Archived: Virgin Care Limited

Updated 30 June 2017

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

The Care Quality Commission (CQC) carried out a comprehensive inspection of Virgin Care Limited between the 16 – 19 January 2017 with a further visit on 1 February 2017 for an arranged focus group in the unannounced period.

Virgin Care Limited provides integrated children’s services in Devon under Community health services for children, young people and families core service, and specialist community mental health services for children and young people core service.

During our inspection we visited the following registered locations:

Capital Court, Lescaze Court and Springfield Court.

We rated Virgin Care Limited as good overall.

Our key findings were as follows:

• Staff demonstrated a good awareness of their responsibilities around safeguarding young people. Procedures for supporting staff around safeguarding were robust and effective.

• Staff received regular appraisals and supervision and said they felt well supported in their roles.

• Effective multi agency working was embedded in practice and provided positive outcomes for children.

• Staff demonstrated care and compassion at all times during our inspection. We saw staff treating parents, children and carers with dignity and respect.

• It was fully embedded for services and staff to recognise the different needs and cultures of children and their families. This allowed support to be provided and reasonable adjustments to be made. Staff demonstrated their knowledge and skills around consent consistently. We saw staff always asked for the consent of the child or young person they were seeing, and where appropriate, documented this consent. This also applied when parents had given consent.

• The risk registers of individual services reflected the concerns of the staff we spoke to. Whilst risks could not always be mitigated they were discussed and staff were confident their managers were aware of the challenges they faced.

• Care and treatment was delivered in line with the National Institute for Health and Care Excellence (NICE) guidelines, with a system in place to ensure this guidance was communicated with staff. We also saw this information being shared with parents and carers.

• Staff described an open culture, where they felt confident to raise issues, and in the response they would receive. Achievements were recognised, and staff felt valued for the work they did.

• Caseloads were monitored through regular caseload supervision and job planning.

• Teams worked together to support each other and allocation of new patients was agreed jointly with staff and managers depending on staff capacity at the time.

• Staff offered psychological therapies and support as recommended by National Institute for Clinical and Health Care Excellence.

• Teams had good working links with primary care, paediatric services, social services and other teams external to the organisation.

• Young people participated actively in their care and there were opportunities to be part of the service development.

• The eating disorder and assertive outreach work had reduced length of stay and inpatient admissions to tier four psychiatric inpatient services.

However:

• Front line staff and managers did not demonstrate a full awareness of the presence of the standard operating procedures regarding enteral feeding tubes which underpinned their work.

• Vaccines were not always managed in a way which ensured they were fit for use. The storage temperature of vaccinations was not monitored when vaccinations were being transported.

• The Public Health Nursing service was performing below national targets within the Healthy Child Programme; namely for new born and six week checks of babies.

• The organisation did not always have a clear oversight of the numbers of children who were at various levels of the safeguarding process. Although processes were in place, these were not always followed in a timely manner or correctly to ensure staff had access to the most up to date information about children’s safeguarding statuses.

• Infection prevention and control (IPC) processes were not followed by all staff. We saw examples of poor IPC practice.

• There were differences in staff awareness of what should be reported as an incident and there were examples where reporting and learning was not always shared across services.

• Care and treatment was not always received in a timely manner, particularly for therapy where some children exceeded the aim of an 18 week referral to treatment time. However, waiting times were reducing. Families and young people felt isolated and frustrated whilst waiting to be seen and resulted in complaints being received by the provider.

• Turnover was high in some areas, and some posts were difficult to recruit to, such as psychology.

• There were concerns with the safety of the environment at Evergreen house. With no alarms and security for staff and areas which had a low standard of cleanliness.

• The learning disabilities services did not always have risk assessments in place for children and young people.

• There was variability in recording consent in the learning disabilities and assertive outreach teams.

• There were long waiting times from referral to assessment in the autistic spectrum conditions diagnostic pathway and for internal waiting times for treatment across CAMHS services. Shortages in psychology provision were affecting these waiting times for children and young people. However, waiting times were improving despite increased referrals.

• The learning disabilities team did not have access to the same electronic records system as the rest of the service and systems did not interface to enable information to be shared.

• Some families described difficulties with communications once they were in the system.

• There was limited local oversight of the management of complaints and concerns. Complaints were not always responded to in a timely manner and learning and action points were not always clear.
• Lone working procedures were not consistently implemented across all services to ensure the safety of staff.
• The requirements under Fit and Proper Persons were not completed in full for director level staff.

We saw several areas of outstanding practice including:

• Multidisciplinary working was embedded within the service and provided positive outcomes for children and young people. We saw effective and committed multidisciplinary working both within and outside of the organisation, and this was consistent across teams.

• We saw examples where outcomes for children and young people were greatly improved due to the joined up and holistic working of both educational and health services provided by Virgin Care Limited.

• The use of a data reporting system provided managers with real time bespoke reports on service outcomes. Managers reported how it was easy to use, provided them with comparison and tracking reports for their services, and immediately highlighted areas they needed to focus on.

• The eating disorder pathway model was developed in collaboration with consultant paediatricians and had been successful in reducing the need for tier 4 inpatient beds. The pathway had been recognised as national good practice by NHS England and published in the British Medical Journal in May 2016. This pathway was embedded in Exeter and East Devon and had been rolled out across the county.

• The Devon wide assertive outreach team provided intensive community CAMHS support. Since this service was in place the number of children admitted to inpatient services had significantly reduced. The team was shortlisted for a health service journal ‘value in health care’ award in January 2017 in recognition of their work.

• The palliative care team assisted with planning of patient funerals at the request of patient families. The culture within the team encouraged staff to openly support and challenge each other.

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

Importantly, the provider must:

• Reduce waiting times from referral to assessment in the autistic spectrum conditions diagnostic pathway and for internal waiting times for treatment across all services.

• Ensure that all patient areas are clean and well maintained.

• Ensure there are alarms and security for staff in community buildings.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 30 June 2017

We rated community health services for children and young people as good because:

• Staff demonstrated a good awareness of their responsibilities around safeguarding young people. Procedures for supporting staff around safeguarding were robust and effective.

• Staff received regular appraisals and supervision and said they felt well supported in their roles.

• Effective multi agency working was embedded in practice and provided positive outcomes for children.

• Staff demonstrated care and compassion at all times during our inspection. We saw staff treating parents, children and carers with dignity and respect.

• It was fully embedded for services and staff to recognise the different needs and cultures of children and their families. This allowed support to be provided in an appropriate way and reasonable adjustments to be made. Staff demonstrated their knowledge and skills around consent consistently. We saw that staff always asked for the consent of the child or young person they were seeing, and where appropriate, documented this consent. This also applied when parents had given consent.

• The risk registers of individual services reflected the concerns of the staff we spoke to. Whilst risks could not always be mitigated they were discussed and staff were confident their managers were aware of the challenges they faced

• Care and treatment was delivered in line with the National Institute for Health and Care Excellence (NICE) guidelines, with a system in place to ensure this guidance was communicated with staff. We also saw this information being shared with parents and carers.

• Staff described an open culture, where they felt confident to raise issues, and in the response they would receive. Achievements were recognised, and staff felt valued for the work they did.

However:

• Front line staff and managers did not demonstrate a full awareness of the presence of the standard operating procedures regarding enteral feeding tubes which underpinned their work.

• Vaccines were not always managed in a way which ensured they were fit for use. The storage temperature of vaccinations was not monitored when vaccinations were being transported.

• The Public Health Nursing service was performing below national averages within the Healthy Child Programme; namely for new born and six week checks of babies.

• The organisation did not always have a clear oversight of the numbers of children who were at various levels of the safeguarding process. Although processes were in place, these were not always followed in a timely manner or correctly to ensure staff had access to the most up to date information about children’s safeguarding statuses.

• Infection prevention and control processes were not followed by all staff. We saw examples of poor IPC practice.

Updated 30 June 2017

We rated specialist community mental health services for children and young people as good because:

Buildings were clean and maintained and had alarm systems, with the exception of Evergreen House.

Parents and young people were involved in service development and commented positively on the skills of staff and inclusion of staff. This was supported and facilitated by the countywide involvement lead.

There were innovations across the service. The eating disorders pathway had been recognised as national good practice by NHS England. The assertive outreach team was shortlisted for awards from the British medical journal and the health service journal ‘value in healthcare’ award in January and February 2017.

Staff were skilled and adopted evidenced based practices recommended by the National Institute for Health and Care Excellence (NICE). Staff were positive about the organisation and passionate about their work. The organisation demonstrated commitment to staff development and supported staff to undertake accredited training. Workforce planning included succession planning for staff that were due to retire and vacancy rates were highlighted in the service wide risk register. There were still 18 staff vacancies at the time of our inspection. Staff had job plans, which were plans to help ensure staff workloads were manageable. These plans were monitored in staff supervision. However, the commitment to specialist training had led to short term gaps in staffing.

Services worked well with other partners to develop effective pathways. Outcomes from evidence-based practices had improved experiences for young people, such as the eating disorders service and specialist assertive outreach teams that had reduced admission to tier 4 inpatient psychiatric services and length of stay. CAMHS, learning disabilities and specialist CAMHS were developing pathways across the county and the provider was starting to recruit by pathway rather than geographical location and staff were specialising in clinical areas.

The CAMHS team, which had received transformational funding, were meeting the referral to treatment targets and waiting lists were reducing despite the increase in demand. However, we were concerned that some waiting times were still too long. Parents and carers commented negatively about the waiting times in all areas, but in particular the autistic spectrum assessment service pathway where there were concerns that young people’s education had been adversely affected by the delays in receiving a potential diagnosis. Parents were critical about the waiting times across all services and once they had been seen there were sometimes further waits for therapies, such as internal waits for cognitive behavioural therapy in Eastern and Southern Devon.

We were concerned that the autistic spectrum assessment service was not meeting the 18 week target and staff felt pressure working in an area with long waiting lists and frustrated parents and families.

We found that some systems were not fully embedded that could improve waiting times and staffing, such as staff working across clinical pathways rather than geographical locations.

We saw that the CAMHS team had implemented changes following recent serious incident reviews. However, we were concerned that these had not adopted service wide.