Norfolk Community Health and Care NHS Trust

Updated 22 June 2018

Not used

Updated 22 June 2018

• Community health inpatient services improved from requires improvement to good overall. The question of safety stayed as requires improvement. Effective and well led improved from requires improvement to good. Responsive remained good and caring improved from good to outstanding. There were inconsistencies in equipment service and maintenance checks and local leadership, which resulted in some processes and procedures not being embedded and implemented across the localities. Storage of medicines in some wards was not in keeping with trust policy. However, the service was very proactive in the use of risk assessments, all patients were routinely assessed by nurses and therapy staff. Staff cared for patients with compassion and kindness, which promoted people’s dignity. Staff recognised and respected patient’s personal, social and religious needs and respected people’s wishes and preferences.
• Community health services for adults remained good overall. Safe, effective and well led remained good. Responsive improved from requires improvement to good and caring improved from good to outstanding. Feedback from patients was continually positive about the way staff treat people and staff encouraged patients to be involved in their own care and promoted independence as much as possible. The service had improved waiting times for services, including neurology and foot health services. We found areas for improvement relating to monitoring of and access to equipment, monitoring of medicines and staff appraisal.
• Community health services for children, young people and their families remained good overall. The questions of effective, caring and well led remained good. Responsive went down from good to requires improvement. Safe improved from requires improvement to good. The service had improved the premises at Squirrels respite care unit with the addition of a dedicated clinic room and extended bathroom. The management and administration of medicines at Squirrels respite care unit was now safe. We found areas for improvement relating to compliance with records management policy and the use of patient outcome data for external benchmarking. Implementation of a specific strategy for the children young people and families service was in progress.

Updated 22 June 2018

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

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

• 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.

• The service provided mandatory training in key skills to all staff and made sure everyone completed it. Records dated 01 March 2018 showed compliance with mandatory training was 92.9%, which was above the trust target.

• 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.

• Staff supported patients with the assessment and management of nutrition and hydration in order to meet their needs and improve their health.

• The service monitored the effectiveness of care and treatment and used the findings to improve them.

• Staff of different kinds worked together as a team to benefit patients. Nurses, therapists and support staff worked with professionals from other services to provide good care.

• Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.

• Staff understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

• 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.

• The service planned and provided services in a way that met the needs of local people.

• Waiting times had improved and people could access the service when they needed it. Response times and waiting times were monitored and senior staff took action to improve access to the service.

• The service took account of patients’ individual needs.

• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.

• The service had effective systems for identifying risks and planning to eliminate or reduce them.

• Most staff we spoke with told us managers promoted a positive culture that supported and valued staff. Two staff mentioned concerns around support for staff in the continence service and the response to concerns raised. We raised this with senior leaders, who were aware of the concerns and confirmed that the concerns had been investigated and that those raising concerns were satisfied with the outcome of the investigation. 

• The trust engaged well with patients, staff and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.

However,

• Although staff had access to mobile working (which meant they could complete patient care records while remote working in the community), use of this system was not fully embedded with all staff.

• Staff did not always monitor and store medicines well. We reviewed records at Wymondham health centre and found that daily checks of fridge temperatures had not been completed consistently and concerns had not been escalated. We reviewed emergency adrenaline supplies carried by two community nurses and found one ampoule of adrenaline that was out of date. We raised these concerns with staff, who took action to address the concerns.

• Staff did not always monitor equipment effectively. Staff did not have a clear process in place for setting and monitoring airflow mattresses and the process for recording and monitoring calibration of blood glucose monitors varied between different community teams.

• Staff did not always have access to equipment to meet patients’ needs. Six staff reported difficulties with timely delivery of equipment to patients by a third party supplier, including equipment for prevention of pressure ulcers. Senior staff were aware of these concerns and were working with the equipment supplier to improve the timeliness of deliveries.

• Records provided by the trust showed compliance with staff appraisal within the service was 82.3% on 01 March 2018. This did not meet the trust’s target of 90%.

Updated 22 June 2018

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

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.

• 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.

• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

• 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 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.

• The trust planned and provided services in a way that met the needs of local people.

• The service took account of patients’ individual needs.

• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.

• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.

• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

• The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

  However:

• The trust had two vacant positions for paediatricians which had impacted on waiting lists.

• Although the service monitored the effectiveness of care and treatment and used the findings to improve them, we did not see evidence that they compared local results with those of other services to learn from them.

• Access to a number of specialist services was limited which meant an increased risk to the most vulnerable patients and families.

• Three of the eight services within children and young people’s services were below the trust waiting times target for referral to treatment.

Updated 19 December 2014

There were systems and processes in place to keep people safe.  Staff knew how to report incidents and there was evidence of learning from these.  There were good infection prevention and control procedures in place and staff took responsibility for this.  Staff demonstrated an in depth knowledge of decontamination best practice.

Equipment was serviced and was checked before use.  We found the temperature checks of the medicines refrigerators were not consistently taking place but this was being addressed.  Apart from drugs stored in the refrigerator, other medicines were stored safely.  Staff could describe their responsibilities under safeguarding patients in their care and we found where concerns had been raised the appropriate procedures had been followed.

Records were well maintained and consent was taken prior to procedures being carried out.  There were procedures in place to assess and respond to patients risks.  Patients medical history was obtained and individual risks were identified.  Emergency equipment was available and although at one clinic we found the checking of this had been inconsistent it had been identified and was being addressed.

The dental service worked in partnership with other services for example the local acute hospital and referring dentists to provide coordinated and timely care to meet the needs of patients. Pain relief was well practised.

Specialised treatment was undertaken at dedicated centres with the appropriate trained staff and support systems to ensure patient safety. Staff received on-going mandatory and specialised training. New staff received an induction to ensure they were able to undertake their role safely and effectively. 

The service was effective at monitoring and improving patient outcomes. A number of audits had taken place and the results had been used to improve the service. Treatment was given according to national guidance.

People were overwhelmingly positive about the care and treatment received.  We saw people were involved in their care and they were given time to ask questions about any aspect of their treatment. We saw good interactions between staff and patients.  People we spoke with felt their particular needs and concerns were understood and respected by staff. Staff we spoke with demonstrated they cared about their patients.  We found staff to be proud and committed to providing a specialised dental service for patients.

We observed people were consulted at each stage of treatment to ensure they had their permission to proceed and that people were given reassurance before continuing. The staff were familiar with the patients fears and took time to reassure and relax the patient without the need to use medication. Staff were able to demonstrate a good understanding of how and why it was important to obtain and record consent for examination and treatment.

Patients were given clear explanations during pre- assessment avoiding the use of technical terms and providing diagrams to enhance the patients understanding of planned treatment. Patients were given different choices of treatment and the benefits of each option were carefully explained.

There were pictorial care pathways provided for children who had been assessed as requiring general anaesthetic. This was provided to help them understand what to expect and minimise their fears about planned treatment.  During appointments the dentists asked questions about each patient’s current oral hygiene practice and gave suggestions how this could be improved to prevent problems.

People were referred to the community dental service who had been assessed as having complex or special needs, including learning difficulties, where treatment with a general dental practitioner was not possible. Staff understood the special needs of their patients and provided a service to meet those complex needs. Most patients were seen within six to eight weeks from referral.  The dental service also provided a domiciliary (home visiting) service for people who were not able to attend the clinic due to illness or disability.

There was good collaborative working between the service and other healthcare services to ensure good patient outcomes.

Obtaining feedback from patients was actively promoted and we saw evidence that information was used to improve the service.   We saw results of patient feedback were displayed in public areas, which showed there was a high level of satisfaction with the service provided.  There were four complaints relating to dental services during 2012/13.  Two of these complaints were upheld and no trends in the reasons for the complaints were identified. Staff were able to describe what actions they should take if a patient or their relative/carer made a complaint.

Staff were able to describe the aim of the service .  There was clear leadership and a quality framework was used to ensure delivery of safe care and effective use of resources. There were few incidents or complaints within the dental service.

There was commitment from staff to obtain and learn from feedback from patients including the use of audits to improve the quality of the service. We saw evidence of improvement initiatives and monitoring of the quality of the service.

Staff said senior managers within the trust were supportive and responsive but they could tend to make decisions about the service without the involvement of the dental team. Staff had opportunities to meet with their line managers and team members. Arrangements for one to one supervision of staff had been put in place and staff felt valued.   

Updated 22 June 2018

• Clinical areas were visibly clean and staff complied with infection control procedures. The trust results of the Patient-led Assessments of the Care Environment (PLACE) audit was above the England average of 98%. All patients we spoke with spoke positively in regards to cleanliness and hygiene.

• The service had close multidisciplinary team working. There were daily MDT handovers and formal weekly MDT meetings. The service used a MDT progress sheets to record actions and tasks for all relevant professions.

• Patients were involved in their own rehabilitation, goal setting and discharge planning from their admission to the wards. Discharge dates were set and agreed as a goal and individual needs and rates of recovery were considered at multidisciplinary meetings.

• On all the units we visited, staff were caring and compassionate towards patients. Staff treated patients with kindness, dignity and respect. We found that staff were sensitive to the needs of the patients and their families.

• The service took account of patients’ individual needs, such as those living with dementia, patients that had non-English language requirements, cultural and religious beliefs.

• The service was very proactive in the use of risk assessments, all patients were routinely assessed by nurses and therapy staff. The use of assessments was actively monitored.

• Staff we spoke with were aware of how to report incidents and the trust had a robust system of incident investigation and learning.

• The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients.

However:

• The service did not meet the trust compliance target for mandatory training. Overall training compliance was 84% against a trust target of 90%.
• There were inconsistencies in equipment service and maintenance checks.
• Storage of medicines in some wards was not in keeping with trust policy.
• There were inconsistencies in leadership within the service. For example at Kelling hospital the local leadership were unaware of the challenges in the ward, didn’t know how to access the performance monitoring data or tell us what the current establishment or vacancy rates for the ward was.
• Leadership was very locality based therefore some processes and procedures were not being embedded and implemented across the localities.

Updated 19 December 2014

Staff were aware of and had access to the trust’s online incident reporting system.  We saw evidence of learning from incidents to improve practice. Overall the standards of cleanliness and hygiene were good and staff demonstrated a good knowledge of procedures for the management, storage and disposal of clinical waste, environmental cleanliness and prevention of healthcare acquired infection guidance. Procedures were in place to ensure equipment was regularly maintained and fit for purpose.

There were appropriate systems in place to protect patients against the risks associated with the unsafe use and management of medicines. The trust had replaced all of its syringe drivers in accordance with national guidance. 

There were effective safeguarding policies and procedures which were understood and implemented by staff. Staff were aware of the trusts’ whistleblowing procedures and what action to take. The trust could not be assured that all of the faith leaders who visited patients had been subject to a DBS check.

We looked at eleven sets of patient medical notes and reviewed the DNACPR (do not resuscitate in the event of a cardiac arrest) documentation. Generally we found these were completed in accordance with best practice, however there were some gaps on some forms.

Throughout the community end of life services we were told of concerns regarding the number of staff available to enable the effective delivery of care and treatment. Community nursing staff reviewed their caseloads according to patient need and end of life patients took priority. Relatives and patients we spoke with spoke positively about access to staff and we did not find evidence to suggest that community nurse staffing levels were adversely affecting the quality of patient care. 

Staff told us that there were delays admitting patients to the Ogden Court unit because of the staffing levels.  Whilst we were at Ogden Court an afternoon admission was refused because of the staffing levels and the risk this posed.

There was a trust wide safe staffing reporting mechanism in place.  This was reported to the Quality Risk and Audit Committee (QRAC) on a monthly basis.  

Most staff we spoke with demonstrated little or no understanding of their responsibilities regarding the Mental Capacity Act 2005 and did not know what to do when patients were unable to give informed consent.

Patients were triaged and assessed accurately so that safe treatment and care was provided to guard against risks associated with their condition. Risk assessments in areas such as falls, pressure care and nutrition were complete and updated as patient’s needs changed.

The trust had removed the use of the Liverpool Care Pathway and implemented interim guidance called “Caring for people in the last days and hours of life.” Training concerning the replacement was still being undertaken by the trust. Patients within end of life services had their pain control reviewed daily. Regular pain medication was prescribed in addition to ‘when required medication’, which was prescribed to manage any breakthrough pain. We saw that care followed the national Institute for Health and Care Excellence (NICE) Quality Standard CG140. The care records we reviewed showed staff supported and advised patients who were identified as being at nutritional risk.

The care and treatment provided achieved positive outcomes for patients. Patients receiving end of life care received support from a multi-disciplinary end of life care team, which included a specialist palliative care team, consultants, GP’s, district nurses.  In addition there was a full time social worker at Priscilla Bacon Lodge. In accordance with the Gold Standards Framework, multi-disciplinary team meetings took place weekly to ensure any changes to patients’ needs could be addressed promptly.

We saw evidence that end of life services monitored the performance of their treatment and care.  Records were completed to a good standard and contained a clear pathway of care which described what the patient should expect at each stage of their treatment.

Community end of life services were caring. We observed positive interactions between staff and patients in their homes and in every unit we inspected Patients were treated with compassion and empathy.  Throughout our inspection staff spoke with compassion, dignity and respect regarding the patients they cared for. We noted there was an apparent mutual respect amongst the staff. 

All of the patients and relatives we spoke with told us that care was good. They were treated with respect and dignity and felt involved in their care and treatment.  The specialist palliative care team supported people emotionally. The team had received training to enable them to support patients and families; they also delivered training to community staff. 

The trusts palliative care service provided care for 652 patients during 2013/14.  We found the service had a good understanding of the different needs of people it served.  Services were planned, designed and delivered to meet those needs. We saw through advanced care planning, patients were able to dictate both their preferred place of care and preferred place of death. The trust monitored the performance of their end of life treatment and care service.

We saw numerous letters and cards expressing positive feedback from patients and relatives. Staff were aware of the trust’s policy for handling complaints and had received training in this area.

Staff told us there was active reflective practice and learning following complaints, for example, improvements had been made in facilitating timely patient discharge from hospital as a result of learning from a complaint.

The end of life service had a clear local vision to improve and develop high-quality end of life care. The increase in investment to support the implementation of seven day service supported this vision. Most staff were aware of the trust’s vision and strategy however this was not fully embedded amongst all the staff.

There was good leadership and support from local managers and most staff felt engaged with senior management. There was a positive culture in the service. 

Risk management and quality assurance processes were in place at a local level.  The end of life service held governance and patient safety meetings and records showed risks were escalated and included on risk registers and monitored each month. Local quality dashboards were also completed which showed how the service was performing against key quality indicators. We found managers were aware of the quality issues affecting their service and shared them with the staff.

Across all of community end of life services, staff consistently told us of their commitment to provide safe and caring services, and spoke positively about the care they delivered. At a local level all staff felt listened to and involved in changes within their team and spoke of regular involvement in staff meetings.