Archived: Central Surrey Health, Head Office

Updated 30 June 2017

For a full summary of this inspection, this report should be read in conjunction with the individual location reports for Dorking Community Hospital, The New Epsom and Ewell Community Hospital, Molesey Community Hospital and the overall provider report.

Central Surrey Health Limited (CSH) is a profit for social purpose enterprise, set up by its employees (called co-owners) in 2006. As the first of its type in the country, the organisation re-invests any financial surplus from activities back into the business and local community projects. Around 40 other providers in England have followed this model of healthcare since.

Central Surrey Health Limited is the registered provider.

Dorking Community Hospital provides a community inpatient service on Ranmore ward which has 22 beds. On the day of inspection, an additional four beds had been opened in response to increased demand and 26 beds were in use. The services provided include palliative care and rehabilitation. Patients are admitted to community inpatient services from acute hospital or from their own home. At Dorking Community Hospital the medical services are provided by a local General Practitioner Practice.

The New Epsom and Ewell Community Hospital provides a community inpatient service on one ward which has 20 beds. Four of the beds are designated for neurological rehabilitation, the remaining 16 are for rehabilitation. Patients are admitted to community inpatient services from acute hospitals or their own home. Medical services for the hospital are provided by a local General Practitioner Practice.

Molesey Community Hospital provides a community inpatient service on one ward which has 12 beds. The services provided include palliative care and rehabilitation. Patients are admitted to community inpatient services from their own home or from acute hospitals. At Molesey Community Hospital the medical services are provided by a local General Practitioner Practice.

The services provided for children and young people (CYP) include health visiting, school nursing including specialist school nursing, services for Looked After Children (LAC), speech and language therapy, physiotherapy and occupational therapy, and dietetics.

CSH provides a range of nursing and therapeutic services to the adult population of mid Surrey. These services included district nursing, physiotherapy and podiatry. Local commissioning bodies purchased additional specialist nursing and therapy services, which included end of life care, frailty and falls, continence, respiratory, heart failure, tissue viability and integrated rehabilitation services.

CSH delivers these services in people’s homes, clinics, schools, children’s centres and community hospitals. Clinics in the community hospitals also accept outpatients discharged from the wards or from other hospitals in the area. In addition, a wheelchair service operates from one community hospital.

The delivery of care was divided into two main groups, called ‘planned care’ and ‘unplanned care’. Planned care included musculoskeletal physiotherapy, hand therapy, podiatry, wheelchair and continence services. Planned care utilised waiting lists and had targets set in agreement with the commissioning bodies. Unplanned care services included district nursing and domiciliary physiotherapy, community matrons and specialist nursing teams that responded directly to referrals from GPs and local hospitals.

Updated 30 June 2017

Updated 30 June 2017

We have rated this service as good.

• Overall, patients were protected from the risk of abuse and avoidable harm. A range of risk assessments were utilised by the various clinical teams to assess and manage risk and co-owners could escalate risks that could affect patient safety. We saw systems in place for reporting, investigating and learning from incidents.
• There were sufficient employees (co-owners) with the right skills to care for patients and co-owners had been provided with induction, mandatory and additional training for their roles.
• Co-owners had a good awareness of policies and procedures, which were based on National Institute for Health and Care Excellence (NICE) guidelines and other national standards. We saw evidence of local and national audits undertaken to monitor the quality, safety and effectiveness of care.
• Clinics were visibly clean and there were appropriate systems to prevent and control healthcare associated infections. Rooms were equipped with sufficient equipment and consumable items for their intended purpose. Medicines were managed safely in accordance with legal requirements and checks on emergency resuscitation equipment were performed routinely.
• Care was delivered by a range of skilled co-owners who participated in annual appraisals and had access to further training as required. We found evidence of multi-disciplinary team (MDT) working across all of the areas we visited and we saw good collaborative working and communication amongst all co-owners. Patients told us they felt very well supported and informed at all stages of their treatment and commented very positively about the care provided to them by the co-owners from the clinics and in their own homes.
• We saw co-owners address issues with tact, diplomacy and in a caring yet professional way. Therapy and treatment room doors were kept closed, and co-owners knocked before entering clinic rooms to maintain patients’ privacy.
• People’s concerns and complaints were listened and responded to and feedback was used to improve the quality of care. There was a system in place for capturing learning from complaints and incidents and there was very good local ownership of any problems with teams working closely together to resolve any issues that arose.
• We saw good local leadership with an open and transparent culture. There was a very clear vision and focus on the delivery of excellent quality care. Co-owners were overwhelmingly positive about their experience of working in the organisation and showed commitment to achieving the provider's strategic aims and demonstrating their stated values.
• The governance framework ensured employee responsibilities were clear and that quality, performance and risks were all understood. In addition to features of the organisation such as an employee council, the senior management team were visible and regularly engaged with co-owners and patients.

However,

• Training and mandatory training rates were not meeting the targets set by the organisation and we found that the quality of incident investigations varied. We acknowledge CSH were addressing this.
• While care was evidenced based and there was participation in national audit programmes, the range of audits was restricted and some of the information provided to us dated.
• Care was delivered by a range of skilled workers who participated in annual appraisals and had access to further training as required. Whilst the co-owners were supported to undertake training and annual appraisals, compliance rates for both were below the organisational benchmarks.

Updated 30 June 2017

We have rated this service as requires improvement.

• We identified incidents were under reported in the Children and Young People (CYP) service. We found the quality of incident investigation was varied, and there was a lack of senior management and governance oversight of the quality of incident handling. This meant that that the organisation’s ability to learn, improve, and prevent future recurrence was affected. The governance structure was not well understood by co-owners and the flow of information was not effective.
• We identified concerns about senior manager oversight of the Special Education Needs and Disabilities (SEND) service. This related to a lack of timely, proactive service planning to ensure the SEND team could meet the complex needs of those who used the service.
• Data demonstrated very low levels of complaints in the service. However, the complaints we reviewed showed the quality of the investigations, response tone and learning from these was inconsistent.
• Co-owners in the service were found to be stretched across the service. Whilst we recognise an active recruitment drive was in progress, there were high vacancy and workforce turnover rates. Data from the recent co-owner survey suggested low satisfaction levels in response to the question ‘do you feel there were enough co-owners in your areas of work to get everything done’.
• Appraisals rates reported in the performance report 2016, showed that the appraisals rates for the service was low. This meant that a significant number of co-owners did not have an annual appraisal. The reason given for this poor performance was current workload, managing vacancies, and long-term sickness.
• The records we viewed demonstrated that co-owners had achieved a compliance rate of 89% which was not meeting the provider’s benchmark of 95%.
• Areas we visited were visibly clean and tidy, and local cleaning records were available. However, we asked the provider for evidence of departmental oversight of hand hygiene and environmental cleaning audits. We were not provided with meaningful data that demonstrated departmental oversight of compliance or evidence of trend and theme monitoring.
• There were significant delays in accessing the tongue-tie service. Tongue-tie can be defined as a condition present at birth that restricts the tongue's range of motion. With tongue-tie, an unusually short, thick or tight band of tissue (lingual frenulum) tethers the bottom of the tongue's tip to the floor of the mouth. This meant the service was not managing to meet the needs of local people.
• Duty of candour was well understood and co-owners understood their role to ensure compliance with this regulation.
• Medications were safely handled, managed, and stored appropriately. However, we requested evidence of medicines audits which was not received.
• CYP were protected from the risk of foreseeable emergencies because suitable equipment and competent co-owners were made available.
• There were appropriate systems and processes to ensure major incidents and foreseeable events were managed effectively.
• The care delivered reflected national guidance and data showed that patient outcomes were favourable when compared to national averages.
• Children and young people were protected from the risk of abuse because there were systems in place to ensure risks were identified and appropriately managed. The service had embedded multidisciplinary working to ensure that service users received the best and most effective care available.
• Children and young people had their individual healthcare needs assessed and were involved where possible in planning their care.
• Records were contemporaneous, fit for purpose and available to all members of the MDT which aided care continuity. Where paper records were used, files were held securely and kept confidential.
• Co-owners were observed providing professional, kind and compassionate care that reflected people’s wishes and diverse needs.
• Working relationships between co-owners was strong, and had a boundless focus on integrity, as well as compassion and support for each other, as well as the children and families they came into contact with.
• Feedback received from children and young people was entirely positive. CQC did not receive any complaints about this service during the inspection time frame.
• Co-owners clearly understood and were completely committed to the organisation’s values, beliefs, vision and strategy. Morale was found to be very high. There was evidence that staff engagement was meaningful and much valued.
• There were systems to ensure the views of the public could be sought.