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Terrence Higgins Trust Outreach Sexual Health Service - Buckinghamshire

Inspection Summary


Overall summary & rating

Updated 6 April 2017

We carried out an announced comprehensive inspection on 1 November 2016 and unannounced inspection on 4 November 2016 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

Background

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Buckinghamshire has a population of approximately 521,922. The rate of teenage pregnancy and sexually transmitted disease is better than the England average. The level of deprivation in Buckinghamshire is better than the England average.

The Terrence Higgins outreach service delivers a level 2 sexual health service across Buckinghamshire. The service offers clinics for guidance and treatment of sexual health issues including contraceptive services and screening and treatment of sexually transmitted diseases. The range of services included:

  • A range of contraception services including oral contraception, emergency contraception and long acting reversible contraception (LARC)
  • Screening for a range of sexually transmitted infections (STI’s)
  • Human immunodeficiency virus (HIV) prevention and support
  • Wellbeing in sexual health (WISH) training for individuals and organisations
  • Health promotion
  • National C-card condom scheme.

The service was commissioned alongside a local NHS trust to provide an integrated level 2 and 3 sexual health service for Buckinghamshire in April 2016. The service currently provides 10 clinics at a range of locations including colleges, GP surgeries and community centres. From April 2016 to September 2016, the service saw 547 patients, the majority (approximately 77%) were female. The majority (40-45%) of patients are aged 18 to 24 years old.

The service currently employs 13 members of staff. This includes one service manager, three nurses, four youth engagement officers, an HIV and sexual health practitioner, two administration staff, wellbeing in sexual health trainer and results officer. The service had three vacancies at the time of our inspection.

We do not currently have a legal duty to rate single speciality services or the regulated activities they provide but we highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

The service manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We spoke with three patients who all provided positive feedback about the service. Patients commented the service was helpful, provided an easy consultation and they would recommend to others.

Our key findings were:

  • We observed staff provided kind, compassionate care and maintained the privacy and dignity of patients. This was supported by patient feedback survey results. Staff provided emotional support to all patients and in particular patients living in vulnerable circumstances.
  • The service used nationally recognised guidelines to develop services and contributed to two national clinical activity datasets. The patient electronic record generated clinical protocols based on the patient’s condition.
  • The service had a system in place to manage medicines including the ordering, storage, dispensing, administration and disposal. However, there were some aspects of this system that did not meet national guidelines. This included the documentation of receipt and checks of medicines, security of key safe and arrangements for the disposal of unwanted or expired medicines.
  • There were systems in place to safeguard young people and adults from abuse. Staff were aware of how to make a safeguarding referral and had completed training on child sexual exploitation and female genital mutilation. However, we found not all staff were clear about the policy for reporting sexual assault in adults over the age of 18.
  • Governance arrangements were managed jointly between the local service and corporate team. For example, governance meeting were held at board level but day to day management of incidents and performance were managed locally. Although the service did monitor the quality of service provision in some areas, it did not meet the requirements of the corporate audit programme.
  • The service referred to advice in national guidance for example the British Association of Sexual Health and HIV (BASHH) and Faculty for Sexual and Reproductive Health (FSRH) to develop services. However, there was no formal process for reviewing new clinical guidelines and applying changes to practice.
  • All the clinics we inspected were visibly clean and tidy. We observed staff adhering to basic hand hygiene and personal infection control practices. However, in two clinic locations there was no clinical waste bin and staff had to tie an open waste bag to the sink.
  • The service placed outreach services strategically and held events in a variety of locations in order to meet the needs of local people. Staff had developed services for hard to reach groups such ethnic minority female groups. Patients could access the service using a single access telephone number. However, the provision of some clinics had to be altered due to staffing issues. There was no clear protocol for the management of patients who did not attend their appointment.

There were areas where the provider could make improvements and should:

  • Review processes in place for medicines management to ensure they meet national guidelines.
  • Ensure all staff follow the organisations policy on reporting sexual assault in adults over the age of 18.
  • Review the arrangements for managing patients who fail to attend their appointment.
  • Review clinical audit arrangements to ensure all areas of the service are monitored for quality assurance.
  • Review the process to consider changes to clinical guidelines and how these are applied within clinical practice.
Inspection areas

Safe

Updated 6 April 2017

We found that this service was providing safe care in accordance with the relevant regulations.

We found the following areas of good practice:

  • All staff knew how to report incidents and could give examples of how practice had changed as a result of incident reporting.

  • Staff had a good understanding of how to make a safeguarding referral and had undertaken additional training in child sexual exploitation and female genital mutilation. The service had a system to flag vulnerable people on the electronic patient record.

  • Patients records were secured securely, either on an electronic system or in tamper proof envelopes. All the records we reviewed were completed in line with the Faculty of Sexual and Reproductive Healthcare (FSRH) guidelines.

  • Patient group directions (PGD’s) were in date and authorised by appropriate staff. Staff recorded the administration of medicines in the electronic patient record in line with FSRH medicines management guidelines. The service had an agreement with an NHS trust to label and dispense medicines.

  • The service manager kept up to date records of all disclosure and Baring service (DBS) checks and evidence of professional registration.

  • All staff were aware of the chaperone policy and information for patients regarding chaperones was available in all clinics.

  • All clinics we visited were visibly clean and tidy and staff adhered to infection control guidelines such as bare below the elbows and use of personal protective equipment.

However, we found the following issues that the service needs to improve:

  • Not all staff were clear about the policy of reporting sexual assault for adults over the age of 18. Two members of staff told us they would have a duty to report all cases of sexual assault. This could lead to a breach of confidentiality and place the patient in danger.

  • We had some concerns regarding the management of medicines. The keys to the medicine storage at the base office were stored within a general key safe and therefore unregistered staff could access medicines. Documentation regarding checks and receipt of medicine did not always include the name or signature of the person performing the task, which made it difficult to track. The service did not have a service level agreement in place with a pharmacy for disposal of medicines as recommended by FSRH guidelines.

  • The service did not monitor or record the hepatitis B immunisation status of their staff.

  • The service was not following their own lone working policy in regard to providing all staff with a panic alarm.

  • At two clinics we visited there was no clinical waste bin and staff used an open bag tied to the sink. This could pose an infection control risk.

Effective

Updated 6 April 2017

We found that this service was providing effective care in accordance with the relevant regulations.

We found the following areas of good practice:

  • The service used nationally recognised guidelines such as the Faculty for Sexual and Reproductive Health (FSRH) and British Association for Sexual Health and HIV (BASHH) to develop services.

  • The service submitted data to the genitourinary medicine clinic activity dataset (GUMCADv2) and sexual and reproductive health activity dataset (SRHAD).

  • The service performed slightly better than the BASHH benchmark to inform patients of their test results within 10 days. From July 2016 to September 2016 the service achieved 97% against a benchmark of 95%.

  • The service performed slightly better than the BASHH benchmark for treatment times. From July 2016 to September 2016 97.5% of patients were treated within six calendar weeks of a positive result against a benchmark of 95%.

  • The service carried out a universal assessment for all patients at every appointment. This generated a protocol recommending assessment and treatment based on the patient’s symptoms.

  • The service achieved an appraisal rate of 100% for all staff.

  • There was a competency assessment process in place for all clinical staff.

  • The service worked with the local NHS trust level 3 sexual health service to deliver an integrated service to patients. The service also worked with a number of other services including the child and adolescent mental health service (CAMHS), sexual assault referral centre and school nurses.

  • Staff had a good understanding of Fraser guidance in relation to providing sexual health services to young people under the age of 16. We reviewed three records for young people under the age of 16 who had all had a Fraser competency assessment completed.

However, we found the following issues the provider needs to improve:

  • The service did not meet the requirements of the corporate clinical audit programme. During our inspection, we saw evidence that only two out of the 12 clinical audit areas had been completed.

  • There was no clear process in place for reviewing new clinical guidelines and applying changes to practice.

Caring

Updated 6 April 2017

We found that this service was providing caring services in accordance with the relevant regulations.

We found the following areas of good practice:

  • All the patients we spoke with told us the staff were helpful and approachable.

  • The service employed a practitioner who specialised in HIV and provided support to patients and families living with HIV.

  • Staff were aware patients may receive bad news during consultations and had plans in place to manage this for example some clinics had access to a counselling room and staff could extend appointment times.

  • Patients were treated with dignity and respect and involved in decisions about their care.

  • The patient satisfaction survey for November 2016 showed 100% of patients felt they had been treated with dignity and respect and felt the service was confidential.

Responsive

Updated 6 April 2017

We found that this service was providing responsive care in accordance with the relevant regulations.

We found the following areas of good practice:

  • The service worked with the local NHS level 3 sexual health service to provide an integrated level 2 and 3 sexual health service. Services were strategically placed to meet the needs of the local population and there was a single point of access telephone line in place.

  • The youth engagement team held events in a variety of locations and worked with different community groups to access hard to reach groups. For example, the service had recently started an Asian women’s group.

  • The service promoted equality and diversity and provided clinical and emotional support to people living in vulnerable circumstances. For example, people living with HIV in prison. The service also ran an early intervention programme to provide one to one support and education for vulnerable groups.

  • There was a fast track appointment system in place for vulnerable and high-risk patients who needed to be seen urgently. This included looked after children.

  • The service used pictorial information sheets to give information to patients with a learning disability.

  • Information on how to make a complaint was displayed in all clinics and there was evidence the service had made changes based on patient comments.

However, we found the following issues that the service provider needed to improve:

  • From April 2016 to October 2016 the service cancelled 9.6% of clinics. The service had to make adaptions to service provision due to staffing issues. For example, one clinic only had nursing provision on alternate weeks instead of weekly.

  • From April 2016 to October 2016, the 16.7% of patients did not attend their appointment. There was no standard protocol in place for managing patients who did not attend their appointment.

Well-led

Updated 6 April 2017

We found that this service was providing well-led care in accordance with the relevant regulations.

We found the following areas of good practice:

  • The organisation had a system in place for governance arrangements.

  • Staff were passionate about their work and took pride in working for the Terrence Higgins Trust.

  • The organisation had clear vision and values and staff could describe these.

  • The service collected patient feedback and had made changes in practice because of this. The service also contributed to the corporate staff survey.

However, we found the following issues that the service provider needed to improve:

  • Although the service had completed some clinical audits, this did not meet all the requirements of the corporate audit schedule.