HCRG Care Services Ltd

Updated 25 August 2017

Wiltshire Children’s Community service is a business unit of Virgin Care. This business unit delivers children’s services only for the county of Wiltshire. Virgin Care secured the contract to deliver these services in April 2016 for the duration of five years plus a possible two year extension. Prior to this contract five providers delivered the service and under Virgin Care they have come together under one contract, with staff being transferred under the Transfer of Undertakings Protection of Employment (TUPE) regulations.

Services provided include; health visiting, school nursing, school immunisations, family nurse partnership, speech and language therapy, paediatric therapy, community paediatrics, children’s continuing care, children’s community nursing, looked after children nursing and learning disability health team.

The service covers a geographical patch where the birth rate is approximately 5000 births per year. There are 402 children on child protection plans and 451 looked after children across the age range of 0-18 years. They offer a universal service to 240 schools and delivered a flu vaccine programme in 2016/17 to 12,000 children.

During our inspection, we visited clinics, staff bases and schools. We accompanied health visitors, school nurses and other staff members on community visits. We spoke with 63 staff, 26 parents/relatives/carers and 14 children. Two focus groups were held whereby 36 staff attended to talk to inspectors. We observed how children and young people were cared for, and looked at 26 care and treatment records. Policies and procedures, data and information, provided by the organisation and other stakeholders, was reviewed before, during and after our inspection.

Updated 25 August 2017

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

Virgin Care Services Limited (VCSL) locations were inspected during February, March and April 2017 as part of our programme of planned, comprehensive inspections of independent healthcare community services. We did not visit all locations but sampled all services and made inspection visits across the country. Some locations were moving into and out of the providers realm of responsibility during the reporting period. These services have not been reported on to avoid confusion about where accountability sits.

We looked at the following core services; Community Healthcare Services for Adults (including end of life care) , Community Healthcare Services for Children and Young People, Community Inpatient Healthcare Services and Sexual Health Services. We did not inspect prison healthcare services or services registered as primary medical care services as part of this inspection.

We rated Virgin Care Services Limited as Good overall.

There were exceptionally robust systems in place for providing assurance to the Board about the safety and quality of the services provided. Data collated as part of the assurance and governance framework was used to drive service improvements. The governance structure was comprehensive but not unduly complex and encouraged operational staff to take responsibility for the services they delivered.

VCSL could demonstrate through documented evidence that following acquisition of services, they had managed to bring about a sustained, significant improvements to patient care. The Clinical Governance RAG rating score for Wiltshire services, acquired in June 2016, had improved month on month from 45% to 85% in an eight month period. Similar patterns of improvement could be seen for other acquired services. Some more established services sustained scores of over 90% with North East Lincolnshire scoring 100% over the reporting year.

The staff spoke positively about the culture of the organisation and felt that they were supported to provide good care. There was a very clear vision and explicit behaviours that were known to staff of all grades and disciplines. Learning and development were seen as key to staff satisfaction and high quality service provision. This was true of both established services and more recently acquired teams.

VCSL had an explicit quality statement and vision which was, “ To attract the best practitioners, to have the best systems and to deliver the best outcomes….providing the tools and creating the environment where quality flourishes, demonstrated throughout outcomes that everyone feels the difference”.

Our key findings were as follows:

• Incident reporting was encouraged and there was very good oversight at business unit and Board level. Each Head of Operations and each Clinical Governance Lead reviewed every incident report personally. There was evidence of organisation wide dissemination and sharing of learning from incidents.
• The metrics for incidents showed that serious incidents (SIs) were a small proportion of the overall number of incidents reported. Serious Incidents in health care are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. The provider policies and protocols for incident management mirrored the guidance contained in the Serious Incident Framework (NHS England Patient Safety Domain, 2015).
• All SIs were reported to the national clinical director by telephone within 24 hours of the event.
• Mandatory training completion rates were very high with most services showing 100% compliance with most of the required training. Where there were lowered levels it was because the figures were a year end total and the year was not complete at the time of the inspection visits. The exception to this was Wiltshire children’s services which were acquired in April 2016.
• The Chief Pharmacist provided strategic medicines optimisations advice and support. They held the corporate responsibility for ensuring legal and statutory frameworks in relation to medicines management were adhered to. All medicines related incidents were reviewed via the Medicines Management committees which reported into the Virgin Care Clinical Governance Committee.
• The Chief Pharmacist was the Accountable Officer for Controlled Drugs.
• There were two senior pharmacist who reported to the chief pharmacist. One was the National Quality Pharmacist whose sphere of responsibility included policy oversight, education and competency. They worked alongside the National Development Pharmacist who was responsible for medicines optimisation in the procurement and acquisition programmes.
• Each business unit pharmacist was line managed by the Chief Pharmacist.
• There was a very comprehensive annual medicines management audit which posed 250 questions. Themes and trends were identified and responded to. Individual outliers were managed through the business units.
• The organisational Caldicott Guardian was the Clinical Director. There were deputy Caldicott Guardians working across local services.
• There was an Information Governance Committee that reported directly to the Executive team via the Executive Committee .
• Confidentiaity audits took place each quarter and showed high levels of compliance.
• The provider’s links to the wider Virgin group of companies allowed access to expert advice and support from the Virgin Security Intelligence Group, a global Virgin group, particularly in areas such as cyber security.
• Safeguarding was given sufficient priority and the Board had good oversight of the safeguarding arrangements. Services for children in Wiltshire had a Named Nurse who was available to provide advice and support across the organisation, in addition to the Designated Nurses from lead CCGs. The Safeguarding Adults and Children’s Committee reported to the Virgin Care Clinical Governance Committee and had representatives from each business unit.
• Business units had local safeguarding leads and service safeguarding champions.
• The Chief Nurse line manages the national safeguarding leads for the organisation reporting into the Clinical Director who was the executive lead, and had a good oversight of all concerns.
• Data provided demonstrated that there had been demonstrable improvements in the outcomes for patients over time. The collation of outcome data was fairly new but the provider was able to show, for example, a reduction in pressure damage due to attributable care lapses.
• Monthly information was collected on patient’s preferred place of care (PPC) and preferred place of death (PPD) and then this was compared to the actual place of death. We saw evidence that across Surrey patients achieved 96% to 100% of their PPC and PPD.
• The provider was working to the Gold Standard Framework (GSF) an evidence-based approach to optimising care for patients approaching the end of life.
• We observed a number of patient visits and we saw that staff were respectful, kind and caring in their approach. Treatment options were openly discussed and the patient was seen to be part of the decision making process.
• The results of the Family and Friends Test were consistently high. In some services the score showed 100% of patients who would recommend the service to others. The results had been sustained over time and the surveys had good response rates.
• The provider had a Nursing Strategy that was under review at the time of the inspection visits. It had been identified that whilst nurses formed the majority of frontline professional staff, there were therapists and other staff groups who needed to be included. Going forward the Nursing Strategy was to become the Health and Care Strategy; the organisational values were being mapped to the professional Codes of Conduct which formed the basis of the strategy document.
• The provider had a Risk Register Policy that was used effectively locally and at Board level. Each service and business unit had its own Risk Register that it was responsible for. High scoring risks were escalated to the Virgin Care Clinical Governance Committee and upwards to the Virgin Care executive team. Significant corporate risks were escalated to the parent company.
• Individual executives were able to talk to us about the most serious risks within their remit. Examples were given of how the provider had responded and mitigated against risks.
• The provider had three Freedom to Speak up Guardians, one whom was the legal counsel for the organisation. The guardians were supported by an anonymous online system.
• Staff were also encouraged to make direct contact with Board members if they felt their concerns warranted senior intervention or they felt they were not getting an adequate local response.
• The provider supported and encouraged and open and transparent culture which sought solutions to problems rather than apportioned blame.

We saw several areas of outstanding practice including:

• The provider had introduced a very comprehensive Internal Service Review process and web tool that was used by registered managers to review and evidence their levels of compliance mapped against the CQC inspection framework. There was an expectation that every service or location would complete the review twice a year. The Board saw the ISR as both a monitoring tool and a development tool. Front line staff had worked with subject matter experts to create the review tool.
• The provider had achieved the Cybersecurity Standards of the General Data Protection Regulation (GDPR). This legislation will apply in the UK from 25 May 2018. There were 22,000 data flows across the organisation that were mapped to check the provider was GDPR ready.
• Equality and diversity training was in place for staff and 100% of community staff had completed this mandatory training.
• Staff could apply to the ‘Feel the difference’ fund to help with ideas and innovations. Staff felt innovation was encouraged. This was a £100, 000 fund that seed funded local initiatives suggested by staff that focussed on patient experiences. The bids could be suggested by any staff and were approved by a peer panel. There was an option for very small bids to be fast tracked. Innovations so far have included standing desks, body blocks and a body mapping system.
• The motor neurone disease (MND) multi-disciplinary team from Farnham had been presented with the extra mile award by the motor neurone disease association for their exceptional care for people with MND.
• The speech and language team had purchased tablet computers with specific therapy applications; these were used by patients to practice speech for relaxation and mindfulness.
• In Grimsby, the service had initiated local multidisciplinary team working to produce information sharing and care / referral pathways regarding unaccompanied asylum seeking children (UASC) and FGM to learn from their experience and ensure there was a holistic multi-disciplinary approach to caring for these children in the future.
• The Grimsby service worked in partnership with a local authority outreach worker who ensured very vulnerable patients could access services and treatment at times to meet their specific individual needs.
• Staff from the Grimsby service delivered sexual health education to a variety of groups including; a young mother’s group, and had also attended a group for people with a learning disability to help the group mentor answer any questions relating to sexual health.
• The ‘Wiltshire Splitz support service’ is a registered charity delivering support services to women and young people experiencing the trauma of domestic abuse. Health visitors would, with appropriate consent, refer mothers to the service for additional advice and support as well as making appropriate referrals to the Multi Agency Risk Assessment Conference (MARAC) where domestic abuse was identified.
• VCSL utilised the ‘You Said, We Did’ methodology for all their services every month. This was used proactively to improve care. Some examples of how feedback from children, young people and their families influenced their services in Quarter 3 were as follows: Parents requested information on managing sleep for children and young people with learning difficulties at the Wiltshire Parents Carers Council Event on 13th October. The provider team used Sleep Scotland materials to provide an informative presentation to 20 parents on managing sleep. Excellent feedback received.
• The provider was working with representatives from Wiltshire council to engage the parents of children who were being educated at home or outside of Wiltshire County Council area, to ensure they had knowledge of VCSL and ensured they could access health services. Wiltshire Children’s Community service were currently working with external partners on ensuring leaflets about information sharing and consent were clear and to explain why certain information, such as compliance with the accessible information standards is collected.
• There was a robust, visible person-centred culture. Staff within the children and young people teams always focused on the needs of children and young people and put them at the heart of everything they did. Children, young people and their parents or carers told us they were fully involved in their care and treatment. Relationships between people who used the service, those close to them and staff were strong, caring and supportive.
• The speech and language therapy team completed case load audits annually as part of clinical supervision. This was completed one to one between the therapist and their line manager and looked at case note quality and clinical decision making. The review process provided the opportunity to discuss cases and feedback directly to the therapist of both good practice and areas for development.

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

Importantly, the provider should

• Ensure that Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms are always completed in line with the guidance about ‘Decisions relating to cardiopulmonary resuscitation’. VCSL should implement the new Recommended Summary Plan for Emergency Care and Treatment guidance.
• Review the process for transcription of outreach records onto the electronic system and continue to merge patient records where the online booking system has created duplicates to ensure the standard of one patient record is achieved. Consider allocating nurses sufficient time to enable this. It is acknowledged that the provider was aware of this and taken action to mitigate any risk. A merging process was in place and monitored.
• Ensure all staff required to do so complete the mandatory Mental Capacity Act (2005) training.
• Review lone working procedures across all Wiltshire Children’s Community teams and ensure there are clear processes to follow when a lone worker perceives themselves to be at risk.
• Ensure the integrated therapy model of the Wiltshire Children’s Community service is developed and delivered as soon as reasonably practicable. It is acknowledged this is a commissioning led review and that the provider is dependent on the commissioners for leadership of this.
• Consider improving benchmark targets for the healthy child programme within the Wiltshire Children’s Community service.
• Continue working towards reducing the reliance on agency and bank staff across services.

Professor Sir Mike Richards Chief Inspector of Hospitals

Updated 21 August 2017

• There was a comprehensive ‘safety management system’, which took account of current best practice models. The whole team was engaged in reviewing and improving safety and safeguarding systems. Innovation was encouraged to achieve sustained improvements in safety and continual reductions in harm. There was a positive, no blame culture towards incident reporting with effective mechanisms to investigate and learn from incidents.
• There was a thorough analysis and robust investigation of things that went wrong. Learning was clearly identified and all staff were encouraged to participate in learning to improve safety as much as possible. Robust safety monitoring and benchmarking systems were used to drive improvements across the organisation. The safety monitoring systems were based on a monthly clinical governance scorecard. Data reviewed showed high scores against KPIs and sustained improvement over time.
• Staff treated patients with kindness and compassion and respected patient’s dignity at all times. We saw staff involving patients and their families and carers in decision making about their care and providing emotional support with great depth of understanding.
• The provider and individual staff were committed to developing services that considered individual needs and preferences. Services for carers were a strength and there was evidence of working with specific groups (such as the Nepalese community and the MND community) to ensure that their members wider needs were met.
• Community end of life care services were of a very high quality, followed the Gold Standard framework and ensured that effective multidisciplinary and interagency working was provided for the benefit of patients approaching the last days of life.
• There was a strong focus on multidisciplinary working within the organisation and with external agencies such as local acute care providers and adult social care.
• Staff had the appropriate skills and knowledge for their roles and received regular mandatory training, clinical supervision and peer reviews. The provider focussed on improving the quality of care provided through ensuring staff were trained and supported to work “At the top of their grade”. The organisation actively supported staff to develop and extend their knowledge and competencies, and encouraged innovation.
• Staff were supported with strong local leadership and felt empowered to make changes that improved patient care. Staff felt valued and had a clear understanding of the organisations vision and strategy.
• Complaints were investigated and managed appropriately in a timely manner with learning identified shared, staff were able to give us examples of learning.

However:

• The vision and strategy for the care of patients with dementia was not embedded or understood by staff and there was a lack of training in dementia awareness.
• There was a lack of sepsis training and staff awareness about this condition.
• Do Not Attempt Cardiopulmonary Resuscitation forms were not always completed in accordance with the full national guidance. The provider had not yet introduced the new Recommended Summary Plan for Emergency Care and Treatment.
• There was high use of agency nursing staff.

Updated 25 August 2017

We rated community health services for children, young people and families as good:

• There was a robust, visible person-centred culture. Staff within the children and young people teams always focused on the needs of children and young people and put them at the heart of everything they did.
• The feedback received for the children and young people services was excellent. Children, young people and their parents or carers spoke about how they were treated with respect and dignity and that staff were very friendly, warm, caring and professional.
• Children, young people and their parents or carers told us they were fully involved in their care and treatment. Relationships between people who used the service, those close to them and staff were strong, caring and supportive.
• Staff demonstrated high levels of care and compassion at all times during our inspection. We saw staff treating children, young people, parents and carers with dignity and respect.
• Fully embedded into services and staff was the ability to recognise the different needs and cultures of children and their families. This allowed support to be provided and reasonable adjustments to be made.
• Staff demonstrated a good awareness of their responsibilities for safeguarding children and young people. The procedures in place for supporting staff with safeguarding were robust and effective.
• Staff received regular appraisals and clinical and safeguarding supervision. Staff said they felt well supported in their roles.
• Effective multi-agency working was well embedded in practice and provided progressive outcomes for children.
• Staff demonstrated their knowledge and skills around consent consistently.
• The risk registers of individual services reflected the concerns of the staff we spoke to. Whilst risks could not always be mitigated they were discussed and staff were confident their managers were aware of the challenges they faced.
• Care and treatment was delivered in line with the National Institute for Health and Care Excellence (NICE) guidelines, with a system in place to ensure this guidance was communicated with staff. We also saw this information being shared with parents and carers.
• Staff described an open culture, where they felt confident to raise issues, and in the response they would receive.

However:

• Lone working procedures and processes to keep staff safe were not always well embedded across services.
• Staff vacancies and high caseloads were present in some services, although these were being managed to ensure safe care and treatment, there was a risk it would impact negatively on the delivery of care and staff morale.
• Not all staff working with children were up to date with their mandatory training including basic life support and the mental capacity act 2005.
• Remote working technology was yet to be developed to maintain a real time picture of services in the region.
• Benchmark targets for the healthy child programme required improvement, they were below the national average.
• The integrated therapy model was not yet fully developed or delivered. However, this was a commissioner led review and the provider was awaiting their leadership in supporting the service model going forward.

Updated 10 August 2017

Safety was a primary strength of this service at both local and provider level. There were very effective systems in place for monitoring the quality of care and safety of services. Local staff were encouraged to take responsibility for using the corporate tools (such as the Internal Service Review) to drive improvement in patient safety.

There were highly effective corporate safety systems for monitoring services and acting on concerns. Performance was shown to improve over time across all services in the organisation. Any dips in performance trajectories were investigated and the root cause identified. Openness and transparency about safety was actively promoted. Staff understood and fulfilled their responsibilities to report incidents and near misses.

The provider gave high priority to safeguarding people from abuse, there was good leadership nationally of both adult and child safeguarding. Staff were knowledgeable and had completed the appropriate level of training.

There was a proactive stance in identifying individual needs and preferences.

Medicines were managed appropriately and staff had been assessed as competent to administer medicines against the corporate medicines management policies. There was good oversight by the Chief Pharmacist.

People had comprehensive assessment of needs that included clinical and social needs. The multidisciplinary care plans created from patient assessments were reviewed and updated regularly. Care and treatment was planned in delivered with due consideration of national and best practice guidance. Care and treatment outcomes were monitored to ensure consistency across the entire organisation.

Staff were supported through a comprehensive education programme. Core skills such as medicines administration were assessed using a competency based framework. Revalidation for nurses and other professionals was supported and monitored.

There was evidence of good multidisciplinary working and we observed good inter-professional communication.

Consent to care and treatment was sought in accordance with national guidance and corporate policies. Staff had a good understanding of capacity to consent and knew how to respond if they felt someone lacked capacity.

We observed that people were treated with compassion and dignity. Feedback from patients and their carers was continually positive with high scores in the Friends and Family Test.

There was good service planning to meet the needs of the local communities serviced by the hospitals. The delivery of services was planned in consultation with Clinical Commissioning Groups (CCGs) and other providers, even where the provider had lost services in the commissioning process. Planning for newly acquired services was comprehensive and covered a 100 day period when all aspects of the new services were reviewed.

Facilities were appropriate to the services being delivered. Some premises were in need of refurbishment and VCSL staff were in on-going discussion with NHS Property Services (NHSPS) about this. Patient led assessment of the care environment (PLACE) scores were consistently high, particularly so given the poor fabric of the buildings in some settings. PLACE is an annual assessment of inpatient healthcare sites in England that have more than 10 beds.

Care was individualised and took account of peoples preferences and specific needs.

There were few complaints but those received were reviewed with consideration of clinical risk and safeguarding by senior staff within the business unit. Responses were appropriate and timely.

There was very strong corporate and local leadership. Staff reported positively on their managers and said they were supportive and encouraging. Staff felt the provider encouraged good practice and allowed staff to innovate.

Staff understood VCSL’s vision and strategic plans. They felt empowered to innovate and were supported to do so.

The local and corporate monitoring and governance was a real strength with the board having a very clear picture of the performance of individual teams.

However;

Staffing within the inpatient units was a challenge and there were a number of shifts where the staffing on duty was less than the planned numbers of staff.

There was room for improvement in the documentation of Do Not Attempt Cardio Pulmonary Resuscitation decisions. The service had not yet implemented the new Recommended Summary Plan for Emergency Care and Treatment

The Dementia Strategy needed further work to embed fully in practice.