Wirral Community NHS Foundation Trust Also known as Wirral Community Health and Care NHS Foundation Trust

Our rating of the trust went down. We rated it as requires improvement because:

• We inspected five core services during this inspection. We rated community adults and sexual health services as requires improvement. We rated children and young people’s services, urgent care and GP out of hours services as good. We rated two of the trust’s seven services as requires improvement and three as good. In rating the trust, we took into account the current ratings of the two services not inspected this time. These services were previously rated as good.
• We rated well-led for the trust overall as requires improvement.
• The trust was rated as requires improvement in the safe and well-led domains. In terms of the safe domain, across most core services we were not assured there were effective processes in place to identify, escalate and mitigate risks. This led to immediate patient safety risks, which we escalated and the trust responded to at the time of our inspection. Further details can be found below in the overall ‘Are services safe?’ section and the ‘Is the service safe?’ section for each core service.
• In terms of well-led, our main concerns were around systems and processes for risk escalation then the subsequent managerial actions that resulted from this. More detail can be found below in the overall ‘Are services well-led?’ section and the ‘Is the service well-led?’ section for each core service.

However:

• We rated effective, caring and responsive as good. In terms of the effective domain, we found people had good outcomes because they received effective care and treatment that met their needs.
• In terms of caring, we found people were supported, treated with dignity and respect, and were involved as partners in their care. For the responsive domain, we found people’s needs were met through the way services were organised and delivered.
• More information about the effective, caring and responsive domains can be found in the ‘Are services effective?’ ‘Are services caring?’ and ‘Are services responsive?’ sections below. For each core service the ‘Is the service effective?’, ‘Is the service caring?’ and ‘Is the service responsive?’ sections below contain further detail.

Our rating of this service stayed the same. We rated it as good because:

• Throughout the service staff were caring and passionate about providing good quality services to children, young people and families. Staff spoke with enthusiasm about their roles and specialties and demonstrated dedication to improvement and innovation.
• Staff were suitably qualified with the right skills and experience in order to deliver safe and effective care. The service ensured that there were enough staff to keep people safe from harm and protected from abuse.
• The service planned care effectively with external providers to create and implement care plans which were individualised and took into account the specific needs of individuals.
• Leaders and senior managers within the service engaged with staff in order to shape and improve services. This led to the implementation of bespoke services which better met the needs of the local population and improved morale among staff who felt that their opinions were listened to.
• The strategy of the service was aligned with cost improvement planning. Staff at all levels were clear that cost improvement could not be made to the detriment of service quality or safety.
• Talent mapping had been used as part of staff appraisals in order to provide development opportunities for staff who wished to progress in their careers. This meant that staff in leadership roles were passionate and enthusiastic.
• The culture of the service was focussed around the experiences of people using the services. Staff actively sought feedback from children, young people and families in order to shape and improve services.

However:

• Leadership structures within the service were in their infancy at the time of our inspection. This meant that while areas for improvement had been identified by senior leaders, there had not been time for effective change to have taken place.
• A recent workforce review had been completed without the input of staff with specialist knowledge of the service. This meant that the review findings were not always applicable to the service and time was taken to complete further contextual work in order to develop meaningful recommendations with regards to workforce planning.
• Risks to patient safety were not always identified and acted upon in a timely way. The special school nursing team had been working without policies tailored to care of children with complex needs within the community setting for a number of years.

Our rating of this service went down. We rated it as requires improvement because:

• Nursing assessments were not being carried out frequently enough, or in accordance with trust policies. This potentially put patients at risk and failed to prevent patients from acquiring pressure ulcers.
• There were eight instances of out of date medicines found in stock cupboards, and expired hard copies of patient group directives being used by community nurses.
• Senior managers did not always have full oversight of concerns, issues and risks affecting the day to day working of some services. There was a significant lack of assurance about the organisation’s management and prevention of pressure ulcers that had been a high risk on the risk register for some time.
• Communication lines from senior managers down to team leaders was not always effective. Some team leaders did not feel fully informed about key issues affecting their service, making it difficult for them to manage services effectively.

However:

• There were high compliance rates of mandatory training and 100% of staff had completed safeguarding training for adults and children.
• Services had suitable premises and equipment. They were kept clean to minimise the risk of infection.
• With the exception of the rehabilitation at home team, there were enough staff with the right qualifications, skills and training to meet key performance indicators so that patients were seen and assessed in a timely way and within the prescribed targets.
• The service provided care and treatment based on national guidance. There were processes in place to ensure that guidance was promptly reviewed, disseminated and embedded.
• The effectiveness of care and treatment was monitored regularly and reported to the trust board. Services were involved in the annual clinical audit programme. Audit results and patient outcome monitoring were compared with other services to drive improvements.
• Staff received regular supervision and role-specific training. They were encouraged to take up external training courses that were relevant to their roles.
• Staff worked collaboratively with the local acute trust, GPs and the local authority to deliver effective care and treatment and support people to live healthier lives and manage their own conditions.
• Staff cared for patients with compassion and respected their privacy and dignity. They offered adequate emotional support and involved patients and their carers in decisions about their carer and treatment.
• Complaints and concerns were treated seriously and lessons were learned and shared with staff.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action. The views of staff and patients were used to drive improvements.
• Staff were valued and supported by managers and a positive culture and the wellbeing of staff was promoted.

Our rating of this service stayed the same. We rated it as good because:

• Staff were caring and passionate about providing good quality services to people using the urgent care service. Staff spoke with enthusiasm about their roles and demonstrated dedication to providing timely and effective care.
• Staff were suitably qualified and had most of the right skills and experience in order to deliver safe and effective care. The service ensured that there were enough staff to keep people safe from harm and protected from abuse.
• The service sought to improve the efficiency and quality of community urgent care by developing pathways for patients with minor fractures and suspected deep vein thrombosis without the need for referral to the acute trust.
• The staff we spoke to understood their responsibilities to raise concerns, record safety incidents and near misses and knew how to report these. However they were less familiar with the duty of candour.
• People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards and best practice. We saw that clinical guidelines followed national guidelines and clinical practice was monitored for compliance and consistency.
• The average percentage of all cases triaged September to December 2017 within 30 minutes was 88%. This was below target (95%) but improvement plans were in place to increase the flexibility of nursing roles to improve patient flow.
• There was an effective governance structure in place and a systematic approach to monitoring, reporting and improving the quality of care.

However:

• There were arrangements in place to identify, record and manage risks, but not all risks raised by staff and managers were recorded on the register.
• We had concerns relating to the quality of paediatric life support training and the number of staff trained in it and there was a lack of assurance that competence in cardiopulmonary resuscitation skills was assessed according to the Resuscitation Council standard.
• In urgent care 77% of qualified nursing staff had completed the appropriate level of adult safeguarding training. This was below the trust’s target of 90%. Staff also demonstrated a lack of awareness of mental capacity assessment.
• Systems to manage patient group directions needed strengthening. There was insufficient assurance that all nursing staff received regular clinical reviews.
• Patients gave us a mixed response about the level of privacy experienced at the walk in centre reception desks.
• Facilities for children in each walk in centre waiting room were limited. At each site, parents told us they felt there was little to occupy children while they waited.
• We were unable to evidence regular team meetings took place for walk in centre staff, that divisional management attended or that there was a standard communication mechanism such as a newsletter, when meetings could not take place.
• There was a lack of evidence that the voices of all staff were heard and acted upon around skill mix, working extra hours and access to in-house training. Managers were aware of these concerns but it was not clear what progress was being made to resolve these issues.

This was the first rating of this core service. We rated it as requires improvement because:

• Staff did not understand their role in recognising and preventing potential abuse and links with other agencies were not clear. Although most staff had completed safeguarding training, this was not being demonstrated in application.
• Systems were not in place to ensure that patients were appropriately protected. Staff were not competent with the sexual health electronic patient recording system so staff were unable to use the system appropriately, access patient risk assessment tools within it and record patient information effectively.
• Risks to patient safety were not always identified and acted upon. The records system in place did allow staff to confirm the age of attendees. This meant that professional curiosity was relied upon to try and determine whether patients were the age they reported to be. This was not documented in any of the records we reviewed and represented an immediate patient safety risk, which the trust addressed at the time of our inspection.
• People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards and best practice. We saw that clinical guidelines followed national guidelines. However, due to a lack of audits, it was unclear how clinical practice was monitored for compliance and consistency.
• The trust did not have clear oversight within the service. When staff raised patient safety risks relating to the IT system, the response had not been timely and effective.
• The governance structure in place was not always effective and there was not a systematic approach to monitoring, reporting and improving the quality of care.

However:

• Staff were caring and passionate about providing good quality services to people using the sexual health service. Staff spoke with enthusiasm about their roles and demonstrated dedication to providing effective care.
• Staff were able to describe the relevant national guidance and local procedures.
• There were systems in place to record incidents and staff we spoke with were aware of reporting incidents and how to report them. Managers investigated incidents and provided feedback to staff through team meetings.