Archived: Bristol Community 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

Bristol Community Health C.I.C. was inspected with planned and announced visits over 16-18 November 2016. We visited many community teams, locations, patients’ homes, schools, and clinics during this time. We went back to a number of locations and teams for unannounced visits on Sunday 27 November (the urgent care centre), 28 and 30 November and 1 December 2016.

This inspection was a comprehensive look at all services provided by Bristol Community Health C.I.C., with the exception of its prison healthcare service, which is inspected by a specialist CQC team alongside Her Majesty’s Inspectorate of Prisons. The core services we inspected were:

• 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

Among the sites we visited where services are provided were: New Friends Hall in Stapleton, Bristol and The Withywood Centre in Withywood Bristol. This was to meet people and staff in the community learning disabilities service. We visited the urgent care centre in Whitchurch, Bristol. We visited health centres in Bristol, Eastgate Centre Clinic, Osprey Court, local schools, 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 community nursing teams to patients’ homes, visited Knowle Clinic, an intermediate care centre, and Southmead Hhospital. We met with the palliative home care team and went on visits with them to meet their patients and families they were supporting. In addition, we went on visits with the ‘fast track’ team, who arrange care and support for patients being discharged home from hospital at the end of their life.

All staff throughout Bristol Community Health were cooperative, helpful and supportive to us at all stages of the inspection.

Our key findings were as follows:

• We rated services for their safety as good overall, although some improvements were needed to children and young people’s services, which were working under a temporary contract managed in conjunction with three other health providers. The contract had now been awarded to the three organisations from April 2017 for the next five years, and work to integrate children and young people’s services was commencing. However, this had not affected the quality of care provided by the children and young people’s services. Patients were protected from abuse and harm.
• We rated services for their effectiveness as good overall, although there were some areas in the children and young people’s services that needed improvement. This included issues arising from problems with the computer systems, the availability of patients’ records, and the lack of an effective audit programme. However, patients were receiving good outcomes from their care and treatment. Quality of life was promoted, and care and treatment based upon the best available evidence.
• We rated services for caring as good overall, with outstanding care in the urgent care centre. Patients, their carers, parents and anyone who encountered Bristol Community Health staff were treated with compassion, kindness, dignity and respect.
• We rated all services for their responsiveness as good. Services were planned, organised and delivered to meet people’s needs. The organisation supported people in vulnerable circumstances. It listened to people’s concerns and improved when it recognised something had gone wrong or could be done better. However, there was a variable performance when endeavouring to provide care to people at the right time. Some services were doing well, but others were struggling with the impact of rising demand and shortages of staff.
• We rated services for the leadership and governance as good overall, although work was needed to integrate and improve the systems and use of information in the children and young people’s services. Bristol Community Health was an organisation with a strong culture. Staff were open, honest, and wanting to deliver high-quality person-centred care. The organisation supported learning, innovation and improvement.

We saw several areas of outstanding practice including:

• There was an outstanding, dedicated and committed approach to engaging with people who were patients of Bristol Community Health, their families, their carers, volunteers, and the wider community. The Patient and Public Empowerment programme, underpinned by the patient charter, put patients at the centre of decisions, valued their feedback and input, and made changes and improvements from listening to and engaging with people.
• The chief executive and her leadership team had an outstanding commitment to staff. The organisation had been established as an employee-owned social enterprise. It recognised staff for effort and achievement through a number of different schemes, including award ceremonies and personalised contact.

• The organisation’s approach to shared decision-making and inclusion of the patient was well embedded within their culture. We observed this in practice and in records.
• Specialist services were provided by Bristol Community Health to meet the needs of people. These services were flexible and innovative to make improvements. They enabled services to deliver care and treatment, which was accessible to the local population, with no discrimination. For example, through the migrant health services and the Macmillan rehabilitation support service.
• The Haven service recognised the additional support required for staff who were often dealing with difficult, challenging and upsetting situations. Weekly access to a psychologist was made available for staff.
• In children's services, staff respected and recognised each child as an individual. We observed outstanding caring from staff who were singing a song to each individual child and addressing them using their name when they entered the room for their therapy session. These children had profound needs, and we recognised how their faces lit up when they came into the session and had their special song.
• Families and carers of children and young people provided consistent positive feedback about the service. One parent told us “staff are so supportive and helpful,” “staff are always there when you need them,” while another told us “staff are really friendly, helpful and always welcoming.” Another mother told us '”the service is brilliant, couldn't have asked for a better one.”
• In adult services, we observed outstanding multidisciplinary team working both across the organisation and with other healthcare providers. In particular, staff worked hard to make sure all involved in a patient’s end of life care were up to date with the situation, and their visits were all coordinated.
• There was an outstanding response to people who were coming to the end of their life. The palliative home care team made sure their service worked to meet the needs of the patient and those they were close to.
• The visibility of, and support provided by the safeguarding team had increased the quantity and quality of safeguarding referrals across the whole organisation.
• The multidisciplinary working undertaken by the rapid response team was helping to speed up patient discharges and prevent hospital re-admissions.
• The organisation had effective processes to review staff teams and identify areas of risk to provide active support. These were known as ‘hot teams’. This allowed issues and risks to be identified early, and plans to be made to help support these teams.
• In the urgent care service, we heard of numerous examples where staff had gone the extra mile to support patients and those close to them.
• The urgent care staff had developed a comprehensive support network and a range of referral pathways for adults and children in primary, secondary and community health care settings.
• The urgent care service had engaged the support of the lead emergency consultant at the local children’s hospital to facilitate joint working, and education.

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

Importantly, the provider MUST:

• Take action to ensure all staff in the children and young people's service receive the appropriate level of safeguarding training for their role.
• Ensure a complete set of records are transferred with the child from the health visiting team to the school nursing team in line with Royal College of Nursing guidelines.
• Take action to ensure the health visiting team maintains an individual set of records for each child, which are filed under the individual child’s surname.
• Ensure staff in the children and young people's service comply with safe systems to ensure that toys are cleaned in line with the Cleaning and Decontamination of Toys’ policy and ensure there is a system to monitor compliance around toy cleaning. We also observed poor compliance with hand washing and cleaning of equipment between use after each child.
• Ensure compliance with staff mandatory training and appraisal in the children and young people's service.
• Ensure there are standard operating procedures for the transition of all children into adult services.
• Take action in the children and young people’s service to ensure there is a systematic process of audit to monitor service quality and performance, for example records audits, and auditing the single point of access system.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated community health services for adults as good because:

• There was a well-embedded culture of incident reporting and all staff spoken with were aware of their responsibilities to identify and report incidents.
• We observed good infection control practice through staff washing their hands, using personal protective equipment and following sterile techniques.
• Staff were up to date with their mandatory training and reported the training was of a good quality.
• The safeguarding team were visible and available for support, staff were confident in making safeguarding referrals.
• There were clear tools and templates that were used to help assess patient needs and respond to any risks.
• Policies, care plans, tools and templates were based on best practice guidelines.
• The organisation were aware of staffing pressures it faced and mitigated these to ensure safe staffing levels across community adult teams.
• We saw good examples of audits to monitor patient outcomes and the quality of the services.
• There was good integration of staff roles within teams to achieve multidisciplinary working, different teams linked together to deliver coordinated care and there were appropriate connections with external healthcare organisations.
• We observed good care and positive interactions provided by staff to patients. Patients were treated with compassion, kindness, dignity and respect.
• Shared decision-making was well embedded whereby staff involved patients in planning and making decisions about their care and treatment.
• Where practically possible the service was responsive and planned care to meet the needs and demographics of the local population.
• All staff spoken with were complimentary about the leadership within Bristol Community Health. Staff found local and executive management to be supportive, visible and approachable.
• There was an overwhelmingly positive culture amongst teams with a great sense of teamwork and camaraderie.
• The governance structure enabled information to be cascaded up through the organisation and back down.
• Identifying and managing risk was a high priority. Teams were monitored, and areas of risk were identified with actions to reduce risks and make improvements.

However:

• We did identify an inconsistent knowledge of the duty of candour amongst staff; the duty of candour requires openness and honesty to patients when things go wrong and an apology to be provided.
• The lack of mobile working affected negatively on the effectiveness of staff daily work, reducing access to information when working remotely and causing duplication in paperwork. However, the organisation was in the process of reintroducing mobile working.
• Improvements could be made to access for some services, for example podiatry and therapy teams, where referral to treatment times were below national indicators and therefore patients were waiting a long period of time for both urgent and non-urgent appointments. The organisation had identified their shortfalls in referral to treatment times and had implemented actions to improve these services.
• Staff safety was a risk area for staff lone working in the community. Teams were responsible for formulating their own lone working processes and therefore this was not supported by a detailed lone working policy. Speaking to staff, we found differences in the level of success teams had with their processes for ensuring staff safety.
• There was no oversight on the board for the services provided to people at the end of their life. The service had no specific risk register and there were no audits being undertaken.
• Not all staff supporting people at the end of their life had an understanding of the national guidance: ‘five priorities of care for the dying adult’.

Overall, we found community health services for children and young people required improvement because:

• There was an inconsistent understanding of what constituted an incident.
• Not all staff were compliant with safeguarding training.
• We saw examples where staff did not follow the required infection control protocols with regard to hand washing, cleaning of equipment and toy cleaning.
• Health visiting teams did not maintain an individual set of records for each child in one family and filed records under the youngest child’s surname.
• Children transferred between the health visiting team and the school nursing team without a full set of records.
• There were inconsistencies in relation to how school nurses managed information about children who had attended the emergency department or urgent care centre.
• There were challenges to staffing due to sickness, vacancies and high turnover. The organisation also faced challenges filling vacancies with bank staff and there were issues around the accuracy of the data recorded about the numbers of back staff being requested and used.
• Some health visitor caseloads exceeded average caseload guidelines as recommended by the Royal College of Nursing.
• The service had not issued all appropriate members of staff with a mobile phone and there were inconsistencies between teams about how lone working and staff safety was managed.
• The information technology issues had challenged the service, due to the loss of data regarding mandatory training during the transition of services to Bristol Community Health from the previous providers in April 2016, which was still occurring and had not been resolved.
• The service was falling below key performance targets for new birth visits and child developmental reviews.
• Only the health visiting team had formal guidelines to support staff to manage the transition of children between services.
• Not all staff had completed an appraisal in the past 12 months.
• The principles of Gillick competence were not respected with regards to the immunisation of young people.
• Staff had experienced difficulty when arranging interpreting services.
• There were disjointed operational processes, with different systems and processes to follow between the different organisations in the Community Children’s Health Partnership.
• There were limited processes, such as clinical audit, to monitor and improve quality.
• Not all risks associated with the services had been recorded on the risk register.
• Not all staff were clear with their new roles and lines of accountability since the transition of services from the previous provider to Bristol Community Health in April 2016.
• There were not enough team leaders in the school nursing team to effectively manage the workforce and keep up to date with supervision and appraisals.
• There was no systematic process of audit to monitor service quality and performance.
• Not all children's services had standard operating procedures or guidance for the transition of children into adult services.

However:

• There were systems and processes to safeguard children from abuse and staff were aware of these.
• Staff completed risk assessments as part of the assessment process for children receiving treatment from Bristol Community Health.
• There were systems and processes to follow if a child did not attend an appointment.
• Policies and care pathways were developed in line with national guidance.
• There was good multidisciplinary working between the various teams within Bristol Community Health and other external agencies.
• Staff treated children young people and their families with compassion, dignity and respect. They understood the importance of involvement of the family and those close to them.
• Services were planned and delivered in a way, which met the needs of the local population. Children and their families were involved in service planning.
• There were actions to address referral to treatment times in the services, which were not meeting targets.
• There were clear strategies to improve services.
• Leaders of all levels were visible and approachable.
• The service worked closely with a local children’s charity to ensure service user engagement to help improve services.

We rated this service as good overall because:

• Staff complied with safe systems to protect people from abuse and avoidable harm. The service had a good track record on safety. There was an open culture; staff were encouraged to report concerns and incidents. Incidents were investigated and used to identify learning.
• People had their needs assessed and their care planned and delivered in line with evidence-based, guidance, standards and best practice. Staff had access to a range of national guidance, local protocols and referral pathways and monitored the effectiveness of, and compliance with, processes and referral pathways.
• Staff, including those in different teams, worked together to provide seamless and coordinated care. Staff had access to remote advice and support from healthcare partners.
• Staff were suitably qualified and experienced to undertake their roles and were supported and encouraged to update and extend their skills and to develop areas of interest.
• Feedback from patients and those close to them was consistently positive. The department received overwhelmingly positive feedback from patients and this was consistent with the feedback we received during our inspection. Patients we spoke with were fulsome in their praise for staff. We heard of numerous examples where staff had “gone the extra mile” to support people.
• Staff treated patients with dignity, respect and kindness during all interactions. Patients told us that staff took time listen to them and felt supported by them.
• The urgent care centre provided a convenient and accessible service for patients who could not access primary care services and/or who may have otherwise presented at an emergency department.
• Staff took steps to support patients in vulnerable circumstances and those with complex needs.
• People’s complaints and concerns were listened to and responded to. Learning from complaints was used to improve the quality of care.
• The local leadership team was well respected, visible and accessible. Staff were inspired by and supported by a strong and cohesive leadership team.
• Staff enjoyed working in the urgent care centre. The department had experienced a difficult year, with high demand, high staff turnover and staffing shortage, including holding a management vacancy. In spite of this, morale was high, staff expressed pride in their service and they were optimistic for the future.
• There were effective governance arrangements. Information was regularly monitored to provide a holistic understanding of performance, including safety, quality and patient experience.
• Patients and the public were engaged and involved. Their views were captured and acted upon to shape and improve the service.
• There was a strong focus on learning and improvement. Audit was used to drive improvement, mistakes were openly discussed and learning acted upon. Staff at all levels were encouraged to play their part in improving patient safety and quality.

However:

• The department did not monitor or report on the time that patients waited for their initial assessment (triage). Therefore, we could not be assured that patients were always assessed promptly in order to identify or rule out life threatening conditions.
• Patients were not always able to access care and treatment in a timely way. Increasing demand and periods of under-staffing resulted in the frequent restriction of the service.
• Results from the 2016 staff survery had been mixed. There was some concerning feedback about pressure of work.

We rated community mental health services for adults with learning disabilities or autism as good because:

Teams assessed risk to patients and staff promptly. We reviewed 16 care and treatment records and found there was evidence of risk assessment beginning when referrals were received by teams. Staff triaged referrals using guidance for each discipline in the multi-disciplinary team.

Staff we spoke with from a range of disciplines told us how they found the electronic patient record system beneficial in providing up to date patient care. A consultant psychiatrist told us how they were able to access up to date information from GP’s such as, recent blood results, physical interventions, changes in medication.

The team’s provision for young people transferring from children's services to adult services had a clear pathway including eligibility. Young adults were identified in line with government directives at the age of 14, with assessments of individuals at approximately 17 years, prior to transfer to the adult services.

Staff delivered compassionate care and understood their patients’ needs. We observed positive staff interactions with patients and their carers. We saw how staff clearly and gently explained to patients the purpose of their visits. During clinical meetings staff spoke about patients in a positive and knowledgeable way.

Teams told us they had been offered the opportunity to be involved in past reviews of community learning disability services. They told us they were also included in the development of commissioning for quality and innovation (CQUIN) targets from commissioners. Staff said they felt listened to by senior managers and cited the example of not going ahead with the office move from south Bristol as an example.