Wiltshire Health and Care LLP

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

Wiltshire Health and Care LLP was inspected during planned and announced visits. We visited many community teams, locations, hospital wards, patients’ homes, and clinics during this time. We returned to a number of locations and teams for unannounced visits.

This inspection was a comprehensive look at all services provided by Wiltshire Health and Care LLP. The core services we inspected were:

• Community health services for adults
• Community health inpatient services
• Community mental health services for people with learning disabilities or autism
• Urgent care services (minor injury units)

We visited Chippenham, Savernake and Warminster Community Hospitals and inspected four inpatient wards. We went to County Hall in Trowbridge, and Savernake Hospital in Marlborough, where we met patients and staff in the community learning disabilities service. We visited the minor injury units in Chippenham and Trowbridge Community Hospitals. To inspect the community adults’ services, we visited a range of health centres, and community hospitals, and went out with community nursing teams to patients’ homes. We also met with staff and teams at the organisation’s headquarters at Chippenham Community Hospital.

All staff throughout Wiltshire Health and Care were cooperative, helpful and supportive to us at all stages of the inspection.

Our key findings were as follows:

• We rated the safety of the provider and core services as good overall. There were safety systems and processes to protect patients from avoidable harm and abuse. Patients and their relatives received a sincere apology and explanation when something went wrong. There was openness and transparency about safety, and staff fulfilled their responsibilities to report incidents. However, there had not been a recognisable improvement in some avoidable harm to patients, such as falls and pressure ulcers, although this was from a low number of these incidents. Staffing levels kept people safe and were supplemented by temporary staff. However, this was an area of clear concern and focus for the organisation, which was struggling with vacancies and a high turnover. Nevertheless, this area was improving with ongoing recruitment.
• We rated the effectiveness of the provider and core services as good overall. Care was planned and delivered in line with evidence-based practice. Patients’ needs were assessed and care was delivered, where required, with a multidisciplinary approach. Patients’ rights were protected. There was commitment to assessing patients’ needs before they were discharged to ensure the outcomes of their care were good. However, although most staff were receiving an annual review of their performance, there was some concern around the value of these appraisals.
• We rated the caring domain for the provider and core services as good overall. Patients were respected and valued by staff as individuals. Feedback was continually positive about the way staff treated patients and those who supported or spoke for them. Staff were committed to partnership working with patients and putting them at the centre of what the organisation stood for. There were outstanding practices developed for people with cognitive impairment to help them feel safe.
• We rated the responsiveness of the provider and core services as good overall. Services were organised and delivered to meet patients’ needs. The organisation was committed to playing its role in improving how the whole health and social care economy operated. Wiltshire Health and Care was pivotal in the development of new programmes to ‘fast-track’ patients home. Then to assess them when they were at home rather than in hospital. There was a commitment to deliver care to patients at home where possible, and avoid admission to hospital. Almost all the referral times for patients to be seen were within the national target of 18 weeks.
• We rated the provider for well-led as requires improvement overall. We rated each of the core services as good for this domain. Our concerns at provider level were around how the commissioned portfolio of work had risks for the quality of work the small team were able to deliver, analyse and provide for assurance. There was insufficient quality to governance information, although we recognised significant improvements being made. The organisation was not able to provide information to us to show how it assured itself that the directors or equivalent people were fit and proper persons. There was no strategy for patient engagement, although this was now a work-in-progress, with board leadership. Nevertheless, there was notable dedication and commitment from the board and leadership of the organisation. There was a clear vision and strategy for the future.

We saw several areas of outstanding practice, including:

• In Trowbridge Hospital minor injury unit, staff used ‘distraction boxes’ for children. A charity supplied them on the request of a nurse working on the unit. The toys and games could be cleaned and any broken or missing items replaced by the charity. We also saw staff gave children their own colouring book and pencils to keep them amused and which they could take home.
• The leadership of the specialist community teams.
• The innovative practices for managing continence care.
• The responsiveness of the community teams to patients receiving end of life care.
• The strategies in place to support admission avoidance and early discharge from hospital, such as the high intensity care work and the stroke early discharge team.
• Patients on Mulberry ward (the stroke unit) at Chippenham Community Hospital were actively involved in planning their stroke rehabilitation in partnership with the ward-based therapy team. Patients had a personalised therapy timetable, which was updated weekly and stored at the bedside to enable relatives/carers to be involved in the patient’s rehabilitation.

• Staff on Longleat ward at Warminster Community Hospital were using a dementia reminiscence therapy software package. This included an interactive system that could be used by the patient’s bedside. Complex care patients with a cognitive impairment or patients who were living with dementia benefitted from the reminiscence therapy software as it enhanced staff engagement and helped to reduce anxiety and distress.
• A mural on Longleat ward at Warminster Community Hospital had been created by a local artist. The mural displayed scenes of the local area and was developed in partnership with patients, relatives and staff to support reminiscence activities for patients living with dementia. Feedback from patients and their families was being gathered to support the development of further murals on the ward.
• All staff on Mulberry ward (the stroke unit) and staff from community hospitals, including kitchen staff, student nurses and volunteers, had attended training with the speech and language therapists in helping patients who had difficulty with swallowing.
• There were limited facilities on Mulberry ward (the stroke unit) for patients to practice daily living activities following a stroke. Therefore, the occupational therapist had introduced a weekly breakfast club on the ward to enable patients to make their own breakfast in a supported environment.

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

Importantly, the provider must:

• Improve its governance procedures for the minor injury units. Specifically the provider must address low incident reporting rates, irregular team meetings, and no specific risk register. It must improve understanding of the quality and safety performance of the unit for all staff and ensure routine audits, for example, consent, patient records and medicines are regularly undertaken.
• Demonstrate that directors of the organisation or their equivalent are fit and proper persons to meet the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 5.
• Ensure systems and processes are established and operated effectively to assess, monitor and improve the quality and safety of the services provided. Within its governance arrangements, the organisation must assess, monitor and mitigate the risks to the health, safety and welfare of patients and others who may be at risk. The senior executive team must ensure they can demonstrate that improvements have been made to care and services from the analysis of accurate data, audit, complaints, and investigations into poor care.

Professor Ted Baker

Chief Inspector of Hospitals

We rated community health services for adults as outstanding because:

• The services were monitoring safety effectively and we saw evidence that learning occurred when things went wrong. There was a positive culture around incident reporting which helped promote learning and service improvement for patients. Staff received feedback from reported incidents and told what actions had been taken. There were arrangements in place to safeguard patients from abuse.
• There was a holistic approach to assessing, planning and delivering care and treatment to patients. Relevant and current evidence-based guidance, best practice and legislation was used to develop how the services, care and treatment were delivered.
• The service monitored patient outcomes and undertook a range of audits to promote best practice. Technology was used to enhance the delivery of effective care and treatment and was being positively embraced by community staff.
• Community teams responded quickly and effectively in response to end of life patients who were being discharged from an acute setting.
• Feedback we received from patients was universally and overwhelmingly positive about the compassionate and caring approach from the community staff. This was across all the teams and different specialist services. Patients thought the staff went the extra mile and the care often exceeded their expectations.
• Wiltshire Health and Care had come into operation in July 2016 with a clear programme and plan for the delivery of community services. The services were flexible, provided choice and ensured continuity of care for patients.
• There was evidence of excellent work being done with local services to promote better care and treatment and help prevent hospital admission.
• The service was very responsive to meeting the preferred needs of end of life patients.
• A strategy was outlined in a delivery plan and included a five-year programme of change needed to support the vision. The governance framework ensured that responsibilities were clear and quality, performance and risks were understood and managed.
• There was a programme of clinical and internal audit, which was used to monitor quality and systems, identifying where action should be taken.
• Services were provided with outstanding leadership in the community teams and specialist services. We found there was a positive and motivated culture within the various teams. Staff expressed pride at the quality of service delivered and the care and treatment patients were afforded.

However:

• There was an issue with safe storage of adrenaline medication whilst travelling, and the service had not yet implemented a sepsis pathway with related training for community staff.

We rated inpatient community services as good because:

• There was a well-embedded culture of incident reporting and all staff we spoke with were aware of their responsibilities to identify and report incidents. There had been a high number of falls reported but staff had been proactive in looking for solutions.
• We observed all staff followed best practice guidance for infection control to reduce the risk of infection through staff washing their hands, using personal protective equipment and following sterile techniques. Medicines, including medicines’ related stationary and medical gases, were mostly stored safely.
• The organisation was aware of staffing pressures it faced and risks were included on risk registers and reported to the board. Staffing levels were seen as being safe throughout our inspection.
• Care and treatment provided was evidence based and community hospitals participated in clinical audits. We saw good examples of audits to monitor patient outcomes.
• Most staff had received an appraisal within the last 12 months and they told us they were well supported and had good to access to training and development.
• There was effective multidisciplinary team working at community hospitals. Nursing staff talked positively about the working relationships with allied health professionals, consultants and GPs.
• There was outstanding caring to patients, who were treated with kindness, compassion and respect.
• Feedback from patients and those close to them was positive. Patients told us they were always treated with dignity and respect. We observed staff were, without exception, courteous, kind and respectful.
• Services were well-led and leadership was open and transparent. Staff felt supported and were able to raise issues and concerns. All staff were committed to delivering good compassionate care.

However:

• Access to out of hours loan arrangements for low-profile beds was inconsistent which posed a risk to patients at risk of falls.
• Arrangements for obtaining and storage of some medicines did not keep people safe.
• Informal arrangements were in place for supporting and managing staff but there was no programme of formal clinical supervision for trained nurses.
• Patients were unable to access direct admissions to Savernake and Warminster Community Hospitals due to inpatient delays.
• NHS Friends and Family Test response rates at community hospitals were low.

Overall rating for this service

• There was no assurance around the safe temperature of medicines stored at room temperature.
• Some of the patient group directions relied upon by staff were not the current versions.
• There was no formal clinical supervision for staff on a regular basis.
• Staff recruitment and retention of nursing staff was an issue for the organisation.
• The service relied heavily on bank and agency staff to cover duties required.
• There was not an effective governance framework within both units.

However;

• Patients received safe care. They were promptly assessed to ensure that serious or life-threatening injuries were identified or excluded and that patients were appropriately prioritised. Accurate and comprehensive records for patients were maintained.
• The minor injury units were clean, well maintained, and designed to keep people safe.
• People were protected from abuse and avoidable harm. Staff had good knowledge of safeguarding procedures.
• There were mostly safe levels of well-trained, experienced and skilled staff, supported by agency staff.
• Care was effective and patients had good outcomes.
• Staff delivered care with kindness and compassion. Staff made sure the patient was at the centre of the service, and offered emotional support.
• Staff took steps to support vulnerable people.
• Complaints and concerns were listened to and acted upon to improve services.
• Results of the NHS Friends and Family Test showed almost everyone who responded would be likely or extremely likely to recommend the service.
• Opening hours of both units had been reduced, in consultation with commissioners, to ensure patient safety and correct staffing levels.
• Patients had their needs assessed, care planned and delivered in line with evidence-based guidance and best practice. Patients told us their pain was assessed and they were given adequate pain relief.

We rated Community mental health services for people with learning disabilities  as good because :

• Each hub was accessible, with a clean and well maintained environment. Interview rooms were soundproofed. Staff supported service users to access clinical services and other facilities (for example weight management, blood pressure monitoring) in their local community health centres.

• Staffing levels were good and there was managerial and team oversight of the safe management of caseloads. There were appropriate cover arrangements in place for staff that were absent and posts that were vacant. Staff were experienced and had the necessary qualifications and skills to carry out their role. There were opportunities and support to attend external courses. Supervision was undertaken and staff felt supported operationally and clinically. There was an adequate monitoring system in place for training, supervision and appraisal in all teams.

• Service users were involved in care planning. Staff understood the individual needs of people who used services and knew how to support and involve them in their care. Risk assessments were routinely carried out but these were not always easy to find on the electronic recording system. Care pathway planning and implementation was being developed and there was a good understanding of national and professional guidelines so staff were implementing best practice.

• Teams reported that leadership and management structures were good and they felt supported and listened to. Staff morale was very good and teams were enthusiastic and well-motivated. There was effective multidisciplinary and inter-agency working.

• An incident reporting process was in place and staff were aware of how to report incidents. Systems were in place to share learning from incidents. Staff were able to identify abuse and safeguarding concerns and follow the correct procedures for their service. The service users and carers we spoke to all felt that they would be able to make a complaint if they needed to and felt that this would be listened to, but they had not been given a written complaints procedure. Service users, carers and service providers spoke highly of the teams and told us that staff were inclusive, caring, responsive and they felt listened to.

However:

• Not all of the interview rooms had integrated alarm systems. Staff had been issued personal alarms in the past but did not carry them when meeting with service users.

• The provider did not have a variety of easy read leaflets and documents available to help service users understand treatment options and information about the service.

• There were two vacancies for Psychologists. These vacant posts had an impact on waiting times. Service users had been waiting six months to access psychological treatments. This was not in line with the 18 week time scale recommended by national guidance.