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.
The Care Quality Commission (CQC) carried out a comprehensive inspection of First Community Health and Care C.I.C between the 20 and 22 March 2017.
We inspected this core service as part of our comprehensive Wave 2 pilot community health services inspection programme.
We rated First Community Health and Care C.I.C as Outstanding overall.
Whilst all services were very good and delivered in a truly caring and compassionate way, the children’s services were exceptional at providing services adapted to meet the needs of the community being served.
The organisational culture was open, trusting, caring of the employees and there was a tangible commitment to supporting staff to deliver high quality services. Staff were encouraged to be shareholders and this ownership led to innovation and a real ‘can do’ attitude. All staff we spoke with were positive about the leadership, supported and knew the vision and were very proud ambassadors for the organisation.
First Community Health had a clear vision and strategy that was well understood and supported by staff. Staff were involved in its design and committed to its successful implementation. Staff were loyal to the organisation and excited by, and welcomed the challenges ahead in terms of having a bigger impact on care provision to a larger demographic as part of the STP.
There was a very strong holistic person-centered focus. It was also an outward looking culture in terms of knowing exactly what external services were available and how best to access these services. Staff were empowered to build strong networks with other local healthcare providers, support groups, and charities. Staff also displayed a commendable drive to continuously improve the service through innovation, balanced with meeting people’s social, cultural and individual needs. This ensured that teams were creative in overcoming obstacles to delivering care.
We saw several notable examples of where the senior managers had flexed to ensure that the staff needs were met. Staff knew their executive team well and there was a genuinely open door policy. Many staff worked from the office where the executive team were based, which coupled with the small size of the organisation, led not only to personalised care for patients but also to personalised care of the workforce.
We saw an exceptionally strong commitment to equality and diversity across the organisation, modelled by a part-time Chief Executive Officer and two administrative staff with learning disabilities who were employed on the same terms and conditions as other staff but given high levels of support to fulfil roles they told us, “Had transformed their lives and was the best job ever”. We met with BME staff but were told that each of them felt they were simply members of staff doing their jobs in a supportive organisation. The organisation had considered the Workforce Racial Equality Standards (WRES), was monitoring and considering how best to meet the needs of BME staff but also felt it was more about meeting each member of staff’s individual needs. There was role modelling with a BME Deputy Chief Nurse who had been supported to join a BME Aspiring Director of Nursing Network to enhance their development opportunities. A WRES audit had been carried out and there was an action place to address areas where improvements could be made.
The Board were particularly strong and well informed. They were led by a very confident but collaborative chair. It was clear they understood their roles and could differentiate between operational and strategic management. We saw a real depth and breadth of understanding from the non-executive directors, some of whom were recruited following a skills gap analysis review.
Our key findings were as follows:
- The service encouraged openness and transparency about safety. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence of learning from incidents and a positive incident reporting culture.
- The service assessed, monitored and managed risks to patients who use services on a day-to-day basis. This included daily checking for signs of deteriorating health, medical emergencies or challenging behaviour.
- Staff received up-to-date mandatory training, including information governance and infection prevention and control, to allow them to keep patients safe. There was a high level of compliance with mandatory safeguarding training. The service gave safeguarding sufficient priority and staff knew how to recognise and report concerns to keep patients safe.
- The service planned and delivered care and treatment in line with current evidence-based guidance, standards, best practice and legislation.
- All staff were actively engaged in activities to monitor and improve quality and outcomes. There was a dedicated audit lead in place and a healthy audit culture had been developed in the service.
- First Community had more harm free care than the national and median figures during 2015/16
- During the reporting period the provider supported an average of 96% of people at the end of their lives to die in the place that they choose.
- First Community had also implemented a live performance dashboard that staff could access at any time. This promoted ownership and responsibility of the team performance, facilitated the celebration of success, but easily identified areas for improvement.
- The service routinely monitored and collected information about patient outcomes. The service used this information to improve care. Benchmarking data, where available, showed patient outcomes were similar to national averages.
- Staff, teams and services were committed to working collaboratively and had found innovative and efficient ways to deliver more joined-up care to people who used services. This included strong links with other health care providers, local charities and support groups. They embraced new technology to improve the quality of the service.
- Patients felt involved in their care and treatment and the service encouraged patients to be partners in their care. Staff respected patients' wishes and preferences.
- People’s emotional and social needs were highly valued by staff and were embedded in their care and treatment. Whilst this was evidenced across all services, it was most striking and a prominent feature of the work undertaken by the homeless team.
- The service made reasonable adjustments and took action to remove barriers for patients who found it hard to use or access services. This included patients who had communication difficulties, disabilities and those in vulnerable circumstances.
- Volunteer-run services such as bingo and chair-based exercise classes helped meet patients’ social and rehabilitation needs.
- First Community predominantly used an electronic records system. This was accessible by a wide range of health care professional outside of the organisation and promoted safe continuity of care. The records we viewed were accurate, up to date and fit for purpose.
- The average Friends and Family Test Score for 2016/17 was 4.8 out of 5 stars (96%).
- Across all metrics captured by the staff Friends and Family Test that First Community were better than the national average.
- There were effective processes to take account of comments and concerns. People who used services were confident the organisation would respond positively to any concerns raised. Data demonstrated there were very low levels of complaints in the service. No complaints were escalated to the Parliamentary Health Service Ombudsman (PHSO), this demonstrated good local resolution.
- There was appropriate and effective governance, risk and quality measurement processes. These were widely understood by staff and influenced practice and service delivery. Staff were given direct access to outcome dashboards so they could share the success and identify areas for improvement.
- First Community’s Information Governance Assessment Report overall score for the reporting period was 70% and was graded Green (Level 2). They had an action plan in place for 2016-17 to enable them to achieve Level 3 compliance.
We saw several areas of outstanding practice including:
- There was a commendable proactive approach to understanding the needs of different groups of people and to deliver care in a way that meets these needs and promoted equality. This was most evident in the way the service met the needs of the vulnerable, homeless, Gypsy, Roma and Traveller (GRT) and refugee communities and those in vulnerable circumstances with complex social needs.
- There was a unanimous feeling that every individual member of staff counted and was valued, regardless of their role or position. Staff felt they could genuinely effect change and have a positive impact on the service delivered and the teams they worked in. The staff survey demonstrated very high engagement scores and work satisfaction scores. Data also suggested staff were highly likely to recommend the service to others.
- There was an incredibly open culture with accessible leadership demonstrated by the ‘Floor to Board in 5 minutes’ initiative. Staff really could speak with a member of the executive management team within 5 minutes of identifying a concern or idea, if they had not managed to get local advice or resolution or if they felt their comments affected the entire organisation.
- Staff demonstrated a very high level of awareness of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff made DoLS applications appropriately and in a timely manner and senior staff were well informed and able to discuss individual applications.
- Staff connected with the community through the provider Community Forum; a network of groups and organisations linking together to provide the best possible service locally.
- The provider was proactive in ensuring every patients voice could be heard. They shared ‘live’ feedback on their website/intranet. There had been 18,500 reviews over four years via iWantGreatCare.
- We identified the pro-active care matron pilot scheme with the local acute NHS trust as an area of outstanding practice. This was because the service was taking an active role in working towards reducing emergency department admissions at the acute trust.
- The Council of Governors was an elected group of staff members who took a proactive role in representing the shareholders interests in First Community Health and Care, acting as an essential conduit between shareholders and the Board of Directors. As members of the staff group, the Council of Governors promoted and encouraged participation by the shareholders in the company’s affairs.
- First Community re-invested company savings in a phlebotomy service for local house-bound patients. It proved so successful the services have now been commissioned.
- The provider holds an ‘Outstanding’ Unicef Baby Friendly Award for their work to support breastfeeding mothers.
- The child and baby “Advice Line” innovation saved local NHS partners £130,000pa as well as reducing the need for additional face-to-face health visitor support (worth £70,000pa).
- The NHS staff survey 2016 showed an Engagement score of 4.04 compared to 3.79 for NHS Trusts nationally – putting First Community among the best in UK for engagement.
- We identified the yellow wristband system for alerting staff of patients with additional nutrition needs as an area of outstanding practice.
- The service provided by specialist nurses was frequently described as a lifeline with care widened to include support for the patient and their relatives.
However, there were also areas of poor practice where the provider needs to make improvements.
Importantly, the provider should:
- that all areas of the Caterham Dene Hospital (particularly the physiotherapy gym) are cleaned in accordance with the national guidance.
- take action to ensure all nursing staff respond to call bells and patient requests for assistance in a way that meets patients’ needs.