Hounslow and Richmond Community Healthcare NHS 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. 

Overall, we have rated Hounslow and Richmond Community Healthcare NHS Trust as requires improvement. 

Our key findings were as follows:

Safe

• Staff did not always report incidents or near misses in all areas of the trust. Where serious incidents had taken place, there were instances where concerns were identified regarding the quality of initial investigations. A small number of serious incidents had been referred for external investigation which led to significant delays in the investigation being fully accepted by the local Commissioners and the Trust and so this had the potential to lead to delays in improvements being implemented in a timely way.

• High vacancy rates, particularly in community nursing, were impacting on the service. This included placing further pressure on existing permanent staff including under reporting of incidents, the take up of training and the recording of closed visits on the electronic system. The nursing leadership team were relatively new in post and had made meaningful progress however, staffing remained an area for further improvement.
• There was inadequate storage for equipment across locations.
• Staff could only access service user records for their specific location (Hounslow or Richmond) and for their particular service line (universal or specialist services).This presented risks in ensuring all pertinent information was immediately available to practitioners.
• Teddington Memorial hospital was operating with a substantial nurse vacancy rate. Although recruitment processes were underway there remained substantial vacancies to be filled.
• There was an increased risk that patients and visitors may be harmed as the minimum level of basic resuscitation equipment was not available for use in an emergency at Teddington Memorial Hospital.
• At Teddington Memorial Hospital, risk assessments and care plans were in place however we noted substantial gaps in recording observations, documenting scores in the early warning system and a lack of appropriate action when changes in patients ’observations were observed.

However, we also found that

• Policies outlined the processes for safeguarding vulnerable adults and children. Staff followed specific guidelines and care pathways where concerns around safeguarding children and young people were identified.

Effective

We have rated the trust as requires improvement in its delivery of effective, evidence based care and treatment.

We found that:

• We found end of life care and treatment was not provided in line with appropriate professional guidance of the National Institute of Health and Care Excellence (NICE).Regular and meaningful clinical audits and bench marking were not carried out consistently across the end of life care services.
• The trust reviewed the National Care of the Dying audit but did not participate as it was acute focussed. As a community provider, the trust was not eligible to contribute to the national minimum data set for end of life care. The trust undertook its own internal notes audit in 2015/16 and was in the process of implementing a full audit plan for 2016/17.
• Although there were pain management protocols in place and the majority of staff ensured that patients were kept comfortable, we did not see evidence of pain evaluation following the administration of analgesia and we observed an incident where a member of staff ignored when a patient was in distress and asking for pain relief.
• Weekly multi-disciplinary working meetings took place however these only related to rehabilitation patients and not those funded for continuing care. The multidisciplinary team did not always include a doctor.
• The trust had systems and processes in place to ensure that all staff had thorough employment checks before starting work. Permanent and bank staff wereappropriately qualified and undertook relevant trainingto their roles. There were appropriate arrangements in place for the appraisal and management of staff.Therapy staff had regular supervision arrangements inplace. However agency staff did not always receive induction to the ward and there was no system for ensuring their competency.
• Although there were appropriate policies and procedures in place and staff received training on the Mental Capacity Act (MCA) and deprivation of liberty standards (DOLs) we found one patient whose DOLs had expired several weeks before and had been detained since then without authorisation. Staff were aware of obtaining consent before any procedure but did not always obtain verbal consent before undertaking daily living tasks such as washing and dressing.

However, we also found that:

• Patients consistently achieved positive outcomes following rehabilitation care and treatment atTeddington Memorial Hospital. We found staff were providing care according to evidenced based policies and procedures and were monitoring outcomes to improve practice.
• Universal and specialist children and young people services were based on evidence and good practice and delivered in line with national guidance. There was good provision of evidence-based advice and guidance to service users.
• Within the children, young people and famillies service, there was a comprehensive local audit programme. The trust engaged with local and regional panels, peer review and was involved in regional research projects. There was effective internal and external multidisciplinary working. This was facilitated by co-location of services and partnership working with other service providers. There was good inter-agency partnership working with local authorities and other safeguarding partners.
• Improvements had been made on rates of clinical supervision within community nursing, which included agency and bank staff.

Caring

We rated the trust overall as requires improvement in providing care that provided respect and dignity to all patients in a compassionate manner.

We found that:

• Privacy of patients when carrying out initial assessments at busy times was not always considered.
• Few of the patients receiving care and treatment at Teddington Memorial Hospital had any understanding or involvement in their care and treatment. Although care plans were in place, we did not see any evidence of patients or their relatives’ involvement in planning their care. Whilst the trust provided patients with an information leaflet on admission to Teddington Memorial Hospital, patients reported that they received little information to support them and their carers in understanding their care and treatment during their stay in hospital.
• We had feedback from patients at Teddington Memorial Hospital of several instances where the care and treatment patients received did not meet the level of care expected. We also observed staff not behaving with the level of care and compassion expected. This included ignoring patients in distress, walking past confused patients who were exposing themselves and ignoring call bells. This was confirmed in the findings from a recent survey undertaken by the occupational therapists, where although the majority of feedback was positive, concerns had been raised about staff attitude particularly at night.

However, we also found that:

• We saw that care was provided in a compassionate way in the majority of instances to those receiving care and support in the community setting and that community patients were involved in their treatment and care

Responsive

We have rated the trust as requires improvement in how it organises and delivers services to ensure they meet the needs of people.

We found that:

• Waiting list trends showed a majority of services were meeting waiting time targets, however a number of services including podiatry, continence, diabetes and musculoskeletal services were consistently breaching trust targets.
• Missed appointments or shifts that had not been filled were not always recorded or reported within the district nursing team meaning it was not possible to see if capacity met demand in this respect.
• We found that although the majority of beds at Teddington Memorial Hospital were designated as being for patients requiring rehabilitation, an increasing number of patients living with dementia and those requiring continuing care were being admitted and were sharing the same ward space. This meant that staff spent a lot of time caring for patients with challenging behaviour and caused a great deal of distress and disruption to the rehabilitation patients.There were delays in transferring these patients to a more suitable setting due to their complex needs. We found that patients’ needs were not always met at night with noisy staff and patients shouting, lights on and loud music playing at midnight. Patient feedback indicated that this was not an isolated event and that the wards were often very noisy at night.
• There was no child or family friendly waiting area or cubicle and not enough seating in the waiting area at busy times at the urgent care walk-in centre.

However, we also found that:

• Community services had a model of integrated community teams across health and social care to ensure people received joined up working. There were multiple languages spoken across the two boroughs and the need for interpreters was understood by staff. Staff were from diverse backgrounds, reflecting the communities they served and were able to draw on their language skills as required.
• In the main, complaints were being recognised and lessons were being learnt from the concerns. Relatives were being invited to share their experience, to learn and improve the delivery of end of life care. Nursing staff responded to complaints quickly to ensure that it was resolved quickly. Lessons learnt from complaints were shared at staff meetings.

Well-led

We have rated the trust as requires improvement in how the organisation is led and managed and how the governance of the organisation assures the delivery of high-quality person-centred care.

• There was a trust wide corporate vision, strategy and mission statement. However we did not identify acohesive strategy for the inpatient unit either as arehabilitation unit, a specialist dementia unit, stepdown continuing care or end of life unit. The hospital was attempting to meet the diverse needs of all these very different client groups.
• The trust’s had developed core staff values which were demonstrated by the majority of the staff most of the time. However there were instances both observed during the inspection and reported by patients where these core values were not being met.
• There was a clear leadership structure and regular contact with the Clinical Commissioning Group and systems for monitoring and reporting on services. The trust oversight and management of the walk-in centre was effective, but the trust appeared to have less influence on systems at the UCC.
• Some staff felt that change management was not handled very well within the trust, with limited opportunities for dialogue or involvement in decision making, for example: relocation of services and redeployment of staff.

However, we also found:

• The staff generally felt supported by their immediate managers and told us the trust was a good place to work. This was supported by the results from the most recent staff survey and the staff family and friends test.
• Middle managers felt there was clear leadership at executive level and managers told us the chief executive was approachable. However, some staff told us directors were not very visible in the local offices. Staff generally reported a positive culture in community services.
• There were clear governance processes and lines of accountability in place. The community nursing leadership team were all relatively new in post but meaningful progress had been made on improving the quality and sustainability of the service.

We saw several areas of good practice including:

• There were effective formalised processes for CYP staff to receive regular planned clinical and safeguarding supervision to reflect on learning. The CYP service had introduced an innovative joint supervision approach to provide externality and objectivity in supervision sessions. For example, some supervision sessions were attended by district nurses or social workers.
• The trust’s audiology service performed consistently well and this was recognised nationally with accreditation under the Royal College of Physicians’Improving Quality in Physiological diagnostic Services (IQIPS) programme. Accreditation was granted by the United Kingdom Accreditation Service for the audiology services delivered by the trust.
• The trust’s paediatric immunisation team performed well in London-wide benchmarking analysis, and came second amongst all trusts for delivery of paediatric influenza vaccinations. 
• The redesign of a skin integrity tool to help identify and reduce the risk of patients developing skin pressure damage.
• The introduction of the Freedom to Speak up Guardian role.

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

Importantly, the trust must:

• The trust must reduce the staffing shortages, high turn over of staff, and heavy and unsustainable caseloads for practitioners.
• Ensure the staff vacancy rate does not compromise patient care.
• Ensure agency staff always receive an induction to the ward or clinical setting and there is a system for ensuring their competency.
• Reduce the delays in transferring the patients living with dementia to a more suitable setting due to their complex needs.
• Ensure that the ward environment at night is conducive to patients rest and sleep.
• Arrange the ward routines to support patients care and treatment.
• Ensure patients are always treated with dignity and respect.
• Make sure patient rights are always upheld and verbal consent is obtained before undertaking daily living tasks such as washing and dressing. 
• The trust must ensure that all pertinent information in service user records is immediately available to practitioners on the electronic record system, across localities (Hounslow and Richmond) and service lines(universal and specialist services).
• The trust should further mitigate against the negative effects of short staffing. This includes pressure on existing permanent staff, delays in incident investigation, the under reporting of incidents, the take up of training and the recording of closed visits on the electronic system.
• The trust must review its existing governance arrangements to ensure that incidents are reported and investigated in line with national standards.

Also, the trust should:

• The trust should improve storage space for equipment across all locations.
• The trust should develop a documented vision and strategy for each core service and ensure that operational staff are engaged and involved in its development.
• Ensure the current tools used to benchmark and monitor treatment are consistently implemented and used.
• Have a clear audit of monitoring and management of end of life care practices as their current practices was varied and was not consistent across the trust locations.
• Ensure the roll out of the Five Priorities of Care of the Dying or a suitable alternative is implemented swiftly. 
• The trust should do more to meet its own waiting time targets for services including podiatry, continence,diabetes and musculoskeletal services which were consistently breaching trust targets.
• Review streaming to protect privacy of patients and ensure sufficiently detailed information is captured at the initial assessment to enable safe prioritisation at the UCC.
• Review scope for a more child and family friendly service at the UCC.

Professor Sir Mike Richards

​Chief Inspector of Hospitals

Data showed there had been an improvement in harm free care. Risk assessment tools assisted community services to respond to identified patient risk. There was good infection control practice in people’s homes and premises where patients were treated were clean and hygienic.

At present the high vacancy rates, particularly in community nursing, were impacting on the service. This included placing further pressure on existing permanent staff, a delay in incident investigation, under reporting of incidents, the take up of training and the recording of closed visits on the electronic system. The nursing leadership team were relatively new in post and had made meaningful progress however, staffing remains an area for further improvement.

The trust had recently recruited two practice development leads who had made firm plans and some progress on equipping the nursing service with the right skills to carry out their roles competently. Improvement had been made on rates of clinical supervision within community nursing, which included agency and bank staff.

We found many examples of respectful and compassionate care. We observed nursing staff explain procedures to patients and gain verbal consent to carry out procedures. Staff were respectful and friendly to patients, offering emotional support in all of their interactions we observed.

Community services had a model of integrated community teams across health and social care to ensure people received joined up working. Staff were from diverse backgrounds, reflecting the communities they served.

The number of predicted contacts for community nursing services had been increased for 2015/16 but had already been exceeded with two months left to the year end. Waiting list trends showed a majority of services were meeting targets, however a number of service including podiatry, continence, diabetes and musculoskeletal services were consistently breaching trust targets. The trust was meeting emergency and urgent community nursing referral targets but consistently breached routine targets.

There were clear governance processes and lines of accountability. The community nursing leadership team were all relatively new in post but meaningful progress had been made on improving the quality and sustainability of the service. There were two newly created practice development lead posts. The leads stated clear goals and aims for the coming year.

Staff generally reported a positive culture in community services.

We found that services for children and young people at Hounslow and Richmond Community Healthcare NHS Trust were effective, caring, responsive and well-led. 

We rated the children and young people (CYP) service as good for safety. This was because:

• There were comprehensive processes and training for child safeguarding.
• Incidents were reported and investigated appropriately. Learning from incidents was disseminated.
• All of the locations we visited were clean and tidy and staff complied with infection prevention and control processes.
• There were effective risk management systems in place, including a robust lone working process for staff.

However,

• There were significant staffing shortages, high turnover of staff, and heavy and unsustainable caseloads for practitioners. This was across all universal and specialist services.
• Staff could not immediately access service user records outside of their specific location and service line which presented risks in ensuring all information was immediately available to practitioners.

We rated the CYP service as ‘good’ for effectiveness. This was because:

• Universal and specialist services were based on evidence and good practice and delivered in line with national guidance. There was good provision of evidence-based advice and guidance to service users.
• There was a comprehensive local audit programme. The trust engaged with local and regional panels, peer review and was involved in regional research projects.
• There was effective internal and external multidisciplinary working. This was facilitated by co-location of services and partnership working with other service providers.
• There was good inter-agency partnership working with local authorities and other safeguarding partners.
• Consent processes and documentation were robust and applied consistently.
• The trust assessed they effectiveness of different services using nationally recognised outcome measures.
• There were good learning and development opportunities for staff including well-structured preceptorships and support for professional development and revalidation.
• The trust applied robust competency frameworks and comprehensive supervision structures for staff.

We rated the CYP service as ‘good’ for caring. This was because:

• Staff across the CYP service were courteous and professional. We saw staff communicating with service users in a polite and caring way.
• Service users told us health visitors and therapists had a caring approach. Parents of children using services were universally positive and highlighted the encouragement and support of health visitors in clinics and home visits.
• Service users were treated with dignity and in an age appropriate way.
• Friends and Family Test results and other evaluations were consistently very good across universal and specialist CYP services with a good response rate.
• Some universal services were delivered in noisy and busy children’s centres. This did not always allow for adequate privacy or dignity, particularly when needing to communicate with service users confidentially.

We rated the CYP service as ‘good’ for its responsiveness to service users’ needs. This was because:

• Services were planned and delivered in line with local needs. The trust worked with commissioning bodies to target local provision of services.
• There was good access to multiple CYP services, facilitated by the co-location of services in one location.
• Service users had good access to provision across different locations.
• There were varied appointment times to suit different service users.
• Clinics and therapy sessions were held in child friendly environments.
• Staff communicated with children and young people in an age appropriate way and involved them as decision makers in their care.
• There was good understanding of the different cultural needs and backgrounds of service users. The diverse local community was reflected in the diversity of trust staff. Many staff members spoke community languages and were allocated caseloads accordingly.
• There was good access to translation services, with good provision of patient literature in community languages.
• Service users were able to self-refer for some services, such as speech and language therapy.
• There were some reported challenges with wait times for referrals to therapy services, such as SALT and social communication pathways. Service leaders were aware of these delays and had put in place resources to reduce wait times.
• Some CYP services were only delivered to service users in one borough, for example, Family Nurse Partnership was provided to Hounslow residents only and not those in Richmond. There were some problems with continued access to services if a service user relocated between boroughs.

We rated the service as ‘good’ for well-led. This was because:

• Staff told us that service leaders were very supportive, accessible and approachable.
• The staff we met reflected the trust values and vision. Staff felt autonomous, empowered and trusted to make decisions.
• There was effective representation of children and young people matters such as safeguarding at the trust board.

• There were effective processes for involving service users and the public in the development of services and resources.

• There was effective dissemination of governance and performance information.

• There was no clear, documented vision for the CYP service as a whole and operational staff were not clear about the strategic direction of the CYP service. Although there was a five year plan, local challenges within the health economy were impacting on the trust’s ability to maintain and develop the CYP service.
• Although Hounslow Primary Care Trust (PCT) and Richmond PCT merged to become HRCH in April 2011, the CYP service still presented as two very separate entities: as Hounslow and Richmond. There were limited opportunities for staff interaction and sharing resources across the two boroughs.
• Some staff felt that change management was not handled very well within the trust, with limited opportunities for dialogue or involvement in decision making, for example: relocation of services and redeployment of staff.

We rated the community in patient services at Teddington Memorial Hospital as inadequate.

There was not a cohesive strategy in place for the inpatient unit. The hospital was attempting to meet the diverse needs of a wide range of different client groups. The hospital was increasingly being asked to admit patients outside of its admission criteria because of pressures on the local acute trusts. This was proving a challenge to adequately staff and to provide positive patient experiences for all those receiving care and treatment there. We found that staff spent a lot of time caring for patients with challenging behaviour and this caused a great deal of distress and disruption to the rehabilitation patients. There were delays in transferring the patients living with dementia to a more suitable setting due to their complex needs.

We found that patients’ needs were not always met at night with noisy staff and patients shouting, lights on and loud music playing at midnight. Patient feedback indicated that this was not an isolated event and that the wards were often very noisy at night.

The hospital routines were not always arranged to support patients care and treatment but were organised around staffing priorities. For example medicine rounds taking place after patients have gone to sleep and patients not getting washed until lunch time and not getting dressed into day clothes.

The trust’s core staff values were demonstrated by the majority of the staff most of the time. Feedback from patients and relatives was mostly positive and we observed many examples of staff being thoughtful and treating patients with kindness. However there were instances both observed during the inspection and reported by patients where these core values were not being met. Patients were not always treated with dignity and respect. Their rights were not always upheld. Staff were aware of obtaining consent before any procedure but did not always obtain verbal consent before undertaking daily living tasks such as washing and dressing.

There was an increased risk that patients and visitors may be harmed as the minimum level of basic resuscitation equipment was not available for use in an emergency. The emergency medicines held by the hospital were not readily available, held securely or regularly audited. However the staff reported there were no problems with accessing equipment generally.

The hospital was operating with a substantial staff vacancy rate with difficulties with recruitment. Medical cover was provided by a GP consortium during the day and by the local GP out of hours service at night.

The staff generally felt supported by their immediate managers and told us the trust was a good place to work. Staff had access to appropriate training and development; they had regular appraisals and supervision. Whilst a local induction pack was in place, agency staff did not always receive induction to the ward.

We found that there was effective multi-disciplinary working across the nursing and therapy teams. Medicines management and patient records were generally well managed and national guidelines were followed. The environment was generally visibly clean, tidy and fit for purpose however the design of the wards did not always protect patients’ privacy and dignity.Following the inspection the trust took urgent action to protect address this by applying privacy transfers to glass partitions on the ward. There were suitable arrangements in place to maintain safe infection control standards.

The trust had robust governance arrangements in place with systems to monitor the quality of care and treatment provided. This included systems to record, investigate and learn from untoward incidents, safeguarding events and complaints. Patients consistently achieved positive outcomes following rehabilitation care and treatment at the hospital.

Overall, we rated community end of life care as good because;

• Patients were protected from abuse and avoidable harm. When something went wrong, people received a sincere and timely apology and were told about any actions taken to improve hospital processes to prevent the same event reoccurring. Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses; they said they had been fully supported when they did so. Monitoring and reviewing activities enabled staff to understand risks and gave a clear, accurate and current picture of safety.

• The senior nurses regularly reviewed incidents and shared the findings with individual staff and at team meetings. We were, however, unable to find evidence of this learning being shared trust wide other than at team meetings at the clinics where the incident occurred.

• Nursing staff completed risks assessments and we noted that the shared care record was being used appropriately by the EOLC clinical nurse specialist (CNS) and the district nursing teams. The shared care record (Palliative Care Plan) was a document used when patients were identified as being in the last few days of their life. There was good access to out of hours support and advice for nursing staff from the local hospices.

• The feedback from people who used the service and their families were positive about the care received by patients nearing the end of life. Staff always took patients personal, cultural, social and religious needs into consideration when delivering care. Patients’ emotional and social needs were valued by staff and were an important part of their care and treatment. Families were very positive about staff and the service they received. The service demonstrated a high level of compassionate care to patients and their families.

• Patients’ needs were assessed appropriately and care and treatment planned and delivered accordingly, however this was not in line with current legislation. There was a multi-disciplinary collaborative approach to care and treatment within community services as they worked closely with Princess Alice and Meadow House Hospices.

However;

• Some of the DNACPR forms we reviewed did not contain discussions held around Mental Capacity Act (MCA) and best interest decisions. It was unclear how patients’ mental capacity had been assessed particularly in relation to documenting best interest decisions.
• There was no plan in place for the end of life service to be accredited to best practice in alignment with the gold standards framework (The National Gold Standards Framework Centre (GSF) help doctors, nurses and care assistants provide the highest possible standard of care for all patients who may be in the last years of life. It’s a model that enables good practice to be available to all people nearing the end of their lives, irrespective of diagnosis. It is a way of raising the level of care to the standard of the best). There was no recognition of this work having been commissioned and undertaken by the lead director for end of life care. There was very little evidence of audit to support some of the work been undertaken. This meant there was a lack of systems and processes to help identify people entering the last 12 months of life.

Overall we judged the urgent care services managed by the trust as requiring improvement. The arrangements for the walk-in centre were appropriate for the size and type of service. However, we had some concerns about aspects of the urgent care centre, which was the gateway to the hospital emergency department, and assessed and treated patients with a wider range of ailments and injuries.

• Incident reporting was low and there was limited evidence of action in response to some local audit audits. Findings from audit did not feed into risk management and service improvement nor were information from complaints and incidents communicated widely to staff.
• There were not always sufficient staff at peak times to assess patients, particularly children, promptly, and to treat all adults within four hours.  
• The initial assessment process in the UCC was light for a service that made decisions about streaming patients to the hospital emergency department as well as prioritisation within UCC.
• The UCC waiting and treatment areas were not child or family friendly, although we later learned that plans to change this had been approved.
• The shared management of the Urgent Care Centre between the trust and a sub contractor were not clearly understood by all staff. Some staff did not feel actively engaged with the trust or able to suggest change.

​However

• At both locations safeguarding arrangements were well understood by staff and staff had completed relevant training in child protection and safeguarding vulnerable adults.
• Patients were generally treated in line with national guidelines
• The arrangements for ordering and safe storage of medicines were appropriate.
• The environment was clean and tidy and infection prevention and control was good.
• Plan were in place to respond to emergency situations.
• Staff enjoyed working at both centres and considered they offered a good service.