Bridgewater Community Healthcare NHS Foundation Trust

Updated 17 December 2018

Bridgewater Community Healthcare NHS Foundation Trust is a provider of community health services in the north west of England. The trust provides community and specialist services to a population of 1,304,500 people living in Halton, Oldham, Bolton, St. Helens, Warrington, Wigan Borough. The trust employs over 2,972 staff and has an income of £143 million which comes from commissioners, NHS England and local authorities.

Updated 17 December 2018

Our rating of the trust stayed the same. We rated it as requires improvement because:

• We rated effective, caring and responsive as good, we rated safe as requires improvement. We rated four of the trust’s eight services as good and one as requires improvement. In rating the trust, we took into account the current ratings of the three services not inspected this time.
• Although we rated leadership at service level as good, the overall trust rating is determined by our trust-wide assessment of well led, which we rated as requires improvement considering high executive turnover in 2018 and the relatively short tenure of new executives. Our findings are in the section headed Is this organisation well led?
• Our decisions on overall ratings took into account, for example, the relative size of the services and we used our professional judgement to reach a fair and balanced rating.
• The trust had made changes in response to the actions identified at our last inspection in 2016. Each of the services inspected showed improvement but there remained areas of improvement in community health services for children, young people and families.
• The calibre of the executive team was good however the trust had experienced high levels of turnover at executive level since 2017.
• The strengthening of senior management arrangements was yet to be fully implemented.
• There was an improving culture across the organisation and a recognition there was more work to do
• The trust recognised its weakness in integrated reporting and were currently implementing systems to improve the trust`s analytical capability and timeliness of information. It would be some months before this implementation was complete and embedded.
• The quality of serious incident investigations was variable. The trust’s learning from deaths was behind the national average. Following the inspection the trust sent evidence to show the quality of the serious incident investigation reports and systems for death reviews were improving.
• There was a mixed picture in the strength of joint working with commissioners and other external stakeholders. The trust reported they were leading contributors to all place-based reform programmes and in respect of specialist services development in the community dental networks. The trust was refocusing executive and non-executive support to places and services.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RY2/reports.

Updated 17 December 2018

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• Staff showed good knowledge and understanding of patients at risk and the interventions needed to maintain safety.
• Equipment was easily accessible and staff could order equipment to support patient’s when required.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• There was effective management of caseloads and processes to assess new patients. Patients were prioritised according to the complexity of their condition and those at high risk were seen on the same day.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Staff were encouraged to report incidents to alert staff to potential risks and maintain patient safety.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff used nationally recognised assessment tools to screen patients for risks.
• Data from local and national audits was used to monitor the quality of the services and improve the quality of care for patients.
• There was effective integrated teams and joint working across the trust to provide a range of services for patients.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff engaged with patients and encouraged them to manage their condition or treatment.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff involved patients and those close to them in decisions about their care and treatment.
• Staff provided emotional support to patients to minimise their distress.
• The service had managers at all levels with the right skills and abilities to run a service and there was a clear commitment by the service to developing an integrated care model across all services we visited.
• Staff in all services had strong working relationships with each other which supported new and innovative ways of working in collaboration with other services across the boroughs.

Updated 17 December 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

• Training and knowledge of the recognition and treatment of sepsis was not yet embedded, and compliance with basic life support training was low in the Halton and Oldham boroughs.
• We found examples where children had faced lengthy delays, particularly at the Woodview Child Development Centre where processes to improve effectiveness of the multidisciplinary complex case panels was still embedding.
• Storage limitations in some buildings meant that equipment was not always stored securely.
• The recording of medicines prescription pads was not robust enough to ensure accountability for prescription pad issuing and usage.
• The service did not consistently collect or manage information well across service and borough boundaries. Where services held multiple sets of paper records for individual children, we found no standard procedure for sharing information with other professionals involved in their care. There was limited staff awareness of sharing learning from incidents and complaints. Continuous improvement and innovation was not consistently shared.
• Managerial staff were not always able to explain how their work aligned to the service’s strategy. Non-managerial staff across the services were aware of the strategy.
• The service’s risk management system was not consistently effective as, at the time of the inspection, not all open risks had identified control measures and gaps in controls, assurances and gaps in assurances.
• We had specific concerns around service provision within the borough of Halton. Children had experienced lengthy delays for treatment due to an ineffective pathway at Woodview Child Development Centre. Compliance with basic life support training was low compared with other boroughs. There were no formal channels for communication between specialties such as physiotherapy, speech and language therapy, paediatrics and children’s nursing teams, although following the inspection the trust developed terms of reference and proformas to improve information sharing between the multidisciplinary team. We found that the use of FP10 prescription pads was not monitored effectively and services within the borough did not seek to share learning with other boroughs, including those where similar services were provided.

However,

• Care was provided safely by staff across the services who had the right skills and knowledge to provide appropriate care and treatment and to safeguard vulnerable people from abuse. Staff kept contemporaneous records and managed medicines well, and when things went wrong staff reported incidents, apologised and provided support where needed.
• Staff were competent in their roles and delivered evidence based care in line with the service’s policies and with the consent of patients and their carers. Holistic care plans took into account children’s preferences and needs for food and drink, and systems were being embedded to monitor patient outcomes.
• Staff were compassionate and caring in their delivery of care. They supported people’s emotional needs, and involved children and carers in their treatment.

Updated 17 December 2018

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

• Staff had the qualifications, skills and experience to keep patients safe. They had access to training to support their roles.
• Premises and equipment were well maintained and there were systems in place to deal with patients becoming acutely unwell.
• Incidents were reported, acted on and learning was shared across the directorate. Infection control procedures were in line with nationally recognised guidance.
• Staff were aware about issues relating to safeguarding and there were systems in place to refer children and vulnerable adults.
• Staff provided care and treatment based on nationally recognised guidance. There was an effective skill mix at the service to assist with the ever-increasing complexity of patient.
• Staff worked together as a team and with other healthcare professionals in the best interest of patients. Staff understood their responsibilities under the Mental Capacity Act 2005 and with regards to Gillick competence.
• Staff cared for patients with compassion. We observed staff treating patients with dignity and respect. Feedback from patients was positive. They told us staff were friendly, compassionate and professional.
• The service took into account patients’ individual needs. Clinics had been adapted to ensure they were accessible for all patients. The appointment system met patients’ needs.
• The service dealt with complaints positively and efficiently. The service was reaching out to vulnerable groups.
• There was a clearly defined management structure. Managers had the right skills and abilities to provide high quality sustainable care. There were systems and processes in place for identifying risks and planning to reduce them. Staff engaged with patients and other healthcare professionals in order to continually improve the service.

However:

• At some locations we visited clinical waste was not stored securely.
• There was a lack of clinical leadership in the Greater Manchester area. The service was in the process of appointing a new clinical director to ensure equal clinical leadership across the whole footprint of the directorate.

Updated 6 February 2017

At this inspection we rated community inpatient services as Good overall because;

• The service has a good safety performance record and collected data which was used to drive improvement.

• There was a good culture of openness, reporting and investigation of incidents. There was evidence of positive improvements and changes made as a result of incidents. Learning was taken from the investigations and this was disseminated and shared with staff to prevent future occurrences.

• The environment at Newton Community Hospital was clean and hygienic with low levels of healthcare associated infection and high levels of harm free care. Statistics showed that Newton Community Hospital performed better than similar providers in terms of the safety thermometer data.

• Staff were aware of their responsibilities regarding safeguarding and the correct procedures to follow; training rates were satisfactory and staff could describe the safeguarding processes. There was evidence that safeguarding referrals had been made appropriately.

• At Newton Community Hospital, medicines, including controlled drugs and intravenous (IV) fluids were stored safely and in line with agreed protocols.

• There was good knowledge and application of the duty of candour procedures and patients were The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of ‘certain notifiable safety incidents’ and provide reasonable support to that person.

• At Newton Community Hospital and Padgate House intermediate care facility staffing levels were good and safer staffing records showed a minimum of 95% shift fill rates.

• There was adequate provision for the identification and assessment of patients at risk and those who deteriorated.

• Care and treatment was evidence-based and was provided in line with best practice guidance and evidence based practice.

• At Newton Community Hospital, care plans and clinical care bundles were implemented and reviewed regularly to ensure they were in line with changes in patients’ needs and progress.

• Pain, nutrition and hydration were well assessed effectively and were well managed.

• Staff had access to information they required to undertake their roles and were confident and competent to deliver effective care. They received the right training and supervision to enable effective care delivery.

• The multidisciplinary team worked effectively, ensuring the holistic needs of the patient were met, through the evaluation of outcomes and patients’ own goals in relation to their rehabilitation.

• Data showed patient outcomes were positive, the majority of patients successfully returned to their homes and many reported improved Barthel scores, which was an established technique used to measure improvement after rehabilitation.

• The staff were trained and competent in consent procedures, the Mental Capacity Act (2005) and the deprivation of liberties safeguards.

• We observed staff treating patients and their relatives with the upmost dignity and respect. Patients told us staff were exceptionally kind, caring and compassionate.

• Staff were exceptionally attentive and responded quickly and compassionately to patients who needed help or assistance, they anticipated the needs of their patients and offered assistance proactively.

• Staff were always positive and receptive about making improvements to patient care, they actively sought ways to make patients stay more pleasant by working with them to identify ways to make things better.

• Nursing and therapy staff promoted and supported patients’ independence, encouraging autonomy whilst remaining supportive and reassuring.

• There was a strong person centred culture and staff were motivated to provide comprehensive holistic support to patients and relatives, taking into account and accommodating their emotional, mental, physical and social needs.

• Feedback from people who used the services was continuously positive, patients and relatives spoke highly of staff and the care that was delivered. Many believed that staff went above and beyond their role in the way they care for their patients.

• We saw many examples of staff going the extra mile for their patients, they showed flexibility and innovation in finding ways to improve the service provided to patients.

• Patients and their relatives were actively involved in their care and treatment and played an active role in determining their care.

• There was a holistic and person-centred care approach to the delivery of care for all patients, attention was paid to individual differences and patients’ needs. We saw positive examples that patient’s individual needs were accommodated, such as patient activities that were planned and based on their personal preferences.

• Vulnerable patients were identified on admission and staff provided individualised care to meet their needs.

• Staff were aware of the referral criteria for intermediate care and rehabilitation and ensured the patient received the right care to promote the right level of care to match the patient’s needs.

• The services worked with local commissioners, community and acute and other healthcare organisations to meet the holistic and individual needs of patients.

• Newton Community Hospital had few complaints, but those that were received were handled effectively and appropriately in line with trust procedures.

• There was an established trust strategy in place and staff were broadly familiar with trust priorities and plans.

• The culture within the services were very positive, most staff stated the organisation was a good employer and they were proud of the work they did and the care they delivered, they found their work meaningful and satisfying.

• Staff stated they felt valued, listened to and felt able to raise concerns without fear of recriminations.

• The trust had acted in response to concerns about the quality of care within the Newton Community Hospital. Managers had made effective changes to the structure and staffing to ensure patient safety, internal governance, risk management and an improved culture.

• We saw that local managers were passionate and enthusiastic leaders, who led by example and inspired their staff to develop and seek improvements in quality, performance and expertise.

• Since our last inspection, we found that there had been major improvements in the culture and governance structures within the service at Newton Community Hospital.

• All of the staff we spoke with told us that the ward manager at Newton Community Hospital had made a positive difference to the culture of intermediate care services. There had been improvements in the sickness rates which had fallen, staff were more engaged and positive and staff reported less conflict than there was previously.

• The service had good methods for engaging with the public and used this information to implement positive changes. There was evidence of positive and effective staff engagement initiatives that had empowered staff to get more involved in seeking and securing improvements in their working environment and care delivery.

Updated 17 December 2018

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

• The service had completed their action plan to implement changes since our last inspection in 2016. The plan addressed previous concerns we had in its safety, effectiveness and leadership.
• There was a consistent approach to medicines management for end of life care services which had not been apparent in our last inspection. Staff regularly reviewed the effects of medications on each patient’s physical health.
• There was improvement in the quality of record keeping. Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
• Staff provided a range of treatment and care for patients based on national guidance and best practice.
• End of life care services were planned, organised and delivered well. Care was delivered by competent, practitioners who considered the needs of all patients and families in their care.
• Staff were caring and showed compassion and kindness to patients and their families.
• At our last inspection end of life care services had no strategy. The service now had a clear vision and strategy which was developed with the involvement of staff and external partners.
• The trust had changed the executive lead responsible for the service and we saw improvement in the management and leadership of the service at both strategic and local level.

However

• Although the service provided a snapshot of the education and training that was taking place to support end of life care, systems were not developed enough to report on the percentage compliance in this area as the service did not hold an eligible staff group list to measure activity against.
• Whilst we saw numerous cards and thankyou letters, there was no formal feedback from patients or relatives recorded by the service. The service was planning to carry out a patient survey of care at the end of life and feedback from the patient’s next of kin or carers was being sought on cases from August 2018.