• Organisation
  • SERVICE PROVIDER

Lincolnshire Community Health Services NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Outstanding read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

18 June 2016

During a routine inspection

Our rating of the trust improved. We rated it as outstanding because:

  • We rated safe, effective and caring as good and responsive and well-led as outstanding. We rated three core services as good overall and one as outstanding. In rating the trust, we took into account the current ratings of the three core services not inspected this time.
  • We rated well led for the trust overall as outstanding. The rating for well led is based on our inspection at trust level, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement.

18 June 2016

During an inspection of Community health services for adults

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Data from April 2018 showed compliance with mandatory training was 93.2%. Although the trust target was 95%, this was better than other comparable trusts.
  • Staff understood their roles and responsibilities regarding safeguarding vulnerable adults and children. Staff had received appropriate levels of safeguarding training and could tell us about examples of where they had identified and raised concerns.
  • Staff demonstrated good practice with regards to hand hygiene and infection control. We saw hand gel available in clinical areas and the environment and equipment were visibly clean. Equipment was regularly serviced and cleaned.
  • There were effective processes for the reporting and management of incidents, most staff were aware of their responsibilities to report incidents and we saw learning from incidents was shared.
  • Patients’ individual care records were written, however, whilst most of the information needed was available to relevant staff in a timely and accessible way, there was inconsistency in the use of printed records in patients’ homes.
  • The service provided care and treatment based on latest evidence and national guidance and maintained a quality dashboard to monitor outcomes. There was a clear approach to monitoring, auditing and benchmarking the quality of services and outcomes for people. The service participated in relevant quality improvement initiatives and local and national audits.
  • Staff of different kinds worked together as a team to benefit patients. Nurses, therapists and support staff worked with professionals from other services to provide good care. Staff had the right skills and knowledge to safely care for patients.
  • Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.
  • Staff understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Staff cared for patients with kindness and compassion and respected their privacy and dignity. Feedback from patients confirmed that staff were kind and caring.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff worked collaboratively with patients and provided emotional support to patients and their relatives to minimise their distress. Services provided mostly reflected the needs of the fluctuating population served ensuring flexibility, choice and continuity of care.
  • Staff took account of patients’ individual needs and made use of technology to improve communication with patients.
  • Although the average time taken to close a complaint was longer than trust policy, service leads analysed trends and shared key areas of learning from complaints with staff.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, we did see a degree of silo working and lack of consistency across the teams with respect to assessments, processes and best practice.
  • The trust had clear governance structures and effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The risk register was reviewed regularly and staff had an awareness of the risks throughout the service.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. The services’ vision and strategy was in line with national priorities.

However,

  • Whilst we saw staff were using a less task-focused, holistic approach to care, we were not assured there was consistent practice across the trust in the approach to assessments and the use of records, tools and care plans to recognise and treat the patients who condition may been deteriorating.
  • Although staff in some areas told us the service had enough staff with the right qualifications, skills, training and experience, others raised concerns about the number of daily visits they were expected to undertake and the unpaid hours they had to work to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Whilst we saw staff were improving and developing services to meet patients’ needs, services were not provided consistently in all areas of the trust. Monitoring of ‘did not attend’ rates was inconsistent, and for some there were long waiting times for ‘referral to initial assessment’ for some specialities.

18 June 2016

During an inspection of Community health services for children, young people and families

  • Risks to children and young people using the service were assessed and their safety was managed so they were protected from avoidable harm.
  • Record and care plans were individualised, clear, accurate and up to date. Records were completed in a timely manner post visit in line with national guidance.
  • There was sufficient equipment available to meet the needs of the children and young people.
  • Overall, we found that care provided was evidence based and followed recognised and approved national guidance. Staff were clear of their roles in care pathways.
  • Staff had access to policies and evidence-based guidance through the trust intranet and staff we spoke with could access policies relevant to their practice.
  • Staff treated parents, children and young people with kindness, dignity, respect and compassion.
  • We observed good, warm and positive interactions between staff and children. Staff maintained eye contact with children, sat on the floor with them, smiled and nodded in response to each child.
  • We found all staff were focused on the needs of the children and young people and actively sought to minimise risks to them. Staff told us how hearing the voice of children and young people was fully reflected in the way care was planned and delivered. Feedback and comments from parents was positive and confirmed their views were sought at all times.
  • Leaders had the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff.
  • Managers across the trust promoted a positive culture that supported and valued staff.
  • The service had effective systems for identifying and managing risks.

However;

  • The trust policy on record keeping was paperless, therefore all records were stored electronically, however, staff we spoke with were not clear on what actions to undertake to access patient records should the electronic system not be available due to either a cyber-attack or other situation.
  • The service did not respond to all complaints in line with the trust policy which stated that complaints should be closed within 35 days.
  • Whilst the service collected patient outcomes on an individual basis, the service was unable provide evidence that it monitored the outcomes of the service as a whole.

18 June 2016

During an inspection of Community health inpatient services

  • Feedback from patients and people who are close to them was consistently positive. Those we spoke with felt that staff often went the extra mile and the care they received exceeded their expectations.
  • There was a strong, visible person-centred approach to care. We saw caring and supportive relationships between staff, patients, and those close to them were valued and promoted by staff and leaders.
  • Patients’ individual needs were highly respected by staff and embedded in their care and treatment.
  • Staff had a good understanding of managing individual patient needs and helping patients living with dementia.
  • Governance arrangements were proactively reviewed and reflected best practice.
  • Leaders had an inspiring and shared purpose. There were comprehensive leadership strategies in place to develop the desired culture.
  • There was a positive culture amongst staff across all wards and departments. Staff and managers appeared receptive of our review of services. Any concerns we identified during our inspection were recorded, shared with relevant staff, and acted upon immediately.
  • Staff were patient-focussed, proud of the work that they carried out and shared responsibility to achieve positive outcome for the patients.
  • There was clear accountability and reporting from ward to board.
  • A hospital based community ward (Digby) was temporarily established over one of the most challenging periods during winter pressures and was staffed by nurses and therapists deployed from Louth County Hospital as well as agency staff.
  • There was an improved culture of shared learning across the organisation following incidents and near misses.
  • There were effective systems for infection prevention and control and the management of sepsis.
  • Staffing levels were planned and reviewed to keep people safe, with any staff shortages responded to quickly. Staff had the skills and competence to carry out their roles effectively and in line with best practice.
  • Dementia screening and training improved.
  • The implementation of the five steps to safer surgery included all stages including briefing and debriefing.
  • Collaborative multi-disciplinary working enabled patients’ independence and supported evidence based care.
  • There had been improvements to governance arrangements, with a number of new initiatives introduced to monitor clinical practice and identify and assess risks to patients.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983, and the Mental Capacity Act 2005.
  • Scarborough Ward at Skegness Hospital had introduced environmental changes known as a ‘Memory Pathway’ to help patients with dementia to find their way around the ward. The pathway was colour coded to direct patients around the ward area and many historical pictures displayed of Lincolnshire landmarks.
  • Reminiscence software was used on the wards to provide stimulation for elderly patients and patients living with dementia.
  • The trust provided transitional care across services and system providers to ensure that home first principles were proactively viewed as the starting position and not the end point.   The service was significant in the system and provided an essential function in supporting the emerging Neighborhood Team models of care to achieve admission avoidance and reduce acute Delayed Transfer of Care (DToC). 

18 June 2016

During an inspection of Community urgent care services

Our rating of this service stayed the same. We rated it as good because:

  • There were robust systems and processes in place to safeguard people from abuse and harm. All staff were aware of how to respond to a safeguarding concern and felt competent and confident to take appropriate action.
  • There was an open and transparent approach to safety and an effective system in place for recording, reporting and learning from significant events. Staff were encouraged to record incidents. Outcomes of investigations were acted upon and learning was shared with staff.
  • There were comprehensive arrangements for audit and the service had a strong focus on monitoring and improving the clinical care of patients to ensure that it was in line with best practice guidance.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • The urgent and emergency care services teams were aware of the needs of their local population and understood that the nearest A&E departments to most of the centres was some distance away from where people lived. They had responded to this and adjusted their approach to delivering care to better meet their needs.
  • Patients could access services when they needed, overall 99% of patients were seen treated and discharged within four hours. This was against a compliance target of 95%.
  • Leaders planned to take account of winter pressures at all centres, and for Skegness centre, there was a summer plan to manage the increased influx of holiday makers during the summer season.
  • The service leads had identified a trend for patients presenting at some centres with more serious illness, and had adjusted their workforce to take account of this
  • Staff were overwhelmingly positive about the leadership within the service, including the chief executive as a very positive role model.
  • Staff had experience in urgent care and had received training to assess and treat adults and children with minor illness/injury.

8-11 September 2014

During a routine inspection

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.

Overall we judged the trust to be good. We identified some concerns regarding how safe services were, in particular concerns regarding staffing levels especially in community services; and a concern regarding the prescription of a controlled drug in the operating theatre at John Coupland Hospital that was contrary to trust policy.

The majority of staff utilised evidence based guidance and received suitable training and support to carry out their roles effectively. Improvements were required regarding supervision arrangements for some staff.

Feedback from patients and their carers was positive with the majority complementary about the caring nature and positive attitudes of staff and involvement in their care.

The majority of services were responsive to the needs of patients, and the majority of targets were being met or performance was improving. However, there were some gaps in children’s and family services, and some specialist adult services.

The majority of services were well led at a local level as well as corporately across the trust. There were some areas of improvement in children's and family services.

8-11 September 2014

During an inspection of Community health services for adults

Overall we judged adult community services to be good.

Staff were familiar with the process for reporting incidents, near misses and accidents and were encouraged to do so. There were some inconsistencies in practice with regards to learning from incidents and sharing of that learning within individual teams and across the organisation.

Staffing levels in some services required improvement. The trust were aware of this and had plans in place to address this. However, in some instances this was impacting on patient care, for example the number of avoidable pressure ulcers, and on staff morale. Whilst the trust’s rate for new pressure ulcers reported in a community setting was below the national average it was not achieving its own targets for 2014/2015 to reduce the number of pressure ulcers.

There were effective arrangements in place to manage and monitor the prevention and control of infection, management of medicines and safeguarding people from abuse.

Services were effective, evidence based and focussed on the needs of patients. We saw some examples of good collaborative work and innovative practice. However, data for completion of patients’ risk assessments varied by business unit and most were not meeting their targets

The majority of staff were up-to-date with mandatory training however staff experience of clinical supervision was variable and some staff were not accessing regular protected time for reflection of clinical practice. Also appraisal rates were low for the year to date.

Almost all staff expressed significant concern about the effectiveness of the IT system for recording patient information and the additional workload that this added on a daily basis. The trust had recognised that improvements were required and actions were being implemented to increase clinical time spent with patients across the organisation.

Services were caring. Patients and relatives or carers told us they were well supported by staff in multidisciplinary teams. We observed a compassionate and caring approach of staff in clinics and in people’s homes. Staff were aware of the emotional aspects of care for people living with long term health problems and ensured specialist support for people where needed.

Services were responsive to people’s needs across the majority of services. Staff worked well in multidisciplinary teams and across organisations to provide support to patients in the community. Patients were on the whole able to access the right care at the right time.

Services encouraged patients to provide feedback about their care. Complaints procedures were in place. Information on patient experience was reported and reviewed alongside other performance data.

There was good leadership and support from local managers and most staff felt engaged with senior management.

Many AHPs we spoke with were concerned that there was no senior/Board lead for their professions and consequently their voices were not heard at a senior level.

During the course of the inspection we met with almost 150 staff across all designations and roles. This included qualified nursing staff, specialist nurses, allied health professionals (physiotherapists, occupational therapists and speech and language therapists) health care support workers, team leaders and managers. Interviews were conducted on a one to one basis, in small groups of two or three staff within a service, or in group discussions arranged as focus groups.

We spoke with about 20 patients in a number of scenarios. We visited some clinics, and we accompanied district nurses to a number of people’s homes to talk to patients and their relatives about their experiences. We contacted some patients by telephone to ask their views of care and treatment received from the trust.  We also received feedback from patients who had completed our comment cards.

We analysed both trust-wide and service specific information provided by the organisation and information that we requested to inform our decisions about whether the services were safe, effective, caring responsive and well led.

8-11 September 2014

During an inspection of Community health services for children, young people and families

Community health services for children, young people and families included a range of services. During our inspection we reviewed the health visiting service, the school nursing service, the vulnerable children and young people’s team, the family nurse partnership service, therapy services and community dental services.

We spoke with 45 health visitors and support staff, 40 staff from school nursing teams, 14 therapists, six members of the family nurse partnership team (FNP) and four staff from the vulnerable children and young people team (VCYP). We also spoke with the general manager, the head of clinical services, and a locality manager and three deputy named nurses for safeguarding.

We spoke with 25 parents who were either accessing services during our inspection or by telephone. We accompanied staff on four home visits. We received 43 CQC comment cards which had been completed by parents prior to or during the inspection.   

Staff told us due to issues with connectivity they were unable to access records within patient’s homes. Most of the staff we talked with was positive about the use of an electronic records system although they felt that it took longer to complete record keeping. This was because they had to make hand written notes during the contact and then record the information electronically within 24 hours. During our inspection we found the numbers of health visitors working in the service and their case load sizes did not match the number provided to us before the inspection. The trust had an active programme of development to increase the number of Specialist Community Public Health Practitioners (SCPHN) within school nursing. However at the time of the inspection the school nursing service was not working within the DH recommendations from Choosing Health or CPHVA guidance of one qualified school nurse for every secondary school and their cluster of pyramids.

The Healthy Child Programme was delivered through skill mix 0–19 child health teams. The teams consisted of health visitors, school nurses, community staff nurses, nursery nurses, family support workers and health care assistants.

Initiatives such as UNICEF baby friendly were in operation. Children and young people’s needs were assessed and treatment was delivered in line with current legislation, standards and recognised evidence-based guidance. For example, the trust had just introduced a FNP team. There were formal processes in place to ensure staff had received training, supervision and an annual appraisal. We saw evidence that over 90% of staff had completed the relevant mandatory training.

As part of our inspection we observed care in patient’s homes, clinic settings and observed staff speaking to clients on the telephone. In order to gain an understanding of people’s experiences of care we talked to 25 people who used services in the family and healthy lifestyles business unit. Staff told us they were passionate about delivering high quality patient centred care. The majority of people we spoke with were generally happy with the care they had received. Throughout our inspection we found members of staff treated children, young people and families with dignity and respect. Parents told us they felt respected, well supported and that staff were always polite and helpful with any concerns they may have. We found all staff we spoke with were child and family focused and offered support to help children and parents cope with their care and treatment.

We identified gaps in commissioned services within school nursing for children and young people who had urinary wetting in the daytime or faecal continence concerns. In addition there was no current system in place to identify children who were not in education for example being home schooled. A lead role had been introduced to look at this however there was no timescale for when this would be achieved.  Staff in school nursing particularly raised concerns about how responsive they could be to meet the needs of children and young people as staffing capacity did not allow them to be as flexible as they needed to be. Staff within all therapy services were meeting the 18 week referral to treatment times however patients sometimes had to wait long periods to seen at a follow-up appointment.

There was confusion over the number of health visitors actually working within the health visiting service and having face to face contact with children. During our inspection we found there were large differences between the caseload numbers health visitors were working with. We asked senior managers about this who confirmed staff had not been deployed in the ‘right places’ across the health visiting service. They were aware this was something they needed to address but were unable to show us firm plans of when and how they would implement this across the trust at the time of the inspection.

Within the school nursing service staff told us they had very little flexibility to meet the needs of children and young people for targeted interventions. The school nursing service was commissioned to deliver interventions on the academic timetable and for children and young people with additional needs but this tended to be safeguarding work. Staff also told us they anticipated it would be difficult to be flexible as some children and young people needed more input than others and this was down to individual need. School nursing staff felt they were limited in the health promotion work they could undertake.

8-11 September 2014

During an inspection of urgent care services

Overall services were safe, and staff used evidence based guidance to provide care to patients at the urgent care centres and minor injury units.

Within the minor injury units and urgent care centres, first contact protocols were in use in most areas so patients at risk of deteriorating were identified to nursing staff immediately. This was not fully implemented at Skegness Hospital urgent care centre.

Patients commented on the caring nature of staff and for the majority were satisfied with their care. Within the minor injury units and urgent care centres evidence demonstrated that the handover from ambulance service to trust staff was less than the 15 minute target and during each quarter of 2013/2014 and over 98% of patients were discharged, admitted or transferred within four hours of arrival at minor injury units and urgent care centres provided by the trust.

8-11 September 2014

During an inspection of Community end of life care

Lincolnshire Community Health Services NHS Trust delivered community based services to people requiring palliative and end of life care and their families, throughout Lincolnshire. It provided a range of palliative and end of life care services within different care environments including hospice, hospital and care in people’s own homes.

At the time of our inspection we judged community end of life services were safe. There was awareness amongst staff to identify and consider patient incidents and most staff we spoke with were aware of incidents within their areas. Staffing levels were generally safe in the services we inspected, although some staff reported often feeling under pressure.

Community end of life services were judged as effective at the time of our inspection. Staff used evidence based guidance and focussed on achieving a positive outcome for patients.

Community end of life services were caring. Throughout our inspection staff demonstrated good clinical practice and spoke with compassion, dignity and respect regarding the patients they cared for. We received positive feedback from all the patients and most of the relatives we spoke with.

End of life services were responsive to patient’s needs. There were systems and processes in place to ensure people from all communities could access services and 24 hour arrangements in place for access to palliative and end of life services.

Overall we found community end of life services were well-led. Staff shared a common vision for end of life services and demonstrated a commitment to delivering good, safe and compassionate care.

8 - 11 September 2014

During an inspection of Community health inpatient services

Systems were in place to report and learn from incidents. There was evidence of local learning as the result of incidents. However, staff were not aware of incidents that had happened across the trust and lessons that may be learned.

Each ward used a reporting dashboard, the Safety Thermometer, which demonstrated how the ward performed on key risk areas. The average percentage of harm free care was 94.4% in June 2014.

The majority of ward areas were visibly clean, and staff were compliant with infection control good practice. There were no reported cases of MRSA or Clostridium difficile over the last 6 months.

Premises were adequately maintained. Equipment was well maintained and tested for safety appropriately in most areas. However, some equipment in use at Skegness hospital was not in date for portable appliance testing (PAT).

The majority of medicines were administered correctly and appropriately. However, there were concerns regarding the use of verbal orders for the repeat prescription of a controlled drug in the surgical day unit at John Coupland hospital; this was contrary to hospital policy. The safer surgery checklist was used; however the full five steps to safer surgery including the briefing and debriefing were not formally used within the unit.

An electronic record system was in use. Patients were assessed using nationally recognised tools and care plans were in place using evidence-based templates. There was a variety of records held by the patient’s bedside; this was not consistent across the hospitals. There was a risk of duplicate or inconsistent information recorded about the patient.

The staffing levels on the wards at Louth County Hospital and Skegness Hospitals were below the staffing levels identified by the trust. The hospitals had vacancies and were actively recruiting, although they reported it was difficult to recruit within the geographical area, particularly at Louth County Hospital. Staff sickness was also a contributory factor and management of this was improving.

Staff had access to policies and guidance on the trust’s intranet and internet. Access to specific NICE guidance was unclear to some staff. They reported finding the information themselves and sharing with colleagues. The trust reported that the screening targets for dementia were not met. Compliance with mandatory training was good and staff reported development opportunities were available. We saw evidence of role development to meet the needs of the patients.

A number of monthly audits were undertaken to monitor quality. Not all planned audits had been undertaken. The monitoring of patient outcomes was not consistent across the hospitals.

Patients spoke positively about the staff and the care they received. We observed staff speak with patients in a compassionate and sensitive way in a variety of situations. The Family and Friends Test (FFT) was implemented in April 2013. Across 2013/2014, response rates ranged from 8-19% and positive responses ranged from 74.3% to 94.2%.

The services at the community hospital wards were planned to meet the needs of patients. Admission criteria and pathways were in place and patients were appropriately admitted to the facilities. The service was able to meet the care needs of more vulnerable patients and those with particular needs. This was hindered in some places due to the environment.

Discharge planning was integral to the care of patients on the community hospital wards. The multidisciplinary team were involved in the process and we saw examples of discharge planning being discussed with patients and their wishes being taken into account. On average, at the end of each month from December 2013 to May 2014, 4 patients’ transfers of care were delayed. All reported delays were for non-acute patients.

Complaints were managed appropriately and lessons learned. Most areas had local clinical governance meetings and were represented on the monthly Quality and Risk Scrutiny business unit meetings. Local risk registers were not maintained. Risks were placed on the trust-wide risk register. Staff felt that senior managers were aware of significant risk issues.

There was dedicated leadership for the services and staff understood the structure and spoke positively about this. Staff reported good, supportive leadership and said that the trust management team were visible. Staff we spoke with were positive about the service, the team and the organisation within which they worked. They felt patient safety and quality were seen as priorities.

Most staff felt supported to develop ideas to improve the service and we saw examples of innovation and improvement. Some areas such as Louth County Hospital felt the environment limited innovation.