Your Healthcare Community Interest Company

Letter from the Chief Inspector of Hospitals

​ Your Healthcare Community Interest Company is a not for profit social enterprise, delivering health and social care community services for residents in Kingston and Richmond. Your Healthcare has around 620 staff in post. The organisation’s healthcare services employ around 427 WTE staff.

Your Healthcare is commissioned to provide health services to all patients registered to a Kingston CCG GP (203,854 NHS Digital October 2016). This exceeds the resident population by 17.5%. Some patients resident in a surrounding borough are registered to a Kingston GP.

Our key findings were as follows:

Safe

• The duty of candour was understood and implemented by staff. The process was appropriately followed and actioned.
• The provider had up to date safeguarding policies and procedures. Staff understood their roles and responsibilities with regards to safeguarding and could tell us how they would escalate any concerns.
• There were effective policies and procedures to manage the storage and administration of medicines. Patients received their medicines on time and when they needed them. They knew if their medicines had been changed and could ask for pain relief when they needed it.
• Community nursing staff had no problems getting equipment such as standard pressure relieving cushions and hospital beds, pressure relieving mattresses and commodes in a timely manner. The provider maintained and safety checked equipment.
• Most staff washed their hands appropriately between patient contacts and adhered to the ‘bare below the elbows’ policy and had access to personal protective equipment (PPE). Staff were observed following infection control procedures and protocols in patients’ own homes.

• There were suitable arrangements for the handling, storage and disposal of clinical waste, including sharps in clinic and home environments.

• Staff knew how to recognise incidents and mostly recorded and reported appropriately. However, due to lack of equipment or IT connectivity issues in the community, staff could not always access on-line reporting in the community, but had to return to a hub office to do so. This could cause delays in reporting incidents.
• The Cedars Unit had not reported any deaths within the last year; although five patients had died on the unit. Providers must report all deaths as a statutory notification to CQC and therefore this should have been completed.
• The Cedars Unit did not carry out mortality reviews and when we raised this with the provider, we were told that it wasn’t required within the community setting. In the absence of any local mortality review process, it is difficult to understand how the provider would be assured that the death of the service user was attributed to the course of the illness or medical condition that treatment was being provided for.
• There were high vacancy rates especially for nurses and speech and language therapists across all services, which impacted on the delivery of care. Senior staff reported difficulties in recruiting nursing staff and recruitment was ongoing. Nurse staffing was listed on the directorate risk register as a high risk and was being looked at strategically.
• Extra space and storage was highlighted by staff as a concern on The Cedars Unit. Beds were close together in bays and there was no space, apart from manager’s offices for speaking to patients and relatives in a private environment. The lack of communal areas meant that patients spent a large amount of the day sat by their beds.
• A number of staff reported that there were issues with the electronic records system and said that sometimes it crashed and did not save the data. The electronic system migration was recorded as a very high risk on the directorate risk register.
• All staff we spoke to said they were up to date in their mandatory training. Community staff in the different teams described good access to mandatory training. However, mandatory training was highlighted by senior staff as an area of risk of non-compliance due to lack of oversight and this was listed on the organisational risk register. Action being taken as result.
• Staff could access and book training through an online system, but there was no means for line managers to be able to check completion rates. 

Effective

• There was no care plan and pathway widely in use that was specific to patients who were dying, during the inspection.
• Some staff working with end of life care patients were not confident about what process they should follow if patients did not have capacity. However, Mental Capacity Act processes were mostly followed and used appropriately when required. It was clear that when there were concerns about a person’s ability to make specific decisions relating to hospital treatment and everyday decisions, mental capacity assessments were carried out. The patient’s family and multidisciplinary team was involved.
• There were gaps in MUST nutritional assessments for patients receiving end of life care, either they were not available in patient records or not completed thoroughly.
• There were no personalised care plans on nutrition and hydration for patients receiving end of life care, to ensure that the patient and their family’s views and preferences around nutrition and hydration at the end of life were explored and addressed.
• The number of young people attending drop in sessions at some schools were fewer than 10 in some schools, but there was no target.
• Community nursing staff told us the specialist palliative care team from the local hospice would measure patient’s outcomes.
• The provider arrangements for end of life care services to achieve the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People, was in draft and being consulted upon. Timescales for implementation of the care plan were not provided.
• There was an audit programme, which was agreed by the audit and assurance board. The provider carried out internal audits such as ‘bare below elbows’ and anti-biotic prescribing. It also took part in external audits such as the sentinel stroke national audit programme.
• The Cedars Unit had taken part in the National Audit of Intermediate Care (NAIC) in 2015. This audit aimed to assess progress in services for older people aimed at maximising independence and reducing use of hospital admission and look at national trends.
• Policies and procedures were consistent with National Institute for Health and Care Excellence (NICE) guidance where appropriate such as NICE CG50 relating to responding to the deteriorating patient. Patient’s needs were assessed and care and treatment was delivered in line with NICE quality standards relating to the assessment and prevention of pressure ulcers.

• The neuro gym service provided a range of specialised sessions to support patient rehabilitation as well as maintenance of movement, based on latest evidence. The service undertook action research on measuring a patient’s arm recovery following their recovery programme. The results showed a good recovery for patients in terms of time and duration taken for recovery.

• The Barthel Activities for Daily Living (ADL) score was used to measure patient’s performance in their rehabilitation

• Staff used outcome measures to monitor patient progress. Key outcome measures were Braden Assessment of pressure ulcer risk and nutrition scoring. However, in most of the records we reviewed, these assessments were not completed accurately, and there were no results provided to the inspection team.
• We found opportunities to participate in bench marking, peer review, accreditation and research were proactively pursued by the service provider. Information about the outcomes of people’s care and treatment were routinely collected and monitored to improve patient care.
• There was no data on the number of children and young people achieving their treatment goals through speech and language therapy.
• Multidisciplinary team (MDT) working was well established on The Cedars Unit and formed an integral part of the wards.
• All staff were very positive about the weekly MDT meetings in the community, which involved a full range of staff providing care and treatment including a GP, nurses, therapists and social workers.
• Patient’s we spoke with told us staff always gained their consent prior to providing care or treatment. We observed nursing staff explained procedures to patients and gained verbal consent to carry out the procedures.

Caring

• Patients received compassionate care which was centred on them, whether inpatients or in the community.
• Patients were mostly positive about their care and treatment.
• The results from a service user engagement survey over the period January to October 2016 showed all of the respondents would be extremely likely or likely to recommend the unit. However, the response rate for both wards was extremely low, with only eight responses for Chestnut Ward and six for Elm Ward.
• Staff told us that the lack of therapeutic activities on the unit had been identified as an issue, and provision of an activity co-ordinator discussed, however funding was not available.
• On Elm ward at night, the Zimmer frames of each patient were put out of their reach, to prevent them using them and potentially falling. However, this did not encourage the patients to mobilise independently
• Call bells on The Cedar Unit were very loud and disturbing to patients.
• Community nurses delivered respectful and compassionate care with attention to their patient’s privacy and dignity.
• The majority of families using the services that we spoke with were very happy with the services provided by Your Healthcare.

• Although there were only small numbers of mothers attending the feeding clinic, mothers at these clinics said staff were 'relaxed and friendly'.

• Staff involved patients in their care; they communicated well with them and provided them with simple information on how to manage their condition and options of treatments available.
• When patients asked questions, these were responded to appropriately and where further information needed to be obtained by a nurse patients were informed in advance.
• Relatives told us that they had been consulted about decisions and understood what was happening and why.
• Staff communicated with children and young people in an age appropriate way and involved them in decisions about their care.
• Staff in all services used written information to supplement verbal information, which was good practice.
• Staff met the emotional needs of patients by listening to them, by providing advice when required, and responding to their concerns.
• There was not a routine chaplain visit to The Cedars Unit; however senior nurses told us that they could contact a local chaplain if it was required.
• Patients and carers felt emotionally supported and reassured by the community nursing visits.
• Health visitors sensitively discussed mothers’ feelings and emotional well-being during home visits.

Responsive

• Patients’ needs were assessed and care planned accordingly. Where appropriate, care planning involved joint visits with staff from other specialties or GPs.
• Patients with complex needs including those who were housebound were discussed between services and a co-ordinated multi-disciplinary plan of care was agreed. Service users could access community nursing services directly and request visits and appointments.
• Staff worked closely with their local hospice to ensure end of life care needs of their patients were met.
• A Tongue Tie Release Clinic had been set up in January 2016, after midwives at the local hospital stopped doing this and instead referred cases to outpatient appointment at another hospital.

• There was a dementia nurse specialist to support patients living with dementia.
• The Cedars Unit used a ‘forget me not’ sticker to identify patients living with dementia. There had been some effort to make the unit a dementia friendly environment such as the use of pictures and word signs on toilets.

• In the community, nursing assessments identified patients living with dementia or learning disabilities and care was provided to meet their needs. The neurodevelopmental services assessed people attention deficit hyperactivity disorder and autism and worked closely the local acute and hospital social services. They provided learning disability awareness training to staff.
• We saw evidence of easy read documents and pictures for people living with a learning disability.

• People were generally seen in a timely manner, with some exceptions and had their individual needs met.

• The average wait for patients to access The Cedars Unit between October 2015 and August 2016 was three days for Chestnut Ward and four days for Elm Ward.
• There was a single point of access to the nursing service. Referrals were triaged immediately and the workload allocated accordingly.
• Waiting times were variable across the community services. Referrals for community nursing visits are often received in advance therefore representing a lead time for discharge home for example rather than a waiting period. Community nursing provides a daily priority based response and in consequence there is no waiting time to access this service. However, therapy services had a triage system in place to identify urgent and non-urgent appointments.
• The SALT service did not hold a traditional waiting list, but described a risk managed monitoring list. Different staff told us that the wait for routine assessment by a therapist was between six, eight or 10 months, so were not meeting the 18 week referral to treatment times.
• Face to face and telephone interpreting services were available. There were also a number of staff on The Cedars Unit that spoke a second language and would assist when it was suitable for them to do so. However, some staff reported that they would often use family if interpretation was needed which is poor practice. The unit had a menu that contained photographs of food choices that could be used for patients who may not be able to read English.
• Staff treated patients with respect regardless of their race, religion and sexual orientation. Relatives confirmed that they and their loved ones were shown dignity and compassion throughout their care.
• The SALT service produced leaflets for parents on the development of speech sounds, stammering and modelling correct speech which gave parents tips on how to help their child.
• There was a complaints policy and staff were trained on handling complaints.
• Staff understood the process for receiving and handling complaints and were able to give examples of how they would deal with a complaint effectively. Managers discussed information about complaints during staff meetings to facilitate learning.
• Our review of records found that there were no formal risk assessments for complaints that would determine how they should be dealt with and we did not see a record of how the learning would be shared. There was also inconsistent evidence on whether complainants were asked whether they were happy with the response.

Well led

• The managing director did not have a formal appraisal of her performance and was the only person in the organisation not required to have one. This was not good practice and must be addressed.
• There was a flowchart which described the governance structure and process. However, this was neither signed nor dated.
• It was clear that the governance process was understood internally, but the flowchart could be improved to demonstrate the overall governance framework. For example, there was no formal policy or procedure setting out the governance framework in narrative to back up the flowchart.
• The board lead for Foundation is on the membership of the Kingston CCG End of Life Care Steering Group, which acted as a forum for the commissioner to ensure collaborative working between their providers.
• Systems or processes were not sufficiently established or operated to effectively ensure the provider was able to assess, monitor and improve the quality and safety of end of life care services.
• There was no documented vision for the children and families service delivered by Your Healthcare.
• The organisation was not clear about its risk tolerance, or had definitive SMART plans with clear milestones for managing risks.
• The provider had developed a manifesto to support their vision. There were clear priorities to help deliver the vision. The manifesto highlighted the status of the provider as a social enterprise with the freedom to use their resources to improve patient care.
• How the organisation is governed is outlined in its articles of association registered with Companies House.
• Risk registers were kept by separate departments and committees, which were amalgamated to inform to organisational risk register.
• The organisation took the health and well-being of its workforce seriously. It worked closely with the Public Health Department.
• Most staff told us they enjoyed working for the organisation.
• We saw an action plan which was agreed by the board, aimed at making progress against the WRES indicators. One desired outcome for the organisation in assessing its progress against the WRES indicators, was improving the percentage of BME staff in senior positions.
• There was active staff and public engagement.
• The multiple sclerosis support group generates income and run exercise classes for themselves. This came about as a result of the provider listening to the service users, to improve the service delivered.
• The Cedars Unit had recently bought a new piece of equipment called the ‘Hover Jack’. This allowed the nursing staff to safely lift patients from the floor whilst keeping them flat so that they could then be transferred to a bed. This reduced manual handling for staff and a better patient experience.

We saw several areas of outstanding practice including:

• The multiple sclerosis support group was recognised as an example of good practice. This group generates income and run exercise classes for themselves.
• The provider re-invested surplus money in its services. This included the appointment of a tissue viability nurse, reduction of waiting times and purchasing of gym equipment.
• The Cedars Unit had a ‘Hover Jack’. This allowed the nursing staff to safely lift patients from the floor whilst keeping them flat, so that they could then be transferred to a bed. This reduced manual handling for staff and a better patient experience.
• The Cedars Unit had a bariatric training suit for manual handling training. This allowed staff to better understand the problems of mobility and routine activity associated with bariatric patients.
• Schwartz Rounds were conducted in the organisation; this is a forum in which staff can openly and honestly discuss social and emotional issues that arise in caring for patients. The provider had supported staff to participate in the “Rounds”.

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

Importantly, the provider must:

• Ensure the managing director receives a formal appraisal of her performance.

In addition, the trust should:

• Ensure there is a formal policy or procedure setting out the governance framework in narrative to back up the flowchart.

• Reduce the risk related to the electronic system migration.
• Correct the electronic data inaccuracy related mandatory training.
• Carry out formal risk assessments for complaints that would determine how they should be dealt with.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service

Requires improvement

Overall, the children and young people and families service requires improvement because;

• The timeliness of some of the five standard development checks within the universal offer in the Healthy Child programme fell below national targets for the new born and one year old checks, although the service performed better than the national average for 6-8 week checks.
• The sexual health clinics were performing below target in several areas.
• There were some staff vacancies in all service areas although a recruitment campaign was in progress.
• The budget for speech and language therapy only allowed the service to support children with higher levels of need. There was a paper process for prioritising provision but not all children were seen for a face to face assessment within 18 weeks of referral.
• The child continence service had not been provided for some months because of staff shortage and had only recently re-started; waiting lists were long.
• Mandatory training was reported by numbers attending without a percentage target, and the provider did not consider their central training record to be accurate, which made it difficult to determine the number of staff who had attended.
• There was an appropriate mission statement but no documented strategic vision for the children and families service as a whole.

However;

• Parents we spoke with had confidence in the staff that provided their children’s care.

• Staff knew how to report incidents although very few incidents were reported.

• Staff working with children were trained in safeguarding and had access to regular safeguarding supervision with expert colleagues.

• There was evidence of good Multi-Disciplinary Team (MDT) working between school nurses and health visitors.

• Health visitors held clinics in a number of different locations across the borough so that families could access them without travelling long distances.

• Care and treatment was evidence based, and children, young people and families were protected from inappropriate care or treatment for which they had not given proper consent.

• Staff working for Your Healthcare were caring. They worked hard to ensure that children received good support. Families were involved in decisions about their children and understood the services available.​

Overall, we rated adult community health services as good for safe, effective, responsive, caring and well led.

• Your Healthcare Community Interest Company provided adult community services to support people in staying healthy in their homes and after discharge from hospital and sought to prevent unnecessary hospital admissions.

• We rated safe as good because their safety performance data was better than the national average for most of the time. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

• Staff followed processes to report safety incidents and manage risks. There was a pro-active approach to following patient safeguarding procedures.

• Staff understood their responsibilities to raise concerns and report incidents and staff told us they received feedback from reported incidents. Safeguarding was embedded in the service and medicines were stored, managed and administered appropriately and safely.

• We rated effective as good because people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

• There was well-established multidisciplinary team (MDT) working across all the teams we visited. Staff had mandatory training and most had had appraisals and access to personal development.

• Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005. We saw evidence that patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.

• We rated caring as good because feedback we received from patients was consistently positive about the way nursing and therapy staff treated them. Patients told us that staff go the extra mile and we witnessed this during our inspection.

• Patient and their families received compassionate, focused care, which respected their privacy and dignity.

• Patients and relatives expressed satisfaction with the service and we found a caring and compassionate approach from staff in the areas we visited.

• We rated responsive as good because services were planned and delivered in a way that met the needs of the local population. The needs of different people were taken into account when planning and delivering services. Staff respected the equality and diversity of patients and their families.

• The service had many examples of responsive teams working collaboratively to meet their patients’ needs. They provided care close to or within the patients’ home environment, thus reducing hospital admissions.

• We saw examples of very responsive and accessible services such as rapid referral and quick assessment of patients.

• We rated well led as good because the provider had a clear statement of vision and values which was integrated within the teams. Staff we spoke with were aware of and based their care around the provider’s values.

• Staff in adult community services told us they were well supported by local team leaders and managers and felt empowered to develop local solutions based on good practice.

However;

• Staff did not always manage to update patient records with all the assessments required.

• IT connectivity problems and pressures on staff time meant there were risks of delayed recording and sometimes incomplete records.

• Risk management and public engagement needed to be improved.

We rated this service as good because:

• The admissions policy and procedure ensured that patients were suitable for the nurse-led care provided.
• Medicines were stored securely and medicine audits had been used to good effect to improve practice.
• The provision of four nurse prescribers on the unit meant that patients’ pain could be relieved in a timely manner.
• Multi-disciplinary team working was embedded within the unit.
• GPs on the Unit had access to a consultant community geriatrician. This was in line with national guidance and is an example of good practice.
• People were treated with dignity and respect and relationships with staff were positive.
• There was consideration for the needs of patients living with dementia and reasonable adjustments had been made on the unit that were suitable for these individuals.
• There had been a low number of complaints and the responses provided to those received had been appropriate.
• Average waits for patients to access the unit were low.
• Staff on the unit were positive about their local leadership and the support that was provided to them.
• The risk register reflected the issues that the unit faced.

However:

• The unit had not reported deaths that had occurred on the wards as part of their statutory requirements.
• There were high nursing vacancies and a high staff sickness level. In addition there was no acuity tool used for assessing staffing levels and this meant that staffing could be stretched, resulting in delays to patient care, particularly when patients had a higher dependency.
• Although the unit collected safety information, it was not openly displayed in the ward environment and was not used as part of regular safety discussions on the wards. Levels of harm free care reported in July 2016 were extremely low at 68%.
• Although patient outcomes were collated and looked at as part of individual care, this was not used to assess the overall outcomes on the unit or look for themes or improvements.
• Walking frames were removed from some patient’s beds at night, meaning that they were not being encouraged to be independent.

We have rated this service overall as requires improvement because;

• Some staff were not confident about what process they should follow if patients did not have capacity.
• There were gaps in MUST nutritional assessments, either not available in patient records or not completed thoroughly.  
• There were no personalised care plans on nutrition and hydration to ensure that the patient and their family’s views and preferences around nutrition and hydration at the end of life were explored and addressed.
• Staff we spoke with were not aware of the vision and values for the end of life care services.
• Systems or processes were not sufficiently established or operated to effectively ensure the provider was able to assess, monitor and improve the quality and safety of end of life care services.
• There was no structured end of life care training plan or register of training to ascertain the skills of staff in different roles and teams.
• There was no care plan and pathway widely in use that was specific to patients who were dying during the inspection.
• Patient’s records were not holistic and not all reflected emotional and spiritual needs, and in some records, relevant assessments had not been completed and recorded.

However;

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses; they said they had been fully supported when they did so. Staff monitored and reviewed safety incidents to enable them understood the risk associated with their services.
• The service worked closely with the local hospices to provide a collaborative multi-disciplinary approach to care and treatment.
• Nursing staff received timely appraisals and were supported with professional development and NMC revalidation.
• Patients and their families were very positive about staff and the service they received. The service demonstrated a high level of compassionate care to patients and their families.
• Community nursing staff providing end of life care services told us they were well supported by local team leaders and managers. Staff across the service had opportunities to review the quality of care and the way that teams worked. They told us they felt empowered to develop local solutions based on good practice.