Archived: Gloucestershire Care Services NHS Trust

Updated 19 April 2018

Gloucestershire Care Services NHS Trust (GCSNHST) is the main provider of NHS funded community health and care across Gloucestershire. Gloucestershire covers 1045 square miles and is made up of the large urban communities of Gloucester and Cheltenham, sitting within a largely rural community from the Forest of Dean to the Cotswolds. The trust was established in 2012 as part of the transforming community services programme and is commissioned by Gloucestershire clinical commissioning group.

GCSNHST provides services to around 600,000 people. During 2016-17 the trust had approximately 1.4 million contacts with patients – which equates to an average of over 3,800 people every day.

The trust has 196 inpatient beds, 31 day case beds and conducts 487 outpatient clinics per week and employs approximately 2,700 staff (1640.50 contracted WTE).The services are delivered at or from;

One management and administrative base,

• Edward Jenner Court

Seven community hospitals including seven, minor injury units,

• Cirencester Hospital
• Dilke Memorial Hospital
• Lydney and District Hospital
• North Cotswolds Hospital
• Stroud General Hospital
• Tewkesbury Community Hospital
• Vale Community Hospital

Two acute hospitals in the county owned and run by Gloucestershire Hospitals NHS Foundation Trust,

• Cheltenham General and
• Gloucestershire Royal Hospital,

In addition, services are provided from five dental clinics, three community clinics, one hub and a medical centre across the county.

Gloucestershire Care Services NHS Trust is registered to carry on the regulated activities of

• personal care
• treatment of disease, disorder or injury
• surgical procedures
• diagnostic and screening procedures
• family planning services
• termination of pregnancies

The trust’s services are mainly commissioned by NHS Gloucestershire CCG covering the local authorities of Gloucester, Cheltenham, Tewkesbury, Stroud, North Cotswolds, South Cotswolds and by Gloucestershire County Council.

Updated 19 April 2018

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

We inspected four of the trust’s seven core services and rated them as good.during this inspection. We rated safe, effective, caring and well-led as good. In rating the trust, we took into account the current ratings of the three services not inspected this time. Responsive therefore remained as requires improvement.

We rated well-led as good because:”

• The trust had an experienced executive and non-executive director and senior leadership team with the skills, abilities, and commitment to lead the delivery of high-quality services. The leadership team recognised the training needs of leaders and managers at all levels, including themselves, and worked to provide development opportunities for deputies ensuring leadership succession.
• The board and senior leadership team had set a clear vision and values that were at the heart of all the work within the organisation. They worked hard to ensure staff at all levels understood them in relation to their daily roles.
• The trust strategy was directly linked to the vision and values of the trust, local sustainability and transformation plans and the joint work with local mental health foundation trust. The trust involved clinicians, patients and groups from the local community in the development of the strategy and work with the local mental health trust.
• There was a clear five-year quality strategy for the period 2014-19. There were strategic objectives which described the principle aims that the organisation aspired to achieve in 2016-17 and plans for implementation of the 2017-18 priorities to provide high-quality care with financial stability.
• Non-executive directors visited all parts of the trust on a three monthly basis and fed back to the board to discuss issues staff faced and challenged directors appropriately.
• The trust had a clear board assurance framework and structure for overseeing performance reports, quality and risk which enabled oversight of issues facing the service and it responded when issues in service where identified.
• The performance reports included quantitative and qualitative data about the services, which non-executive and divisional leads challenged appropriately.
• The trust was committed to improving services by learning from when things go well and when they went wrong, promoting training, research and innovation and it enabled divisions to share learning across the trust.
• The trust included and communicated effectively with patients, staff, the public, and local organisations. It supported divisions to develop their own communication and engagement strategies and encouraged staff to get involved with projects affecting the future of the trust.
• The trust recognised the risks created by the introduction of new information technology systems in the services. Staff managed these risks well at service level.
• We saw improvement to the supervision and leadership arrangements within the minor injury and illness units. There was evidence of high levels of respect between staff and passionate and knowledgeable managers who motivated their staff and made them feel valued. Staff told us how their working lives had improved as a result of changes.
• Board members recognised there were staff shortages in some community services and innovative measures had been taken to improve recruitment in community adults and other areas of the trust.
• The trust recognised that patients could not always access all services when they needed it. Some services were not always achieving targets for receiving treatment including musculoskeletal physiotherapy and musculoskeletal assessment and treatment services. The services were reviewing their waiting lists daily and implementing actions to improve performance.

However:

• Black and minority ethnic staff (BME) we spoke with felt the trusts efforts at enabling opportunities for them to be engaged needed to be better to properly recognise what it meant to individual and groups of BME staff in the service. Board members recognised that work was required to improve staff diversity and equality across the trust and at board level and had plans to engage staff better in 2018.
• Not all staff were trained in the safety systems, processes and practices to keep patients safe in community adults, community inpatients and urgent care. Strategies had been implemented to improve compliance with mandatory training including online training workshops and the appointment of training and development nurses to facilitate local training at community hospital locations.
• Not all staff had received an appraisal on time and some were given late.

Updated 19 April 2018

Our rating of this service improved. We rated it as good because:

• Additional systems had been put in place to protect patients from abuse and there were resources for staff to access for additional support. Safeguarding incidents, issues and themes were escalated appropriately and discussed in a wide range of forums.
• Processes were in place to prevent patients suffering harm. Risk assessments were carried out and risk management plans were implemented in line with guidance. Staff were aware of their responsibilities in ensuring safe care and treatment was delivered to patients at all times.
• Medicine management practices were safe. Staff ensured medicines were prescribed, administered, recorded and stored appropriately. Services use of non-medical prescribing promoted prompt and effective treatment as delays in prescribing were limited which in turn ensured patients received the right treatment at the right time.
• Safety performance was monitored and improved to ensure patients did not suffer avoidable harm. Data on safety was collected safety and shared with staff. Patient safety incidents were reported appropriately and investigated to ensure lessons were learned.
• Evidence based care and treatment was delivered to patients to ensure they achieved the best outcomes. Practice was audited by professional leads to ensure care and treatment was in line with professional standards.
• Staff were competent in the roles they performed. Competency frameworks were completed to ensure the care and treatment delivered to patient was safe. Staff underwent regular clinical and managerial supervision.
• Multidisciplinary working across all services was good. Clinicians within different disciplines worked together to achieve the best outcomes for their patients. Care was delivered in a coordinated way and communication between services, teams and staff was clear and prompt.
• The information available to staff was up-to-date, accurate and comprehensive. Staff could access patient information with relative ease which meant care and treatment could be delivered without delay.
• Patients received care from staff which was compassionate, kind and respectful. Patients dignity was protected at all times.
• Staff were aware of and addressed patient emotional needs and offered support whenever possible.
• Staff ensured patients and those close to them were involved in their own care and treatment.
• The services provided to patients were planned and provided to meet the needs of local people. Patients had flexibility and choice in respect of where and when they wanted their care and treatment.
• Patients’ individual needs were considered and staff took action to manage and support patients living with dementia, learning disabilities and those with visual and hearing impairments.
• Concerns and complaints were reviewed, managed and actioned appropriately. Lessons from complaints were identified and shared with staff.
• Leaders had the right skills and abilities to run their services which provided high-quality sustainable care to patients.
• The vision for services was based around improving the quality and safety for patients. The strategy for achieving the vision was reasonable and was centred on improving services by increasing staffing levels and their competency, improving access to information for staff and reducing the waiting lists.
• The culture within the service was positive and was shared by all staff. Staff felt supported and valued which created a sense of common purpose, promoted challenge and supported performance improvement.
• Services had systems to continually improve the quality of the care and treatment provided to patients. Information was discussed, reviewed and disseminated across services and to all levels of staff.
• Risks within services were identified, rated and reviewed. Systems were in place to ensure significant risks were identified and actions implemented to reduce the impact upon services.
• Information was collected, analysed, managed and used to support all service activities.
• Patients and staff were engaged to plan and manage services. Collaboration with partner organisations took place and resulted in improvements to services.

However;

• Despite a comprehensive mandatory training programme available to staff, mandatory training targets had not been met as staff within the service had not completed all modules. This included some safeguarding training.
• There were three occasions when staff did not follow trust policy, practices and procedures in relation to infection prevention and control.
• Equipment and servicing were not monitored effectively across all services and localities.
• There were staff shortages in some services.
• Record keeping within the service was not always in line with trust policy.
• It was unclear as to whether outcome measure data was being used to improve or benchmark services.
• Appraisal compliance rates were below the trust target.
• Documentation practices, related to the Mental Capacity Act, were not completed in line with the trust policy.
• Referral to treatment time targets were not be achieved in some services

Updated 22 September 2015

Overall community health services for children and young people were found to be good. We found that services were safe, effective, caring, responsive and well-led.

Gloucestershire Care Services NHS Trust provided specialist community services for children, young people and families in Gloucestershire. As part of this inspection we talked to 28 professionals delivering the service. We also met and spoke with five children and young people and nine parents. We visited services at Quedgeley Clinic, Stroud General Hospital, the Springbank Resource Centre and the Independent Living Centre in Cheltenham, the Dilke and Lydney hospitals and trust headquarters. We also spent time on school and home visits with the school nurses, community children’s team, health visitors and therapy staff.

We judged the safety of community health services for children and young people as good. Risk was managed and incidents were reported and acted upon with feedback and learning provided to most staff. This was with the exception of the way medicines were administered by health care assistants in the complex care team.

Care was effective, Care was evidence based and followed recognised guidance. There was excellent multidisciplinary team working within the trust and with other agencies.

Care and treatment of children and support for their families was delivered in a compassionate, responsive and caring manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their families.

We saw that staff understood the different needs of the children and young people and designed and delivered services which met the specialist needs of children.

There were clear lines of local management in place and structures for managing governance and measuring quality.

Updated 22 September 2015

Overall we judged the dental services to be good. Patients were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.

Dental services were effective and focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practises within the service. The service was able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of staff.

The patients we spoke with, their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion and of effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

The service was well-led. Organisational, governance and risk management structures were in place. The operational management team of the service were visible and the culture was seen as open and transparent. Staff were aware of the vision and way forward for the organisation and said they felt well supported and that they could raise any concerns.

There was effective multidisciplinary team working and links between the different clinics to refer people onward for care. Individual assessments were carried out and specialist equipment was available to meet the needs of patients who had reduced mobility or for those patients who were obese. However. the service was not always responsive to people’s needs, with some waiting times exceeding six months.

We found inconsistencies in decontamination procedures across the service. These had not all been identified through routine audit.

Updated 19 April 2018

Updated 19 April 2018

Our rating of this service improved. We rated it as good because:

• Action had been taken to address the concerns raised during the last inspection.
• There was a strong and improving focus on monitoring and improving care for End of Life patients and those close to them.
• Openness and transparency were encouraged across the trust in terms of risk management and safety. Staff were encouraged to report incidents.
• There were safe staffing levels with an appropriate skill mix. Arrangements were in place if demand was unexpectedly high or in the case of adverse weather conditions.
• Staff were motivated and committed to providing the best care and support they could in collaboration with patients and other specialist services.
• There was a positive culture among the staff. Staff respected each other, their managers, their patients and those close to them. There was active engagement with the local community.
• Staff were caring and compassionate providing individualised support to patients and those close to them. They worked collaboratively with specialist services to ensure the best possible care for patients tailored to their needs.
• Patient information was up to date and available to relevant staff. Patients and those close to them were actively encouraged to be involved in decisions about their care.
• Feedback from patients was very positive. Feedback had identified areas for improvement and the trust had acted on these.
• Leaders were accessible, approachable and supportive.
• Staff were motivated and proud to be providing end of life care and support across the trust.

Updated 19 April 2018

• Actions had been taken to address most of the concerns raised following the last inspection
• The arrangements for triage had greatly improved. We found it was conducted by suitably trained staff, in an appropriate area and in such a way that they could ensure the most unwell patients were seen without delay and other patients were seen in order of priority. Self-presenting patients were triaged within the 15 minute target timeframe.
• There were comprehensive arrangements for audit and the service had a strong focus on monitoring and improving the clinical care of patients to ensure it was in line with best practice guidance.
• Arrangements for clinical skills training were excellent. Skills analysis had been undertaken and staff were aware of the skills they should develop in each role and timescales were laid down for achieving them. Enhanced training had been provided in some subjects, particularly in relation to the care of children and mental health patients.
• Safe staffing numbers and skill mix had been determined and escalation arrangements were used for managing risk to patients when staffing was disrupted or demand was unexpectedly high.
• The arrangements for equipment, devices and medicines had been improved. Equipment had recently been safety checked and was in in good condition. Medicines were well-organised, stored safely and at the right temperature.
• A healthy reporting culture existed where incidents were reported and learning from them was shared with all staff. Staff understood their responsibilities to raise concerns. Serious incidents were managed appropriately and changes made to pathways and processes to prevent things going wrong again.
• Consideration was given to the needs of patients with mental health needs. Some staff had received training in suicide prevention, information was available for patients engaged in self-harming behaviours and pathways for referring patients to mental health services had improved.
• Safeguarding procedures and a proactive safeguarding team existed to ensure staff were supported when protecting patients from harm or abuse.
• There was a positive and caring working culture. Staff respected the patients, their colleagues and managers. We saw healthy engagement with the local community, service users and stakeholders. The trust had an open and transparent approach to enquiry.
• We saw that staff were caring and compassionate towards patients. They spoke respectfully at all times and responded kindly if patients were afraid or distressed. Staff understood the need for some patients to have privacy or a quiet space. Staff had also thought of the needs of children receiving treatment, particularly at Cirencester Hospital.
• Arrangements for leadership had improved and staff felt this had directly impacted on their working environment. Staff said that they worked better, were well-supervised and, overall, they felt safer in their work since the new management structure had been introduced.

However:

• Mandatory and some essential training had fallen below the trust’s expected standards in some subjects. These included fire safety, resuscitation (level 2), safeguarding, infection prevention and control, safeguarding and the mental capacity act.
• Not all staff had received an appraisal.
• Cleaning still needed to be improved. Although we saw good hand hygiene and effective infection control arrangements, we saw occasions when beds were not wiped between patients and cleaning checklists were not completed and there was an inconsistent approach to washing toys in the children’s waiting areas.
• Patients in some units could not be observed by staff waiting for treatment. This was a concern for patients who may deteriorate whilst waiting for treatment. This issue was on the departmental risk register, however it had not been resolved since the last inspection when it was highlighted.
• The improved audit arrangements had highlighted some performance concerns where patient records suggested the relevant clinical pathways had not been followed in relation to scaphoid fractures, chest pain and venous thromboembolism. Actions had been agreed and re-audits were already planned.
• The availability of X-ray facilities did not match the times of highest demand. Also, an effective X-ray referral pathway had not been established or discussed with the local acute hospital X-ray department.