Sirona Care & Health C.I.C.

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 between 18 and 21 October 2016. We also carried out an unannounced visit on 1 November 2016 and inspected the following core services:

• Community health services for adults
• Community health services for children, young people and families
• Community inpatients
• Community mental health services for people with learning disabilities or autism
• Urgent care services
• End of life services

Sirona Care and Health CIC also provide adult social care through a number of residential units. These did not form part of this inspection but have been inspected and reported on separately.

During the inspection we visited a variety of locations including all three community hospitals and both minor injuries units. We visited health centres and children’s centres to inspect services for children, young people and families. To inspect the community adults’ services, we went to a range of health centres, went out with district nursing teams to people’s homes, visited health centres and clinics, and met with staff delivering palliative care, accompanying them on visits to meet the patients and families they were supporting. We spent time with the executive, non executive and leadership team, conducting interviews, held focus groups and observed a board meeting.

Staff were cooperative, open, helpful and supportive to us at all stages of the inspection.

Our key findings were as follows:

Safe:

• Compliance with training for both adults and children’s safeguarding was variable and not all staff received training at the correct level.
• The premises at Thornbury Hospital was not fit for purpose. The ward was cramped meaning there was not suitable room for equipment, patient chairs, or adequate space around the beds to perform day to day duties. However, it is recognised that the organisation did not own Thornbury Hospital.
• There were issues with maintenance of the building at Ash House at St Martin’s Hospital in Bath including delays in issues being rectified. For example, there was no working door bell, paint peeling from walls in toilets, stains on the carpets and the ceiling in the manager’s office had recently collapsed.
• Within the learning disabilities service, interview rooms did not have alarms at any of the sites. Staff relied on administrative staff being aware that they were using rooms and for them to call for help if needed.
• Notes were not always stored securely in community hospitals. Notes trolleys were left open and unattended and one trolley did not lock at all.
• National guidance was not fully followed with regard to patient treatment escalation plans (TEP).
• Compliance with mandatory training was variable though shortfalls were being addressed by the organisation through the development of a full days training to ease staff release from the work areas. However, compliance varied from 66-91%.

However:

• There was a good culture among staff for reporting incidents. There were systems in place to report incidents and near misses that staff were familiar with and competent in their use.
• Staff had a good understanding and knowledge of when to apply the duty of candour.
• There were adult and children’s safeguarding systems in place to keep patients safe. Policies were in place and staff were aware of their responsibilities in relation to safeguarding.
• The majority of medicines were stored and administered safely.
• There were reliable systems in place to prevent and protect patients from healthcare associated infection.
• Staff assessed and responded to patient risk. Staff completed risk assessments and where patients presented with high levels of risk, an embedded system of multi-disciplinary working meant teams were able to seek specific support .
• There were business contingency plans in place to respond to emergencies and other major incidents.

Effective

• Patients’ care and treatment were delivered in line with relevant legislation, standards and evidence-based guidance. Staff followed evidence based and current practice when assessing and planning care
• Where documentation existed we saw that pain assessment and management was integral to patient care and treatment.
• In most instances, information about people’s care and treatment, and their outcomes, was collected and monitored and was used to improve care.
• There was participation in relevant local and national audits
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• There was adherence to the Mental Health Act 1983 and the Mental Health Act Code of Practice
• A strong multi-disciplinary working approach ensured co-ordination of care pathways and transition arrangements.

However;

• Services within the community did not consistently document the assessment and management of patients’ pain.
• Whilst consent to care and treatment was, in most cases obtained in line with legislation and guidance, some staff within the minor injuries units were not entirely familiar with the way in which consent was handled for people who could not make their own decisions and within the children’s services, not all staff were clear about the implications of the age of a child in relation to consent.

Caring

• People were respected and valued as individuals and were empowered as partners in their care. Partnership working, led at all times by the patient and family was observed to be embedded, and routinely applied.
• Feedback from people who use the service, those who are close to them and stakeholders was continually positive about the way staff treated people. People were truly respected and valued.
• Staff were often described as going the extra mile and the care people received exceeded their expectations. Relationships between people who used the service, those close to them and staff was strong, caring and supportive.
• Throughout, people were provided with care that was dignified, respectful and compassionate. Staff took people’s personal, cultural, social and religious needs into account and provided truly holistic care.
• People were active partners in their care. They were supported to manage their illness whenever possible and were involved in all care decisions.
• Staff adapted how they provided end of life care to fit around people, so that at all times, patients were involved as much as they wanted to be and were treated with dignity and respect. Staff skilfully balanced humour, honesty and compassion with each situation.
• People and those close to them were given appropriate and timely support and information to cope emotionally with their condition.

Responsive

• Services were planned and delivered to meet the needs of the local communities
• The equality and diversity needs of people who used the services was met at all times.
• Services were planned, delivered and coordinated to take account of people with complex needs and those in vulnerable circumstances.
• There were different approaches to ensure access to the right care at the right time for most people
• There were systems and processes in place for handling complaints and sharing learning as a result. A dedicated customer care service had been established to ensure the smooth handling and follow up of all complaints and concerns, no matter how they were raised.

However;

• Waiting times for some services exceeded the NHS England targets of 18 weeks from referral to start of treatment
• The minor injuries unit in Yate, although providing the service it had been commissioned to deliver, was not able to meet the demand from patients at times. This resulted in frequent early closure of the service.

Well-led

• There was a clear vision and set of values in place that were developed with staff and demonstrated by staff at all levels.
• Throughout the organisation, quality and safety were top priorities and were taken into account whenever financial decisions were made.
• Progress against strategic objectives were measured through ongoing audit
• There was strong and well established leadership of the organisation. Reports received at board meetings were subject to scrutiny and challenge. Members and non executive directors held the executive team to account.
• The organisational ethos of ‘taking it personally’ was developed in conjunction with staff at all levels and was demonstrated wherever the inspection teams went.
• Staff were empowered to suggest change and develop their own services.
• Public and staff engagement occurred in all areas of the organisation. Patient feedback was welcomed and encouraged. Patient stories featured prominently at board meetings.
• The loss of a significant and sizable contract had just been announced. The executive team recognised the impact this would have on staff, services and the remainder of the organisation and were developing plans to mitigate risks and ensure continuity.
• A quality impact assessment was undertaken for all cost improvement programs with the impact of the saving reviewed throughout the year. Where the saving was felt to affect quality, it was not approved.
• Services were empowered to be innovative and progressive.

However;

• Although there were systems and process in place which ensured the governance and risk management of services, in places these required strengthening, most notably in relation to the management and oversight of lower level risks.

We saw several areas of outstanding practice including:

• All staff in the minor injuries units had been provided with a review of their practice and competence in the last year (annual appraisal). Staff also had monthly meetings with their line manager, clinical supervision, and were supported with training and development.
• The matron at the minor injuries unit at Yate had been supported over a two-year period to help establish minor injury services within 29 GP practices in South Gloucestershire. This relieved pressure on this already high-demand service and more widely for the healthcare economy in that area.
• We saw evidence that care provided to end of life patients and those people close to them across the Sirona services was outstanding. Holistic and person centred support was embedded in practice and patients and family were fully involved and informed about all aspects of treatment and care. Relationships were highly valued by both patients and families and staff. The attention to detail and level of care, treatment and support provided by staff far exceeded expectations.
• Patients with end of life care needs were prioritised at all times and care and support was provided 24 hours a day, seven days per week. Partnership working with patients, families and other professionals and services was evident throughout the service, and this enabled coordinated and responsive care to be provided. Staff at all levels were actively supported to develop their end of life knowledge, skills and practice in order to deliver a high quality service.
• Staff positively looked for ways to engage patients and those people close to them with the planning and delivery of services and a range of resources had been developed to promote equality of access to the service. Staff worked above and beyond their roles to ensure wherever possible that patients and families achieved their hopes and wishes.
• The use of reminiscence pods and other activities to stimulate patients living with cognitive impairment within the community hospitals.
• The community adults service demonstrated outstanding multidisciplinary working across services, with GPs and other external health care providers.
• Feedback from patients was consistently positive; patients went to great lengths to tell us about their positive experiences.
• Patients were active partners in their care, and were encouraged to speak about their opinions of their planned treatment. Care was truly person centred, with patient’s wellbeing at the heart of care.
• Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity and were fully committed to working in partnership with people.
• The organisation provided a number of bespoke services across their adult community services such as the active ageing service, falls service, emergency care practitioners and blood transfusion and intravenous service all of which had led to positive outcomes for patients.
• Within the community adults service, staff regularly went the extra mile when caring for patients.
• The transition planning for young people being undertaken by staff in the Lifetime service was outstanding as was the planning of advance care plans and the support of families in completing these.
• Sirona provided placements for people with disability or autism who were often previous users of their services. People were offered roles for a period of time to help them to gain skills in the job market and to boost their confidence.
• The learning disabilities service proactively managed risks for service users who could be detained under the Mental Health Act with other agencies. This had resulted in no admissions to hospital in four years
• In Bath and North East Somerset staff working in the learning disabilities service had a communication passport in a grab bag that they carried with them to all new assessments, designed to ensure that staff communicated with people when they first met them before they had the opportunity to assess any communication needs.

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

Importantly, the provider must:

• The provider must improve its compliance rates for level two and level three adults and safeguarding training and ensure that safeguarding training is received at the right level for the role.
• The provider must ensure that the care records system/s it has in place within the learning disabilities service do not pose unnecessary risk for staff and people who use the services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service

We rated community health services for adults as good because:

• There were effective incident reporting systems in place and staff reported they received feedback and learning from these.
• Staff had good knowledge of safeguarding procedures and felt supported in raising any safeguarding concerns
• Good medicines management protocols were in place to keep patients and staff safe.
• Equipment was available, had been checked and was serviced regularly.
• The needs of patients were assessed, planned and delivered in line with best evidence based practice using recognised assessment tools in most cases.
• Multidisciplinary team working was embedded throughout the service and referrals to different healthcare professionals were coordinated and efficient.
• Feedback from patients was consistently positive, patients went to great lengths to tell us about their positive experiences.
• We saw patients who were active partners in their care, and were encouraged to speak about their opinions of their planned treatment.
• Care that we observed was truly person centred, with patient’s wellbeing at the heart of care.
• Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.
• Staff were fully committed to working in partnership with people and made this a reality for each person.
• Patients were given information about how to make a complaint or raise a concern. There were systems in place to evaluate and investigate complaints.
• There was strong local leadership in place. Staff felt able to approach their managers.
• There were governance and risk management systems in place.
• There was a very positive, supportive culture across all staff groups we spoke with.
• The organisation listened to staff and looked to ways to improve and be innovative across their services.

However:

• Individual care records did not always have risk assessments reviewed and electronic records did not always match with information kept in the patient’s home.
• Staff did not always update records contemporaneously due to connectivity and confidentiality issues.
• Not all staff were compliant with mandatory training in safe systems, processes and practices.
• In some teams staffing levels were below established numbers which meant substantive staff had to work extra hours to cover the workload. The organisation was continuing to advertise and recruit to posts. In some clinic based services, despite being staffed to commissioned levels, there were long waiting lists. the shortage of staff had led to long waiting lists that were The lists were triaged to ensure patients with urgent needs were prioritised.
• The service did not always monitor the completion of timely assessment of risks to patients.
• Some bespoke services that needed specialist staff to run them were not able to be offered if that person was on leave or off sick. Although patients were offered another appointment with an alternative appropriate service.
• There was inconsistency across the two local authority patches in which Sirona worked. This meant different systems were in place in different areas making it difficult to provide consistent and meaningful audit data and an overview of risks across the services.

Overall rating for this core service Good

We rated Community Inpatients to be Good. This was because:

• Safety performance was good. Staff understood their roles and responsibilities to report incidents and lessons were learnt and shared widely when an incident occurred. The duty of candour was upheld for serious incidents and being open and honest was the culture throughout the hospital.

• Day to day risk management of patients’ needs was good. This included for the management of a deteriorating patient and for medical emergencies. Care plans were comprehensive, patient centred and were reviewed appropriately.

• Care was delivered and coordinated with a range of different staff providing an effective multidisciplinary approach to care. This included from services outside of Sirona.

• Feedback from people who use the service and those close to them was continually positive. There was a strong person centred culture and inspectors observed staff showing kindness, preserving dignity, and building relationships between themselves, patients, and their relatives.

• We saw examples of where staff were helping people cope emotionally with their, or their loved ones stay in hospital and encouraged patients to manage their own health to maintain independence.

• Services were planned and delivered in a way that met the needs of the local population and took into account the different needs of people when planning and delivering the service. People living with complex needs had reasonable adjustments made to maintain their wellbeing. The use of reminiscence pods were an innovative idea to encourage engagement of people living with a cognitive impairment.

• We found that there was a clear statement of vision and values which was driven by quality and safety. This was reflected in the attitudes and behaviours of staff. Strong local governance processes ensured adequate oversight of local risk and performance which was monitored on a regular basis.

However:

• Not all staff were compliant in safeguarding level two training for adults and children. The biggest areas of non-compliance was Thornbury Hospital with under half of staff having up to date training.

• Medical records were not always stored securely

• here were multiple consumables, such as dressings, out of date at St. Martin's Hospital with some consumables being three years beyond its use by date.

• There were significant delays in discharge at St. Martin's Hospital and Paulton Memorial Hospital which were outside the organisation's control.

• The environment at Thornbury Hospital was not fit for purpose. It was cluttered, difficult to maintain patient privacy and was not set up to accommodate for people living with dementia.

Overall, end of life care and treatment was rated as outstanding because:

High quality, effective and responsive treatment and care was evidenced as established in practice and provided to patients and those people close to them. National guidance and best practice was seen to be understood and followed. Staff at all levels were well supported and encouraged to develop their knowledge and clinical skills.

The majority of Sirona end of life care was provided in patients’ homes by district nursing teams, most of who were based with GP surgeries. End of life care was also provided within the three community hospitals located in Bath (St Martin's Hospital), Paulton and Thornbury.

There was a truly holistic approach to care and support to patients and those people close to them. Pain and symptoms were regularly reviewed and management plans put in place. Staff proactively and consistently looked for ways to ensure wherever possible, that patients and families hopes and wishes were achieved. Across the services we observed numerous examples of staff who worked in partnership with patients and collaboratively, flexibly and effectively with other professionals, teams and services to provide coordinated care.

Processes were in place to promote equality of access to end of life treatment and care regardless of each patient’s individual differences or personal circumstances. This included the development of end of life care plans for patients with particularly complex or vulnerable needs, and staff training to provide this.

There was a clear end of life strategy in place which was based on service user feedback, national strategy and with local commissioners input. Identified goals and action plans were seen to be kept under regular review. The service was well led and staff were proud of the end of life treatment and care they provided.

Care was safe. Patients had risks assessed, reviewed and actions put in place. Medicines to manage pain and other symptoms were prescribed and provided in advance of requirement. Staff had access to a range of end of life training and were well supported in their roles.

The culture was ‘can do’ and positive. Patients and those people close to them were consistently highly satisfied, with reports that the level of care and attention to detail far exceeded expectations. Practice was truly holistic, patient centred, compassionate and sensitive at all times.

Some improvements were required to the detail recorded on treatment escalation plans and to systems and processes used to monitor and evaluate risks and quality information specific to end of life patients. Improvements were required to the compliance level of staff with safeguarding children and vulnerable adults training.

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

• There was a positive culture around incident reporting which helped promote learning and service improvement for children and families. Staff said they received feedback from reported incidents when this was appropriate and were told what actions were taken.

• There were arrangements in place to safeguard children from abuse that reflected the relevant legislation and local requirements. Staff understood their responsibilities and were aware of the provider’s policies and procedures.

• People’s needs were assessed and care and treatment was delivered in line with legislation and evidence based guidance. We saw numerous examples of best practice being identified, shared with colleagues and delivered.

• There were some outstanding examples of the planning for transition being undertaken. This included the Lifetime service who undertook planning for transfer to adult services and the Bath & North East Somerset (B&NES) speech and language team who were providing transition reports for people with autism moving into further education or going on to university.

• The provider encouraged innovative practice. One of the school nurses had developed an app to help young people make informed choices regarding sexual health and contraception.

• We observed care, support and advice being delivered by a variety of staff in a compassionate and caring manner at all the locations we visited. We had feedback and comments from children and families that was positive about the staff they received a service from. People told us that staff took the time to explain and ensure they understood the care and treatment they were involved in providing.

• The services which Sirona were commissioned to provide were planned to meet the needs of the local population. For example Sirona, as part of the Community Children’s Health Partnership, had worked with a charity in developing a participation strategy. This strategy outlined how children, young people and their families could be involved with service feedback, development and improvement.

• The Lifetime service provided specialised, highly valued care and support to approximately 250 children with life limiting conditions and their families over a wide geographical area. This included some outstanding practice around advance care planning for children and families.

• Sirona had a vision and set of core values that were well promoted and known to staff. Staff were proud of the organisation and the services they were involved in providing. Because the transfer of the Community Children’s Health Partnership had only taken place on an interim basis, Sirona and the other partners had not introduced a new service vision and strategy. Instead, they were focusing on continuing to deliver the service while the contract tender process was being completed.

• There were numerous examples of staff engaging with the users of services to gain feedback and use this information to influence service development.

• We saw examples of teams and individuals engaged in improving their services and its delivery through research and the sharing of learning and participating in innovative projects.

• However:

• There were some shortfalls in the safeguarding training updates being completed by some teams.

• The support staff working within the Lifetime service were being trained to safeguarding level two when the national recommended level for staff lone working in this type of situation is level three.

• We saw examples where staff were not following the required infection control protocols.

• There were shortfalls in the systems for storing of medication used by the sexual health nurses working in the schools.

• There were inconsistencies in the use of risk registers and the understanding of the process for escalating concerns.

We rated urgent care services, overall, as good because:

• Patients had safe care. They were assessed to make sure they had timely care, appropriate pain relief, and their safety was monitored. Good records were kept about patients.
• The units were clean, well maintained, and designed to keep people safe.
• People were protected from abuse and avoidable harm. Staff had good knowledge of safeguarding.
• There were mostly good levels of well-trained, experienced and skilled staff, although the level of nursing staff at the Paulton unit, which was what had been agreed with the commissioners, was stretched at times.
• Care was effective and patients had good outcomes.
• Care was delivered with kindness and compassion. Staff made sure the patient was at the centre of the service, and offered emotional support.
• Vulnerable people were supported to have responsive, safe and effective care.
• Complaints and concerns were listened to and acted upon to improve services.
• The minor injuries services reflected Sirona’s values to deliver high quality care, and to be caring and compassionate to people they looked after.
• The Friends and Family Test reported that almost everyone who responded would be likely or extremely likely to recommend the service.

However:

• The high demand for the minor injury service in Yate meant the organisation could not always meet the needs of everyone who came for treatment.

• There was a lack of systematic management of risks at a unit level. The team meetings at Paulton did not have a specific structure and some areas of governance were not routinely discussed at either location.
• Some staff did not have sufficient knowledge of consent to ensure it was always provided in line with legislation and guidance.

• The resuscitation trolley needed to be tamper evident (Yate). The audit routines did not include checking and approval of the resuscitation equipment and stocks.

Sirona is a community interest company that provides community health and adult social care services and was established in October 2011. Sirona provides a number of services to people with a learning disability including health services and social care.

This inspection focussed on the health services that Sirona provided to people with learning disabilities. The complex health needs team in Bath and north east Somerset (B&NES) and the community learning disability service in south Gloucestershire both provide multidisciplinary services to work with people who have a learning disability who require support for complex health needs including mental health care.

The south Gloucestershire service has a hydrotherapy service attached to it.

The complex health needs team is commissioned by B&NES clinical commissioning group and the south Gloucestershire community learning difficulties team is commissioned by south Gloucestershire clinical commissioning group. Each service is commissioned separately with specific service requirements.

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

• Service users told us that staff were supportive and caring, treating them with dignity, respect and kindness. Service users felt that staff listened to them. Carers commented that staff were interested in them and the service users as people. Staff displayed warmth and genuine interest in people using the service. This was evident for all staff within the teams.
• The service used interventions in line with National Institute for Health and Care Excellence (NICE) guidance delivered by a diverse and skilled multidisciplinary team.
• Service users were seen within four weeks from referral to the service. Service users, their carers and social care providers all said that staff were accessible quickly when they needed them.
• There was clear leadership evident from team leaders and the divisional manager that was respected and valued by staff within the service. Staff we spoke with were very complimentary about the team managers and the support and direction they give the teams.

However,

• Care records were stored on multiple systems and this meant that important service user information was not easily available to staff. Although daily record entries were of a good standard, staff were not readily able to identify where risk assessments and care plans were kept.
• In B&NES there was a lack of oversight of each service user’s care (other than for those receiving care under the care programme approach) as community nurses did not undertake the care coordination role as in south Gloucestershire. Staff told us that this provided some risk for service users and left staff feeling that they worked in isolation