29-30 November, 1,2, 13 and 14 December 2016
During a routine inspection
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
We undertook a planned announced inspection as part of our comprehensive community health services inspection programme on 29 & 30 November and 1, 2 December 2016. We also carried out an unannounced visit on 12,13 and 14 December 2016 and inspected the following core services:
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Community health services for adults
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Community health services for children, young people and families
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Community mental health services for people with learning disabilities or autism
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Urgent care services
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End of life services
We did not inspect the inpatient ward at Clevedon Community Hospital as it was closed for refurbishment at the time of our inspection.
We rated North Somerset Partnership Community CIC and the five core services inspected as good overall. Safety in the community adults service and community services for children, young people and families was rated as requires improvement.
Our key findings were as follows:
Safe:
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There was a good incident reporting culture and evidence of thorough investigation leading to learning from incidents across the organisation.
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Staff understood the importance of being open and honest and we saw evidence that Duty of Candour was applied when things went wrong.
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Staff were knowledgeable about safeguarding which was embedded in practices although not all staff had received training to the level required for their role and contact with children.
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There were business continuity plans in place to respond to emergencies and other major incidents.
However
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There was a lack of auditing compliance with assessing risks to patients such as assessment for nutrition and falls assessments.
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The use of both paper and electronic records led to risk of staff being unable to access patient information in a timely manner due to issues with connectivity of mobile devices. This meant staff did not always complete contemporaneous electronic patient records. These issues had been recognised and were noted on the risk register.
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The organisation did not have an effective process for flagging to managers when compliance with training was low.
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There were challenges in maintaining levels of staffing with an inequality of the capacity and the size of the caseload across the localities for community adults services. Similarly in the services for children, young people and families some staff had very high caseloads and funding for health visitors had reduced.
Effective:
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Staff followed care and treatment guidelines and pathways based on current best evidence.
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Staff had the right qualifications to carry out their roles, supported by competency assessment framework.
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There was effective multidisciplinary working across the organisation and staff had good working relationships with GPs across North Somerset.
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Staff were knowledgeable about mental capacity assessment and deprivation of liberty legislation and obtaining consent for treatment and care interventions.
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Service users had access to psychologists in the team provided by another provider. This allowed them access to therapies recommended by the National Institute for Health and Care Excellence.
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Patients had care from staff who had specialist training in end of life patient care.
However:
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Not all services consistently collect data to measure patient outcomes and they did not participate in national audits to benchmark their treatment and care.
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Health visiting teams provided care as agreed with commissioners. However, this did not always follow national guidance and could have an impact on the health outcomes for children and young people.
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The inadequate mobile working arrangements meant that staff did not always have access to information about the patient.
Caring:
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Patients and their carer’s (when appropriate) were routinely involved in planning and making decisions about their care and treatment.
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Staff communicated effectively with patients and took time to answer questions.
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Patients received care from nurses and support staff that treated them with dignity and respect in the minor injury unit (MIU) and they were always listened to and felt able to raise concerns.
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98.3% of patients in between July and September 2016 said they would recommend the MIU service to others.
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Staff providing end of life care were highly regarded by relatives of deceased patients for their kindness, caring and compassionate attitude.
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Children and families were offered support and staff used caring approaches to help people who found difficulty in expressing their concerns.
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Children and families were offered privacy when it was needed and confidentiality was respected.
Responsive:
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The organisation worked within the contract of the clinical commissioning group to ensure the services met the needs of the local population as far as possible.
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Clinics were scheduled to meet the needs of individuals as far as possible and many patients benefitted from clinics in locations close to their homes.
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The service provided patient group activities, which enabled patients to gain social interaction as well as access to advice, education and support.
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The service received few complaints, but responded to and handled complaints in a timely manner.
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Care was provided 24 hours a day, seven days per week and there was access to end of life and palliative care advice at any time of the day or night.
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The minor injury service (MIU) was planned to meet the needs of all patients, including those who were vulnerable or who had complex needs.
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The average time to treatment in the minor injuries unit was 47 minutes.Waiting times were constantly monitored in real-time by clinical staff and 99% of patients were treated, discharged or transferred within four hours in the last 12 months.
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In services for children and young people the leads were working with public health and commissioners to identify the priorities for the local population. Staff were encouraged to develop services that worked towards these priorities.
However,
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The waiting time from referral to treatment at times exceeded 19 weeks in the outpatient physiotherapy services.
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Patients were not routinely screened for dementia or referred for further assessment.
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School nursing services had a four month waiting list for children and families who needed routine support.
Well led:
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Staff were proud to work for the organisation and liked their roles. They felt they could feed issues up to senior managers and executives and they were listened to at board level.
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The challenges of changes at executive level were recognised and much work was underway to ensure a cohesive team which was visible and accessible.
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Public opinions were sought in a variety of ways which was suitable for the service they offered and where possible, changes were made in response to comments.
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Staff were keen to improve services and acted on ideas for improvement.
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Staff engagement was recognised as key in the employee owned organisation with the staff council being at the heart of plans going forward.
We saw several areas of outstanding practice including:
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The community outreach team had adopted an effective approach to reach out to people and improve their access to health care. They set up ten weekly clinics in Weston-Super-Mare for ‘hard to reach’ groups such as people with substance misuse, homelessness and social isolation. The service provided interventions on a range of public health lifestyle issues such as weight management, healthy eating, reducing substance misuse including alcohol, Between October 2015 and January 2016 the service received 103 new referrals and assisted 11 people to find accommodation.
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Some patients relatives were enabled to give care to relatives after assessment and training by end of life care coordination centre team.
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The end of life care coordination centre had established a library of books in each of the eight teams (for example learning disability, community nurses). This had been enabled by money raised by friends of a patient. They covered all children’s age ranges who might be affected by a death in their life.
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The end of life care coordination centre were providing staff with ‘shadowing’ opportunities so that they could work alongside experienced workers in end of life care.This approach was intended to ensure that workers recruited knew what the role entailed and had the right qualities to work in end of life care.
However, there were also areas of poor practice where the provider needs to make improvements.
Importantly, the provider must:
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Ensure that staff working in the community adults service have access to a system that enables them to complete all care records contemporaneously.
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Ensure that paper and electronic records for patients contain relevant information and are available to all staff at the time needed to ensure the delivery of safe and effective care.
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Ensure that staff working in the community adults service and the end of life care service are compliant with mandatory training in line with the organisations targets.
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In the community adults service, ensure that patient risk assessments are completed in a timely way.
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In the community adults service, ensure that processes are in place to monitor staff compliance with the completion of patient risk assessments.
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In the community adults service, ensure that processes are in place to monitor staff compliance with the completion of audits.
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In the community adults service, ensure that areas where sterile dressings are prepared are regularly cleaned.
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Ensure there are sufficient numbers of staff to meet the needs of children, young people and families in all areas of North Somerset.
Professor Sir Mike RichardsChief Inspector of Hospitals