Kent Community Health NHS Foundation Trust

Our rating of the trust improved. We rated it as outstanding because:

• Safe and responsive was rated as good.
• Effective, caring and well led was rated as outstanding.
• Sexual Health services was rated outstanding overall. The service was rated good for safe, and outstanding for effective, caring, responsive and well led. This was the first time this service had been inspected.
• Urgent Care services were rated good for safe, and responsive. Effective, caring and well led were rated as outstanding. This was the first time this service had been inspected.
• End of Life Care services was rated good for safe, effective, responsive and well led. Caring was rated as outstanding. This was an improvement on our last inspection.
• Dental services were rated good for safe, effective, caring, responsive and well led. This was the first time this service had been inspected.
• In rating the trust, we took into account the current ratings of the three services not inspected this time.

Our rating of this service improved. We rated it as good because:

• There were systems and processes to protect people from abuse and harm. Staff understood their responsibilities and the steps to take in the event of any safeguarding concerns.
• The service controlled infection risk in line with best practice. There were policies to manage effective infection control and hygiene processes.
• The service generally had suitable premises and equipment which was serviced according to the manufacturer’s instructions. Side rooms were available for patients at the end of their life, and staff made sure these were offered, where possible.
• The service had systems and procedures for responding to patient risk. Risk assessments were carried out for patients at the end of life in community hospitals and in their own homes
• The service followed best practice when prescribing, giving, recording and storing medicines. Patients received medication when required and anticipatory prescribing was used effectively.
• The service managed patient safety incidents well. Incidents were investigated, actions taken, and learning was shared with staff. Mortality Surveillance Group meetings took place monthly, which supported the trusts learning from the death review process.
• The service provided care and treatment based on national guidance. Staff had access to up to date policies, procedures and clinical guidelines.
• Staff assessed and monitored patients regularly to see if they were in pain.
• Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• There was a strong, visible person-centred culture, to providing end of life care. Staff were highly motivated and inspired to offer care that is kind and promotes people's dignity.
• Relationships between people who use the service, those close to them and staff were witnessed to be strong, caring, respectful and supportive.
• Staff understood and respected the personal, cultural, social and religious needs of people and how these related to care needs.
• Staff members showed an understanding and a non-judgemental attitude when talking about patients who had mental ill health or a learning disability.
• Staff understood the impact that a person’s care, treatment or condition had on their wellbeing and on those close to them, both emotionally and socially.
• People valued their relationships with staff and felt that they often went 'the extra mile' for them when providing care and support.
• Services were planned and delivered to meet the needs of patients and their relatives.
• End of life services within the inpatient and community localities provided flexibility, choice and continuity of care.
• The service took account of patients’ individual needs. Interpreters could be accessed.
• People could access the service when they needed it. Where identified, patients who may have been approaching the end of their life were supported to make informed choices about their care.
• Leaders had the skills, knowledge and experience required to run a service providing sustainable care.
• There was a strong sense of culture that was centred on the needs of patients at the end of their life.
• There were clear governance arrangements for end of life care, which were embedded in the trust governance framework.
• The service routinely collected, managed and used information to support its activities.
• People were always treated with dignity by all those involved in their care, treatment and support.
• The service monitored some aspects of the effectiveness of care and treatment. The service participated in the national audit for care at end of life, to enable its practice to be compared.
• The service provided training in key skills for staff in care at the end of life. Training for end of life was role specific, not mandatory and was available for staff where it was identified as part of their role.

However,

• As end of life care training was not mandatory there were no central record of training and competence of staff. Records were held locally by teams.
• The trust told us that the pharmacy service undertook audits of ‘just in case’ boxes, but did not supply us with the audit, outcomes, or action plan. However, it was unclear how effective the audits were as the top theme identified for incidents relating to end of life care was medication errors. We did see that incidents were discussed at the end of life care strategy group.
• There was limited formal process followed to monitor staff adherence to national guidelines and local policies. The trust had an audit schedule in place for monitoring do not attempt cardiopulmonary resuscitation form and personalised care plan completion. The service did not audit other key areas such as rapid discharges.
• There were limited facilities for families at community inpatient settings. If relatives wanted quiet time away from the patient there were limited facilities available. One out of three quiet rooms contained comfortable chairs. Another one was also used for storage, patient’s personal belongings and the wards printer. Although the community inpatient settings we visited had outdoor space for relatives to be alone for quiet reflection this was only when weather allowed. None of the locations had a chapel, multi-faith room or a place where relatives could go off the ward for a place of time alone or quiet reflection.

This was the first time we inspected this service. We rated it as outstanding because:

• Patient records were comprehensive, well-structured and had a consistent style across the MIU’s visited during the inspection.

• We found the organisation was receptive to changes in practice and kept comprehensive and up to date clinical guidance.

• Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Patient interactions were always handled with compassion.

• People’s emotional and social needs were highly valued by staff and embedded in their care and treatment of patients. Staff provided outstanding emotional support to patients to minimise their distress. This included providing emotional support to those accompanying children to the units.

• Patient feedback about the care given by staff was unanimously positive with many examples given of a service that took great care of its patients and treated them with compassion.

• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.

• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

• The leadership of the service, at all levels created a culture that meant that staff enjoyed their jobs and wanted to stay working with the organisation. This had the effect that the teams could retain loyal staff.

• Leaders had taken steps to provide opportunities for junior staff to enhance their skills and in doing so had started to succession plan for the service.

• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.

However:

• The waiting area in the Sevenoaks MIU was not fully visible from the reception area and could only be viewed using CCTV situated in the clinical area.

• The waiting area at Folkestone MIU was a large area which was shared with patients that were attending the hospital for other appointments. This meant that it was not easy to quickly identify which patients were attending the MIU.

• We did not see any information available to patients or visitors in any language other than English despite data showing there were members of the community served who did not speak English as a first language. However, the trust had access to a telephone interpretation services that could be accessed if needed.

This was the first time we inspected this service. We rated it as outstanding because:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. We found systems and processes to identify and respond timely to the results of patients who had undergone sexually transmitted infection (STI) screening. A recall system was in place to make sure, patients were contacted and given a clinic appointment or further advice following diagnosis of a positive result. Patients were also added to the list if they required re-testing, immunisations or treatment. The recall list was reviewed daily from the electronic notes by a clinician and patients were followed up daily.

• The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time. Medicines were handled and stored in line with Nursing and Midwifery Council (NMC): Standards for Medicine Management. The trust had a policy in place which provided staff with guidance and information on medicines management.

• Patient Group Directives (PGD) were used by the service. PGD’s in use at the clinic included drugs used for regular, long term and emergency contraception. All PGD’s were initially reviewed by a consultant and all staff completed a competency-based assessment to ensure they had the knowledge and skills necessary to dispense PGD medication. We found PGD’s to be in date and regular reviews of PGD’s had taken place.

• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide excellent care. We found staff, teams and services were committed to working collaboratively and holistically. The service had found innovative and efficient ways to deliver more joined-up care to people who use services. Effective care was fully integrated and provided real-time information across teams and services via the sexual health electronic system and data collection for national audits. We observed evidence of multidisciplinary working within team and governance meeting minutes, patient records and through discussions with staff and patients.

• People were truly respected and valued as individuals and were empowered as partners in their care and feedback from patients confirmed this. . To ensure privacy and dignity was respected always and to stop patients having to discuss their condition or symptoms with reception staff the service introduced a ‘Hello’ welcome leaflet with a form. This form meant that each patient received a health check and could detail their health complaint without discussing at reception. Patients were either called by their name or by a number so that they could remain anonymous if they so wished.

• The service took account of patients’ individual needs.

• People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice. Medway service were commissioned to see patients within two hours of attending walk in clinics. From data received we saw from October 2017 to January 2019, 94.6% of patients were seen within two hours at Medway sexual health services. .

• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care within the service. Senior managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. The leaders within the sexual health service showed they had integrity, knowledgeable, experienced and well respected by all staff we spoke to during our inspection.

Following the last inspection the Trust demonstrated that training programmes, guidance, advice and support in respect of do not attempt cardiopulmonary resuscitation had been developed and implemented across the community hospitals, adult community services and children and young people's services. In addition, the Trust provided evidence of on-going audit programmes in place to provide organisational assurance as well as learning and improvement in all the localities.

Overall this core service was rated as Good. We rated it good for being safe, responsive, caring, and well led. However the service requires improvement in being effective.

Kent Community Health NHS Trust delivers community based services to adults across Kent and Medway and East Sussex. Services are provides in people’s own homes, nursing homes, clinics and GP practices.

Our key findings were as follows;

• Kent Community Health NHS Trust had a detailed vision and strategy in place to meet the needs of the communities it served across Kent. This was communicated to staff and the public through the trust’s website and in leaflets and brochures.
• The Trust had implemented a number of initiatives to improve experiences and health of patients with complex needs that included the chronic knee pain programme and a new integrated discharge pilot.
• Complaints were well handled in the Trust with the majority of concerns addressed at local level. Patients we spoke with told us that they had no problem in accessing the right service in a timely fashion and were happy with the service provided.
• The Trust had been through a sustained period of change and reorganisation leaving certain staff groups feeling disaffected. However the majority of staff we spoke with said they felt valued and supported by their managers and were proud to work for the Trust.
• Staff from some teams told us that the leadership didn’t listen and ‘imposed change’ without listening. The trust was aware of poor leadership in certain areas and communication issues and was working to address this through supporting managers and finding practical solutions where possible.
• Patients were generally pleased with the care and treatment provided by Kent Community Health NHS Trust. Staff were caring, and supporting patients in their needs. Staff had made a difference, enabling patients to cope at home and generally improving the quality of their lives
• There are systems in place to report and record incidents, concerns, near misses and allegations of abuse. However we found that not all managers could access the computer systems and there was a degree of under reporting of safety incidents such as falls, pressure ulcers and missed visits.
• Learning from safety incidents was disseminated through bulletins, on the StaffZone, minutes of meetings and staff meetings. Staff generally received feedback from any incidents however this feedback was variable across the organisation.
• Systems and processes were in place to ensure patients received appropriate evidence based personalised care and treatment. This included monitoring and audits of the service in order to inform priorities and service development. However we found that lack of staff in some areas and poor equipment services had an adverse effect on patient outcomes.
• Recruitment and retention of staff was variable across the organisation with some teams reporting vacancies for over a year. Low staffing numbers and inappropriate skill mix of some teams meant that patients did not always receive the care they needed. The Trust was aware of the staff shortages and had put recruitment strategies in place. Bank and agency staff were being used an interim measure. However where staffing levels had been low for a significant period of time this continued to have an adverse effect on patient outcomes and staff morale.
• The Trust was moving to an electronic system to record care and support teams. However where the paper based system currently in use was not always fully completed by staff and did not give assurance that risks were always identified, assessed or monitored.
• Patients did not always benefit from specific, measurable care planning starting from an initial comprehensive assessment which was updated periodically when needed and subject to effective quality assurance and robust performance management.
• Transcribing of information between computer systems, patients own care records, base records and those made by specialist teams such as out of hours or respiratory specialist nurses gave opportunities for error.
• Although the Trust had provided training and development opportunities the distances to travel, the time required to undertake the training and the lack of resources in certain teams to cover meant that not all staff had undertaken the necessary training to enable them to carry out their job effectively.
• CQC had received concerns that certain groups of staff felt unable to raise concerns or whistle blow out of fear of losing their job and issues such as under reporting and poor record keeping hadn’t been identified by the Trust as a risk.
• Although recruitment and retention challenges and equipment issues were identified as a risk and had action plans in place to address them, staff were still reporting instances where lack of staff or equipment were causing harm to patients and these risks were not being addressed in a timely fashion to protect patients.

We saw some good and outstanding practice including;

• There were robust safeguarding arrangements and the trust worked well with partner agencies to protect vulnerable people from abuse
• There was good multi-disciplinary and cross boundary working which meant that patients were assured of receiving the right care by the right team. The specialist services were especially praised for the support they gave not only to patients but the teams and wider health and social care community.
• Learning from safety incidents was disseminated through bulletins, on the StaffZone, minutes of meetings and staff meetings
• The patients we spoke with were all happy with their nurses’ and therapists’ standards of hygiene. They told us how the nurses used sanitizing hand gel and/or used their own hand washing facilities during visits to their home.
• During our inspection we observed good hand hygiene and infection prevention practice within the district nursing clinics and by staff in patients own homes. We saw that staff throughout the Trust used personal protective equipment such as gloves and aprons and adhered to the ‘Bare below the elbows’ guidance to ensure that lower arms were kept clear of clothing and jewellery to help prevent cross infection.
• When we accompanied the district nurses and attended outpatient clinics we saw that patients were all asked their permission before any treatment or procedure took place and that where necessary consent forms were signed. Staff gave examples of best interest meetings being held in order to support families and patients in unsafe situations.
• Qualified staff told us that there were lots of personal development opportunities available in the Trust. They told us about further training and qualifications they had gained such as foundation degrees, post graduate courses, individual modules and mentorship.

However, there were also areas where the Trust needs to make improvements.

Importantly the trust should

• Address the understaffing, the equipment failings and poor record keeping in order to ensure patients receive safe care and treatment.

We found that overall Community health inpatient services were safe, caring, responsive effective and well led.

Key Findings

• Community health inpatient services had systems and processes in place to keep patients safe. We found there were robust reporting processes that were well understood by staff. We saw that safety information was monitored, for example the NHS Safety Thermometer system. We found evidence that changes were implemented in light of learning from safety incidents.
• The environment was clean across all wards. We saw that the requirements of Department of Health’s, “Code of Practice” on the prevention and control of infections and related guidance” were being met.
• We found that there were arrangements for the safe management of medicines; however, we identified weaknesses in medicine management procedures at the Livingstone Hospital and Gravesham Community Hospital.
• We observed that policies and care reflected current guidance such as that provided by the National Institute for Health and Care Excellence (NICE). Patient outcomes were in line with those expected nationally.
• We saw that patients experienced integrated care that was planned by multidisciplinary teams. This ensured that treatment was delivered by staff with the appropriate, qualifications, skills and experience.
• We received positive feedback from patients about their care and experience. A typical comment was “Excellent service. I am very pleased with everything, very safe and clean and I was listened to”. We observed that patients were treated respectfully and that their dignity was maintained. We found there was an ethos that valued rehabilitation and the promotion of independence.
• Community inpatient services were responsive and we found there were arrangements to meet patients’ individual needs, for example, those living with dementia. We found there were systems to gather patient feedback and saw there were positive responses with appropriate changes made as a result of this. However, we had some concerns regarding the timing of some patient admissions and we were told of instances where patients had been transferred from acute care very late in the day.
• We found that overall services were well led. Staff told us they felt supported to give high quality care by their managers, supervisors and the trust board. We found that staff were motivated and happy at work. However, we identified that the leadership in inpatient therapy services needed strengthening.

We saw some good and outstanding practice including

• Staff were passionate about their work and the difference it made to patients. They displayed positive attitudes and said they were supported by their managers to provide excellent care and services. There was a commitment to a multi-disciplinary approach to care and an ethos that promoted autonomy and independence.
• There was a positive approach to safety management. All staff knew their responsibilities with regard to safety management and were aware of the major risks most relevant to their role and workplace. Incidents were reported and investigated and changes were made to practice or systems in the light of learning from incidents.
• Throughout the community hospitals we found that people’s understanding of the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) was robust. We saw examples of how the principles of the act were implemented in day to day care and how DoLS were used to protect patients’ human rights.
• At Livingstone and Gravesham Hospital we found that there was an effective falls reduction programme which has resulted in the number of falls with associated fracture reducing by one third in a year.

However, there were also areas where the Trust needs to make improvements.

Action the provider SHOULD take to improve

• Review the management of medicines at Livingstone and Gravesham Community hospitals to ensure that there are robust systems for the supply, storage and stock control of medicines including the recording of these processes. This includes processes relating to the management of controlled drugs such as checking stock balances, and the disposal and the disposal of part-used doses.