi-disciplinary teams and routinely engaged with local hospices, GP’s, adult social care providers and other professionals involved in the care of patients. The team delivered comprehensive training to community nursing staff to ensure that care was responsive to people’s needs.

There was an awareness about the trusts visions and strategies, but there was a disconnect between the team and wider trust. There was no audit schedule of key processes in place. Information relating to core objectives and performance targets was not readily available. There was confusion regarding line management within the team.