Bridgewater Community Healthcare NHS Foundation Trust

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 last inspected this trust in April 2014 as part of the pilot project of our new comprehensive inspection methodology. We did not rate the Trust at that time.

However we told the trust that they must make improvements to:

• Incident reporting and learning from incidents.
• Ensuring all staff had appropriate safeguarding training.
• Improving the standard of record keeping and IT systems.

We carried out an announced comprehensive inspection of this trust between 31 May –3 June 2016 and an unannounced inspection on 16 June 2016 to make sure improvements had been made and to rate the service. As part of the inspection, we assessed the leadership and governance arrangements at the trust and inspected the all core services provided by the trust:

• Community Health Services for Adults.
• Community Services for Children, Young People and Families.
• Community Inpatient Services.
• Community Dentistry Services.
• Community Sexual Health Services.
• Urgent Care Services.
• Community Midwifery Services.
• Community End of Life Services.

Before carrying out the inspection, we reviewed a range of information we held and asked other organisations to share what they knew about the trust and its services. These included local clinical commissioning groups (CCGs), NHS Trust Development Authority (TDA), NHS England, Health Education England (HEE), and the General Medical Council (GMC), the Nursing and Midwifery Council (NMC) and the Royal colleges. Patients also shared information about their experiences of community services via comment cards that we left in various community locations across the Halton, Oldham, Southport, St. Helens, Warrington, Wigan Borough and Trafford areas.

Since the last inspection, there had been a number of changes to senior staff at the organisation and there had been a concerted effort to improve the culture and support for staff, which was evident in the majority of services at the time of the inspection.

The trust had developed a transformation programme that had led to services being delivered within a framework of localities across the trust’s geographical footprint.

It was evident that the trust had sought to address the findings of our last inspection and improvements had been made in some areas. However in some cases progress in making the necessary changes was slow with a lack of consistency across the trust and services. Some services required further improvement and were still not meeting important targets, such as those for the healthy child programme, the development of the end of life strategy and the implementation of consistent IT systems across the trust.

Our key findings were as follows:

• At this inspection we saw significant improvements in culture especially in inpatient services.
• Staffing had improved in the community since the last inspection but there were some concerns about the number of staff in children’s and young persons services particularly consultant paediatricians.
• Performance against key metrics in the Healthy Child Programme had improved but progress had been very slow and performance was still below key national targets.
• Waiting times in the community adults and the children, young people and families’ service had improved in some areas but not in all.
• An example of this was the trust reported that 200 children, in St Helens that had been transferred care from another trust, in November 2015, had not been reviewed by a community paediatrician. The trust developed an action plan that stated that all children needing review would be seen by the 31 July 2016.
• In Urgent Care and Walk-in Centres there was a lack of uniform triage processes that met with national guidance.
• The trust medicines strategy expired in 2013. We were told that the strategy, standard operating policy and terms of reference would be reviewed when the new head of medicines management started in June 2016.
• We found unsafe practise regarding the prescribing of end of life medication because it was open to mistake or abuse.
• The trust’s visions and values were widely understood and visible across services however end of life, dental, midwifery and children’s and young people’s services did not have clear embedded service specific strategy, vision and values.
• The governance systems needed to be improved in some key areas to ensure that the trust are using all available information to measure quality and drive improvement in services.

We saw several areas of outstanding practice including:

Community Services for Adults

The matrons at Wigan worked with the North West Ambulance Service (NWAS) utilising the community care pathways (CCPs). The community care pathway consisted of a yellow folder containing the patients care plan; their medication and medical history. The community care plan was left at the patients address next to their telephone. When the patient rang for an ambulance the address would trigger an alert to identify that the patient was on the community care pathway and a matron was involved. This would enable ambulance paramedic staff to determine the most effective referral and treatment options for known patients. One option for the paramedic would be to contact the community matron to attend the address allowing the paramedics to continue onto another patient.

Patients who have known healthcare needs and long term health conditions can have individual care plans produced; this reduced unnecessary hospital admissions and alleviates pressure on A&E departments.

Inpatient Services

We observed staff treating patients and their relatives with the upmost dignity and respect. Patients told us staff were exceptionally kind, caring and compassionate. Staff were exceptionally attentive and responded quickly and compassionately to patients who needed help or assistance, they anticipated the needs of their patients and offered assistance proactively.

Children and Young Peoples Services

The Parallel service, in Bolton, was a new service within Bridgewater that offered a 0 – 19 years’ service for young people as a single point of contact for a range of services. We found the staff to be passionate and committed to young people with a range of specialist skills.

Urgent Care and Walk in Services

The joint initiative for hospital avoidance between Bridgewater and North West Ambulance Service was the highest performing admission avoidance pathfinder initiative within the North West.

End of Life Care

The development of an AHP specialist palliative care team was an example of outstanding practice in this service.

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

Importantly, the provider must:

Trust Level

• Ensure the trust medicines strategy and standard operating policy is up to date.
• Ensure that robust systems are embedded in all services to assess, monitor and improve the quality of the services provided.

Community Services for Children, Young People and Families

• Ensure that children / young people are reviewed in a timely manner and provide assurance of safe care and treatment in the delivery of the service.
• Ensure staffing levels for all clinicians are consistently sufficient to meet the demands of the service.

Urgent Care and Walk in Services

• Ensure that patients are triaged appropriately in line with national guidance.

End of Life Care

• Ensure that there is a trust wide vision for end of life services, which is in line with national guidelines and recommendations.
• Ensure that there is a trust wide strategy for end of life services.
• Ensure that there are trust wide governance systems to monitor progression towards national targets.
• Ensure that an individual plan of care is embedded into all documentation for patients at the end of their life.
• Ensure that there is a safe and consistent system of documentation for end of life medication across all services.

Midwifery Services

• The provider must ensure that staff have the necessary competencies, knowledge, skills and experience in order to deliver care and treatment safely during a homebirth.

• The provider must ensure routine or mandatory trust rotation into the local acute trusts, to keep staff updated with skill aptitude and proficiency.

• The provider must ensure regular training for pool deliveries to ensure staff competencies and trust policies are followed correctly.

• The provider must ensure that basic emergency and resuscitation equipment are immediately available for their homebirth service.

• The provider must ensure staff training for any new emergency equipment purchased.

• The provider must ensure a more robust audit system to assess trends, implement lessons learnt and improve practice and services.

• The provider must ensure the development of robust action plans and methods of implementing audit findings.

• The provider must ensure how risks and incidents are assessed and managed and provide a robust feedback system to staff.

• The provider must ensure easy accessibility and storage location of resuscitation trolleys at the HCRC and the Runcorn clinics and that all midwives take responsibility for daily checks to ensure staff competency in using the resuscitation equipment.

• The provider must ensure the safe and effective use of patient data collection using digital pens.

• The provider must ensure improving the emergency nurse call bell system at the HCRC.

• The provider must ensure establishing a Maternity Services Liaison Committee (MSLC), to enable for maternity service users, providers and commissioners of maternity services to come together to design services that meet the needs of local women, parents and families.

  Dentistry Services

• Ensure the safe  management of medicines and stock control of medicines.
• Ensure the safe stock control of dental instruments.
• Ensure the safe infection control management of used dental instruments on localities where cleaning and sterilisation of dental instruments is provided by a third party company.
• Ensure internal and external assurance systems are in place and managed that ensure clinical services are delivered in a safe, effective, responsive and well-led manner.
• Ensure learning from incidents and complaints is shared and embedded with all staff.

For shoulds please see individual core service reports

Professor Sir Mike Richards Chief Inspector of Hospitals

Overall rating for this core service

We have judged that overall, the community health service for adults provided by Bridgewater community healthcare NHS foundation trust were Good because:

• A ‘weighting tool’ was used across all the locations on the trust. The weighting tool assessed the acuity of the patients and ensured the equitable distribution of workload and ensured that patients received safe care and treatment at all times.

• Across the district nursing teams there was good access to IT systems and adequate computers for staff use. Wigan were trailing the use of personal laptops to use on their patient visits. The laptops were to be rolled out to other areas in the coming year.

• Community adult services were involved in CQUINS; The Commissioning for Quality and Innovation scheme (CQUINs) which is offered by NHS commissioners and encourages care providers to share and continually improve how care is delivered.

• During our visit we attended patients' homes with the district nurses, all the feedback from patients was positive. We observed the nurses explaining to the patients what was happening.

• Staff told us they offered support to patients, in particular band five district nurses provided extra support visits for patients who had additional care needs, sometimes visiting the patient’s home more than four times a day.

• Halton district nursing teams were co-located within GP practices, therefore patients could attend at one location to see their GP, district nurse and attend a clinic.

• The Speech and Language Therapy (SALT) team held a weekly communication group and discuss alternative communication aids with the patients. Partners were invited to attend. The SALT team loan iPad’s out in four week blocks for the patients use. A local charity supported the applications for the iPad’s.

• The trust were currently undergoing an improvement programme and four band seven nurses have been placed on a leadership course for the Halton and Warrington area and eight for the Wigan area.

• We were told by staff at Bath Street Health and Wellbeing centre that since the expansion of the trust they describe the management structure as ‘amazing’ and they described it as an ‘open’ culture and they felt they could talk to anyone.

• The SALT team arrange directly with a local hospital radiology department, for patients to have videofluroscopy x-rays.

However,

• District nursing teams in Halton were based in GP clinics and some had poor facilities and limited office and meeting room space.

• Staff were encouraged to leave a copy of their daily job list with their manager prior to leaving the office, however, in the case of an emergency it was not possible to trace which address the district nurse was at during the course of the day, as they did not report when they were at the address, or when they had left an address.

• The podiatry teams had good links with the district nurses and GP’s; however communication with vascular and orthopaedic clinics was not as effective as it could be. We were told that the nurses could only contact these services via the GP. This was time consuming and delayed patient care.

District nursing staff told us that they had an issue with the changes in the policy regarding the use of their own cars. In some teams this had impacted on morale, especially in the Runcorn and Halton areas due to excessive distances travelled to patients' home addresses.

Overall rating for this core service

Overall we have judged that community service provided to children, young people and their families requires improvement. This is because;

• In some services, children and young people were waiting long periods of time for review appointments. For example, in St Helens, there were children, whose care had been transferred from a neighbouring trust in November 2015, who were awaiting a review of care and treatment.

• There was no evidence seen on inspection in children's care records from the St Helens locality of reviews. These children had been transferred from a neighbouring trust in November 2015.

• There was no evidence seen on inspection in children's records in the St Helens locality that prescriptions,  including controlled medication, had been reviewed by a community paediatrician. These children had been transferred from a neighbouring trust in November 2015. A total of 478 concerns had been reported to the trust as well as 16 formal complaints related to this issue.

• In audiology services in Southport, up to 41% of children had waited longer than the 18 week target for an appointment.

• There were staffing shortages for paediatricians and therapists highlighted that had coincided with an increase in caseloads.

• In areas we visited, cleaning equipment was not stored to prevent contamination.

• Mandatory training compliance was below the trusts target of 100%.

• Maintenance of equipment was not robust. Computers, in areas we visited, did not include evidence of portable electrical testing (PAT) within the last 12 months. However, clinical equipment included evidence of testing.

• There was limited information about how the care of children was transitioned to adulthood.

• A risk register was in place although many of the risks were overdue for review.

However

• There was an electronic reporting system, for the reporting of incidents. Staff understood responsibilities regarding duty of candour.

• There were robust systems in place for safeguarding children and young people with an average compliance of 94.9% staff had received level three training.

• The service was following an evidenced-based approach including the Healthy Child Programme.

• 95.5% staff had received an annual appraisal and regular supervision sessions.

• Information was accessible either through paper based records or an electronic system that was being phased into all boroughs of the trust.

• There was good multi-disciplinary working in boroughs and a number of care pathways in place.

• Staff were confident in the consent process for children and young people and demonstrated an understanding of Fraser / Gillick competence.

• Parents were positive about the care that was provided by the staff.

• We observed staff ensuring the privacy and dignity of children and young people was maintained.

• Children and young people were involved in making decisions about their care.

• Children, young people and families had access to emotional support.

• Services were planned dependent on the needs of the geographical borough.

• When assessed, the needs for children / young people and their families were based on individual need.

• Staff felt supported by their managers and there was an ‘open door culture’.

• There was good team working and commitment.

• Senior management had provided a range of staff engagement activities.

We rated end of life service as requires improvement overall. This was because:

• There was no vision or strategy in place across the trust for end of life services. When we visited there was no end of life steering group in place that could develop a strategic vision and monitor the trust’s progress towards the vision. The trust had recently changed the executive lead responsible for the trust and we were informed that the first end of life steering group was meeting in June 2016. Given this, it was unlikely that a trust vision would be developed in the next few months.
• The trust did not strategically plan its services for end of life care across the trust. This occurred at local government borough and CCG level. This meant that service provision gaps in different areas could not be identified.
• There was no consistent medicines management for end of life across the trust. We saw different standards of documentation and practice with regards to medicines management. In one area, Widnes we identified a prescribing and administration practice that gave rise to confusion and was not safe. The documentation used in Widnes was confusing in that it contained prescriptions for medication administered via syringe drivers and other routes. We also identified two episodes of GPs prescribing end of life medications for a wide dose range, which enabled district nurses to increase the dose significantly without medical review. Staff confirmed that this was accepted practice and that they had not been trained in end of life medications.
• Incidents were not monitored for end of life patients. Incidents were being reported for end of life patients within community adults teams, but there was no system in place to identify these incidents as specific to end of life. This meant that themes could not be identified in relation to end of life care and learning could not take place and be disseminated across the trust.
• The individual care plan to replace the Liverpool care pathway was not embedded into practice in all locations.
• Complaints were not collated for end of life services, which was a missed opportunity to identify themes for service improvement and development.

However,

• End of life services were planned and organised well at local level. Care was delivered by highly skilled, dedicated practitioners who considered the complex needs of all patients in their care.

At this inspection we rated community inpatient services as Good overall because;

• The service has a good safety performance record and collected data which was used to drive improvement.

• There was a good culture of openness, reporting and investigation of incidents. There was evidence of positive improvements and changes made as a result of incidents. Learning was taken from the investigations and this was disseminated and shared with staff to prevent future occurrences.

• The environment at Newton Community Hospital was clean and hygienic with low levels of healthcare associated infection and high levels of harm free care. Statistics showed that Newton Community Hospital performed better than similar providers in terms of the safety thermometer data.

• Staff were aware of their responsibilities regarding safeguarding and the correct procedures to follow; training rates were satisfactory and staff could describe the safeguarding processes. There was evidence that safeguarding referrals had been made appropriately.

• At Newton Community Hospital, medicines, including controlled drugs and intravenous (IV) fluids were stored safely and in line with agreed protocols.

• There was good knowledge and application of the duty of candour procedures and patients were The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of ‘certain notifiable safety incidents’ and provide reasonable support to that person.

• At Newton Community Hospital and Padgate House intermediate care facility staffing levels were good and safer staffing records showed a minimum of 95% shift fill rates.

• There was adequate provision for the identification and assessment of patients at risk and those who deteriorated.

• Care and treatment was evidence-based and was provided in line with best practice guidance and evidence based practice.

• At Newton Community Hospital, care plans and clinical care bundles were implemented and reviewed regularly to ensure they were in line with changes in patients’ needs and progress.

• Pain, nutrition and hydration were well assessed effectively and were well managed.

• Staff had access to information they required to undertake their roles and were confident and competent to deliver effective care. They received the right training and supervision to enable effective care delivery.

• The multidisciplinary team worked effectively, ensuring the holistic needs of the patient were met, through the evaluation of outcomes and patients’ own goals in relation to their rehabilitation.

• Data showed patient outcomes were positive, the majority of patients successfully returned to their homes and many reported improved Barthel scores, which was an established technique used to measure improvement after rehabilitation.

• The staff were trained and competent in consent procedures, the Mental Capacity Act (2005) and the deprivation of liberties safeguards.

• We observed staff treating patients and their relatives with the upmost dignity and respect. Patients told us staff were exceptionally kind, caring and compassionate.

• Staff were exceptionally attentive and responded quickly and compassionately to patients who needed help or assistance, they anticipated the needs of their patients and offered assistance proactively.

• Staff were always positive and receptive about making improvements to patient care, they actively sought ways to make patients stay more pleasant by working with them to identify ways to make things better.

• Nursing and therapy staff promoted and supported patients’ independence, encouraging autonomy whilst remaining supportive and reassuring.

• There was a strong person centred culture and staff were motivated to provide comprehensive holistic support to patients and relatives, taking into account and accommodating their emotional, mental, physical and social needs.

• Feedback from people who used the services was continuously positive, patients and relatives spoke highly of staff and the care that was delivered. Many believed that staff went above and beyond their role in the way they care for their patients.

• We saw many examples of staff going the extra mile for their patients, they showed flexibility and innovation in finding ways to improve the service provided to patients.

• Patients and their relatives were actively involved in their care and treatment and played an active role in determining their care.

• There was a holistic and person-centred care approach to the delivery of care for all patients, attention was paid to individual differences and patients’ needs. We saw positive examples that patient’s individual needs were accommodated, such as patient activities that were planned and based on their personal preferences.

• Vulnerable patients were identified on admission and staff provided individualised care to meet their needs.

• Staff were aware of the referral criteria for intermediate care and rehabilitation and ensured the patient received the right care to promote the right level of care to match the patient’s needs.

• The services worked with local commissioners, community and acute and other healthcare organisations to meet the holistic and individual needs of patients.

• Newton Community Hospital had few complaints, but those that were received were handled effectively and appropriately in line with trust procedures.

• There was an established trust strategy in place and staff were broadly familiar with trust priorities and plans.

• The culture within the services were very positive, most staff stated the organisation was a good employer and they were proud of the work they did and the care they delivered, they found their work meaningful and satisfying.

• Staff stated they felt valued, listened to and felt able to raise concerns without fear of recriminations.

• The trust had acted in response to concerns about the quality of care within the Newton Community Hospital. Managers had made effective changes to the structure and staffing to ensure patient safety, internal governance, risk management and an improved culture.

• We saw that local managers were passionate and enthusiastic leaders, who led by example and inspired their staff to develop and seek improvements in quality, performance and expertise.

• Since our last inspection, we found that there had been major improvements in the culture and governance structures within the service at Newton Community Hospital.

• All of the staff we spoke with told us that the ward manager at Newton Community Hospital had made a positive difference to the culture of intermediate care services. There had been improvements in the sickness rates which had fallen, staff were more engaged and positive and staff reported less conflict than there was previously.

• The service had good methods for engaging with the public and used this information to implement positive changes. There was evidence of positive and effective staff engagement initiatives that had empowered staff to get more involved in seeking and securing improvements in their working environment and care delivery.

We found the overall rating for Community Sexual Health Services as good because:

• We found good processes in place to reduce the risk of abuse and avoidable harm in the services and teams. The service showed us that training was on offer so that teams could identify concerns regarding adult abuse or child abuse.
• We found that good systems were in place to report and record concerns about patients who were treated by the service.
• We found a good incident reporting culture where staff were clear on what to report, who they should report to and where incidents were reflected on.
• In our interviews, staff generally felt that they did make a difference in people’s lives and they saw themselves as effective in their jobs.
• The staff showed empathy and concern for people they treated and were caring and compassionate and treated patients with dignity and respect.
• All clinical and patient areas were visibly clean and there were good infection prevention and control practices in place to reduce the risk of infection.
• The staff including managers and clinicians told us that their services were safe and took pride in their own professionalism and ability to make decisions about risk
• Managers were visible in services and showed leadership.
• Managers and clinicians had put governance systems in place which managed risk effectively.
• There was an interpreter service available for patients whose first language was not English.
• Patients consented to treatment and were informed about their treatment and were actively involved in decisions about their care, which included choices about date of appointments.
• The service had flexible opening times to cater for its population and also good dispersal of satellite services for easy access.
• The service had created good multi-agency relationships which matched the holistic needs of patients.
• The service followed British Association for Sexual Health and HIV (BASHH) Guidance.

• Service provision includes genitourinary medicine (GUM), sexual and reproductive integrated health services.

However,

• The service had faced issues maintaining adequate staffing numbers.
• The Trafford Integrated Sexual Health Service was in the process of being tendered as part of a bigger tendering procurement exercise across Greater Manchester when we inspected the service. The new tender will incorporate Trafford, Tameside and Stockport. The Trafford Sexual health service had lost a number of its staff due to uncertainty regarding future employment. Vacant posts were being left vacant as part of the restructuring process for procurement. Managers had worked with staff collectively to identify how they could reduce the impact of staff reductions until the procurement process was completed. The re-commissioned service had a specification that significantly reduced the budget.

We have judged that overall, the urgent care services provided by Bridgewater community health care NHS foundation trust required improvement because:

• At Leigh WIC the triage system in place did not reflect national guidance and meant that patients were not assessed in a timely manner.
• At St Helens there were delays in triaging patients. However, just over 94% of patients were triaged within an hour.
• There was no electronic paediatric or adults pain scoring system in place which meant that patients’ pain was assessed using different systems.
• The service did not have an electronic standardised early warning score system in place, which is not in accordance with best practice.
• Allergies information was not recorded in 33.3% of the records we reviewed.

However

• There was a culture of reporting and learning from incidents.
• Areas we inspected were visibly clean and tidy and staff responsible for cleaning followed protocols which helped control infection.
• Staff followed guidelines and pathways when caring for patients and some local audits were in place.
• Processes were in place to ensure staff maintained competencies at work. These included working through competency checklists, and developing further skills through study.
• Staff worked together locally and within the region to provide care for patients.
• Systems were in place to support children and adults to provide informed consent to procedures.
• Staff were kind and compassionate in their communications with adults, parents and their children. Patients were given information in a way they could understand.
• Staff knew about populations in their local area and the reasons patients came seeking care or treatment.
• Waiting areas catered for the needs of patients, with enough seating, toilets, and hand washing facilities.

We gave an overall rating for the community dental service of requires improvement because:

• Medicines management and stock control of medicines was ineffective; despite a ‘Lesson Learned’ paper having been circulated to all staff in February 2016, explaining that there had been two separate incidents relating to out-of-date local anaesthetic medicines being administered to patients in January 2016, we still found a number of expired medicines during our inspection.

• On two out of five sites we found that stock control of dental instruments was ineffective and a number of dental instruments had expired.

• At the time of inspection, staff and the management team did not demonstrate that infection prevention and control procedures were adhered to in line with the trust’s Dental Decontamination Policy. For example, staff told us that whilst awaiting collection of used dental instruments by an outsourced provider, they stored used dental instruments dry for up to four days in a closed box in a clinical room. However, the Dental Decontamination Policy detailed that instruments must be decontaminated as soon as possible after use to avoid air drying and where this is not possible, that the use of proprietary products for wetting/soaking are deemed useful. Staff and the management team could not provide documented evidence that the conflicting advice and practice had been risk assessed.

• Staff and the management team were not able to assure us that sufficient quality assurance oversight arrangements were in place to ensure that dental instruments were cleaned and sterilised to recommended guidelines (HTM 01-01) under the existing Service Level Agreement (SLA) with the outsourced provider.

• Although staff were encouraged to report incidents and felt supported by the management team, we found insufficient evidence of learning and sharing of learning from incidents and complaints.

• It was noted that the administration out-of-date local anaesthetic medicines to patients had not been recorded as never events in the Provider Information Return (PIR).

• Dental records audits were not focusing on individual clinicians’ improvement; it was apparent to us that the focus was to change whole practices’ habits

• The management team did not provide us with assurance that risk was managed sufficiently at departmental and local level; we did not see evidence of (local) risk assessments, risk controls and risk reduction plans. For example, we requested a copy of the Sharps Risk Assessment for Dental Services, which was drafted post-inspection on 6 June 2016 and we asked for a risk assessment of the working environment at Seymour Grove Health Centre, but staff were not able to provide such a risk assessment

• We were not assured (during the inspection and after the inspection) that all sites were compliant with legionella assessments and water services maintenance.

• We did not get assurance that water lines and bottles in both frequently and infrequently used clinic rooms, were flushed in accordance with the recommended guidelines.

• Overall, governance systems and processes were weak and the management thereof ineffective.

However,

• Staff were suitably trained to identify and respond appropriately to signs of deteriorating health and medical emergencies and staff had a good understanding of Safeguarding Adults and Children principles and training was provided; staff told us they were encouraged by the management team to initiate safeguarding procedures if they had any concerns

• Overall, staff adhered to general infection prevention and control procedures, such as safe disposal of sharps and handwashing practices. They also checked emergency equipment to ensure it was safe to operate.

• Dental officers’ clinical practice was in line with NICE guidance and in line with the British Dental Association’s (BDA) recommended guidelines and staff worked well together in a multi-disciplinary team setting.

• We found staff to be caring and passionate about their work. They were hard working, committed and they were proud of the service they provided. Staff acted in a respectful, calm and compassionate manner, observing dignity and privacy principles.

• Staff had a clear understanding of the importance of emotional support for adults and children with learning disabilities, adults with dementia related conditions and those close to them; they regularly assessed and treated adults and children with learning disabilities and adults with dementia related conditions and staff told us that they accommodated these patients, by offering appointment days and times, which were most suitable for these patients.

• As a rule, clinics did run on time, meaning that patients did not wait longer than needed in a dental clinic and patients with additional mobility needs were seen at sites which are more appropriate for those patients’ needs.

• Clinical leadership in itself was good and clinical leaders were knowledgeable and visible to staff. None of the staff we spoke with indicated that there was a culture of bullying and harassment. Feedback from patients was overall very positive.

Overall rating for this core service Requires Improvement

• Community midwives did not have immediate access to basic adult emergency equipment for obstretric emergencies or oxygen for maternal collapse at homebirths. Basic emergency equipment such as a stethoscope, amnihook (tool used to rupture membranes), maternal pocket mask, intravenous fluids, urinary catheters and oxygen were not listed on the home birth check list for the service. This did not assure us that in the event of an emergency, basic emergency procedures would be carried out until an ambulance arrived. There was no evidence of completed risk assessments for homebirth equipment. The Resuscitation Council (UK) 2011 state that staff, in the primary care setting, should have immediate access to appropriate resuscitation equipment such as an adult pocket mask with oxygen port and an oxygen cylinder.

• Community midwives did have a resuscitation “Ambu” bag (a manual, hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) for babies born in poor condition. However, the homebirth checklist for equipment did not include any other emergency equipment recommended by the Resuscitation Council (UK) 2011, such as a laryngoscope, airways, portable suction and oxygen.

• Emergency skills and drills training, for dealing with obstetric emergencies, were included in the annual mandatory training. However, the homebirth rate was below 1%; therefore, there were significant time gaps for some midwives between home deliveries. Due to the small proportion of women delivering at home, there was no evidence that midwives were provided with resources to maintain skills associated with homebirth practices as well as emergency complications. Staff did not routinely rotate into any of the four local trusts to maintain their skills.
• Policies and procedures were not robust concerning the management of a deteriorating or collapsed patient during a homebirth. Some staff were not aware of some policy pathways such as removing an unwell patient from a pool.
• Some staff, when asked, were not aware where the emergency call bells were located in all the clinical rooms at the Health Care Resource Centre (HCRC).
• There was no emergency call bells in the clinical area cubicles used at Halton hospital. These clinical areas did not have piped or portable oxygen or suction in the rooms or cubicles, in the event of an emergency.
• Emergency resuscitation trolleys were shared with other health services at both HCRC and Halton hospital sites and were stored out of the maternity areas in both sites. Staff informed us that they were not involved with the daily checking of the emergency equipment and were not aware what the equipment consisted of.
• There was no evidence seen that clinical audit systems and processes were established to continuously assess, monitor and improve the quality and safety of services provided.
• Staff reported that they were aware how to report incidents; these incidents were reviewed and investigated locally by the HOM and risk management midwife. However, there was no evidence provided that feedback from lessons learnt improved service needs or the quality of experience for patients.
• The maternity risk register was up to date however; there was discrepancy between staff about what was on the register and what action plans were being implemented to improve practice.
• The record keeping system involved the use of digital pens (a battery-operated writing instrument that allows the user to digitally record patient information in the handwritten notes). However, use of the digital pens were on the risk register as they did not consistently or effectively collect and store accurate and up-to-date information about patients. Therefore, this did not reassure us that records and information were accurate, complete or contemporaneous. However, there were plans for the service to implement a new IT system using ipads.
• The trust did employ a young parent’s midwife, who provided support to patients less than 19 years. However, the trust did not employ a specific specialist bereavement midwife, mental health midwife or safeguarding midwife however, there was evidence of good multidisciplinary working with the safeguarding nurse team. The Head of Midwifery (HOM) was the named safeguarding link midwife.
• Some midwives were not aware of the trust values or plans for the further of the service.
• Staff informed us that some patients had been involved in the design of the trust maternity hand held notes and pop up information posters that were displayed in the clinical waiting areas.
• There were four supervisors of midwives (SOM), including the Head of Midwifery. This met best practice Birthrate Plus recommendations 2007.
• Clinical areas were clean and tidy and were well sign posted for patients to access.
• The number of midwives employed met best practice Birthrate Plus recommendations 2007. The service had systems in place between team leaders to review midwifery staffing levels regularly.
• At the time of inspection, all staff had completed their annual appraisal review.
• Multiagency and disciplinary working was established and promoted the best outcome for mothers and their babies.
• Patients, we spoke to and observed, were cared for with kindness and compassion and they were positive about the standard of care and treatment provided by the maternity services.
• Staff, we spoke to, informed us that the community teams were managed well by the team leaders and that staff were well supported by the supervisors of midwives.
• During our unannounced visit, management had responded well to some risks, which had been identified and escalated during our announced visit. This included an action plan to review staff competencies, emergency equipment at homebirths and auditing of information