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Inspection Summary


Overall summary & rating

Outstanding

Updated 3 September 2019

Inspection areas

Safe

Good

Updated 3 September 2019

  • Performance showed a good track record in safety.
  • There were clearly defined and embedded systems, processes and practices to keep people safe.
  • Openness and transparency about safety was encouraged. Patient partners were actively involved in the review of safety incidents to ensure the patient perspective was considered.
  • Staff received up-to-date training in systems, processes and practices.

Safety systems and processes

The service

had

clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance and policies were regularly reviewed. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). All clinical staff and patient facing non-clinical staff had been DBS checked.

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. For example, we were told of one situation where a patient attending the memory assessment service had been identified as at risk due to them regularly leaving their front door open. Staff raised a safeguarding alert with the local safeguarding team and an appropriate care package was put in place for the patient to minimise safeguarding risks. Staff who acted as chaperones were trained for the role and had received a DBS check. There were notices in place informing patients of the option to request a chaperone.
  • There was an effective system to manage infection prevention and control. Infection control audits were routinely carried out. We saw that an incident relating to sharps boxes not being used correctly had been identified and addressed with the relevant team at the site. Learning was shared through email communication with staff at other sites to reduce the likelihood of the incident reoccurring.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them. Each site where the service operated had an annual risk assessment carried out which was reviewed as required in response to any changes in the service or issues that arose.

Risks to patients

There

were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. The musculoskeletal (MSK) service was delivered in partnership with a local NHS community foundation trust, providing some flexibility with staffing in order to the meet the needs of the service. The memory assessment service (MAS) was run by a small team of specialist nurses with a bank system in place to provide cover as necessary. Agency staff were not used due to the specialist nature of the service.
  • There was an effective induction system for staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention.
  • There was emergency equipment and medicines available on all clinical sites, including a defibrillator. While the service was not always responsible for monitoring this equipment, appropriate access to it and processes for responding to emergencies was included in risk assessments of each clinical site. All staff had received training in basic life support. An incident where a member of staff had supported a GP practice they were located at in dealing with an emergency situation had been recorded as a significant event so that learning from this could be shared.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.

Information to deliver safe care and treatment

Staff

had

the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

had

reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines minimised risks. Medicines were not kept within the memory assessment service, but a limited range of medicines were in use within the musculoskeletal service. We saw that these medicines were stored securely and appropriately monitored and prescribed.
  • The service carried out regular medicines audits to ensure prescribing was in line with best practice guidelines for safe prescribing. We viewed an audit of non-medical prescribing that was part of the rheumatology pathway and saw that prescribing was identified as appropriate.
  • Staff prescribed and administered medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.
  • Within the memory assessment service (MAS) medicines were prescribed within a multidisciplinary framework. This involved weekly meetings between nurses, the psychiatrist and GPs. Prescription stationery was monitored and stored securely, and prescribing was monitored and audited. We were told of one incident where a patient had been under dosed on a medicine used to treat Alzheimer’s disease and Parkinson’s. The incident was reported, and learning shared with relevant staff.

Track record on safety and incidents

The service

had

a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements. A patient safety manager was in post with responsibility for areas such as coordinating the management of safety incidents.

Lessons learned, and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service. For example, an annual audit of incidents showed that 49 incidents had been reported between November 2017 and November 2018 within the memory assessment service. These had been categorised into identified themes. The largest proportion of incidents related to administration delays with others identified as a delay in diagnosis/management, information governance issues and equipment failure. An annual review of the musculoskeletal service showed that 271 incidents had been reported during the same time period. The findings from the annual review were discussed at quality summit and board meetings where assurance was provided of the learning identified and shared as a result. Incidents were graded as to their severity, those we reviewed were graded as negligible or minor. Within the musculoskeletal service incidents identified as moderate or above were reviewed by the clinical director. There had been no serious adverse events.
  • The service had introduced a new electronic incident reporting system at the end of 2018. As a result of training in the use of the new system the service saw increased reporting of incidents. Between November 2018 and June 2019 189 incidents had been reported across the services.
  • Staff reported that learning from incidents was shared and that they received feedback on any incident investigations. Monthly clinical quality group meetings were held where learning and themes from incidents were reviewed, this meeting included a representative from the patient partner group so that the patient perspective was considered. Incident champions were identified within each team and were responsible for gathering learning from incidents from across the organisation and disseminating this to their individual teams. We reviewed an incident where a patient had been referred for physiotherapy. Additional information had been sent after the initial referral from the GP. The additional information had been attached by administrative staff but had not been reviewed by a clinician, therefore resulting in the patient not being triaged appropriately. The incident was reviewed by the patient safety group. Learning from this included that all additional information received from referrers had to be reviewed by a clinician to identify if it had an impact on patient triage. Information from the patient safety group was cascaded to individual teams during team meetings.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology. We viewed an example of a letter sent to a patient about a data breach relating to a scan that had been stored on a compact disc which had gone missing once delivered to an NHS location. The letter included an apology and details of the investigation and outcome. This included that the service had successfully negotiated an improvement to how scanned images were stored with a local NHS trust and a move to digital storage so that images were no longer delivered by post and could only be sent electronically.
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional staff. Safety alerts were reviewed at governance meetings.

Effective

Outstanding

Updated 3 September 2019

  • There is a truly holistic approach to assessing, planning and delivering care and treatment to all people who use services. The safe use of innovative and pioneering approaches to care and how it is delivered are actively encouraged.

  • All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking and peer review were proactively pursued, including participation in improved accreditation schemes.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines. A pathway specific group for the musculoskeletal service was in operation with a remit to review relevant guidelines and adopt this into clinical pathways as appropriate. For example, the service followed European guidelines for avoiding arthroscopy in favour of more conservative management for patients with degenerative knee disease.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate. The assessment of pain was a key aspect of the musculoskeletal assessment process. We saw evidence of this in-patient records and staff had a good understanding of pain management strategies to address this. For example, physiotherapy staff reported they were in regular contact with patients’ GPs and a pain management consultant as necessary to ensure pain was appropriately addressed. Patients were routinely offered referral to a pain management programme. Staff had identified a gap in relation to chronic pain management so had run a free event in February 2019 for people living in the local community with fibromyalgia and long-term musculoskeletal pain. The event was designed as part of a project looking at the fibromyalgia/pain pathway with a focus on what ‘living well’ looked like. Patients were encouraged to attend the event to provide their view and complete an online survey that looked at how they were supported by services, with a view to using the information to improve services. The project included a review of national examples of good practice and a review of current literature. Recommendations on how to improve services were considered.

Memory Assessment Service

  • Within the memory assessment service, a review had been carried out along with a redesign of the service. This change saw movement from an initial assessment being focused on diagnosis to being focused on meeting patient needs. For example, care plans were now devised from the initial patient contact rather than at the point of diagnosis. The focus of care planning at this stage was on a holistic assessment of patients’ needs, including psychosocial as well as physical needs. Support for patients’ based on these identified needs was provided by the service and through referral to other support services as required. This meant that quality of life and strategies to build patients’ confidence were prioritised through an assessment with a memory support worker. This included help for patients to access support groups and community care services based on the evidence of impaired memory or mild cognitive impairment and the impact this had on their life rather than a definitive diagnosis.
  • We saw evidence of improvements having been made to the dementia diagnosis rate. Staff reported that they had improved assessment processes by reviewing expert guidance around mild cognitive impairment and mild dementia. This had led to improved assessment processes to improve the accuracy of diagnosis. Staff told us this work had been driven by a need to ensure patients were better able to plan their futures and care wishes by having an earlier diagnosis. This had contributed to the local clinical commissioning group (CCG) being in the top three CCGs in the South east for dementia diagnosis. The service had improved their diagnosis rate from an average of 66.7% in January 2019 to an average of 69.8% in May 2019. This was an overall increase of 6% since March 2016. The service had identified a trend in mild dementia diagnoses increasing year on year with the average age of patients reducing, suggesting that they were seeing patients earlier on in their presentation. For example, in 2018 60% of patients showed mild cognitive impairment compared with 2% of patients showing severe and 32% moderative cognitive impairment. In 2013 43% of patients showed mild cognitive impairment, 9% severe and 45% moderate cognitive impairment.
  • The service developed a group medicines programme in 2018 to address delays in medicines initiation for patients diagnosed with dementia. This involved medicines initiation decisions taking place within a multidisciplinary framework that included psychosocial advice, support and guidance. The multidisciplinary meetings were held on a weekly basis and included input from medical staff, a psychiatrist and local GPs. Data provided by the service showed an increase in medicines initiation appointments, showing that 100% of diagnosed patients had received medicines initiation appointments in 2018 compared with 60% in 2017.

Musculoskeletal Service

  • The musculoskeletal service had a focus on supporting patients to self-manage their own condition. In response to data that showed 35% of patients having hip replacements and 44% of patients having knee replacements reporting no improvement or worse general health after surgery, the service had developed a ‘shared decision making’ programme. The programme was the winner in the 2019 Health Service Journal Partnership award shared between the service and other organisations within the musculoskeletal partnership. Within the programme, patients were supported to make decisions that would be most appropriate for them. The programme included training for clinicians to help patients understand their options and potential outcomes. Specific work had included an initial assessment where outcomes were identified between the clinician and the patient following a detailed explanation of potential benefits and risks of each treatment option. A letter was then sent to the patient, with their GP copied in, detailing a specific plan of care that identified agreed goals. The service was working with other care providers to change the language they used on referral, moving away from a ‘referral for surgery’ to a ‘referral to best identify how to meet patient needs’ in order to reduce the impact on secondary care services and unnecessary surgery for patients. We were told of a historical example of a patient who had been a keen gardener and had not been aware that kneeling could be more difficult post operatively.
  • As a result of the ‘shared decision making’ approach to self-management, the service demonstrated a reduction in the number of patients referred to secondary care for surgery. Data provided by the service showed 949 (7%) fewer patients had been referred to secondary care in September 2018 than in September 2016. This was against a backdrop of an increase in referrals to the service overall (60,000 patients in 2018 compared with 55,000 patients in 2016). In addition, of those patients who were referred to secondary care, those receiving surgery increased from 70% to 85%, suggesting that more patients were being appropriately seen in secondary care. Data also showed a reduction in secondary care spend during this time.
  • The service had shared their practice with other services, including through the development of a professional/system case study that was shared with NHS England, as well as presentations to other organisations. Visits from other clinical networks to the service had been arranged to share learning.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. Reviews of both the memory assessment and musculoskeletal services had been undertaken in the previous two years. Reviews included active participation from patients and carers and were driven by national standards and guidance to ensure improved outcomes for patients. The impact on patients showed tangible improvements, for example, through earlier care interventions for patients within the memory assessment service and a reduction in secondary care referrals for patients in the musculoskeletal service.

  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.
  • Audits routinely carried out within the service included non-medical prescribing which was audited on an annual basis, a duty of candour audit to ensure compliance with duty of candour responsibilities, a triage audit to monitor triage competencies and patient outcomes and other quality assurance audits.
  • We viewed a July 2018 audit of shared decision making within the musculoskeletal service upper limb pathway, where patient records were audited to identify where there was information recorded about treatment options discussed along with evidence of what mattered to the patient. Results showed that 87% of records showed evidence of shared decision making with 51% including evidence of what mattered to the patient. The audit identified those clinicians who were performing well and an action plan following the audit included shadowing of these clinicians for other staff working within the pathway. Other actions included discussions at multidisciplinary meetings and supervision and a review of the audit by patient partners in order to ensure that the patient perspective was considered. A re-audit was planned for December 2019.
  • Within the memory assessment service, a critical findings audit was undertaken in relation to an audit standard of 14 days for scans to be reviewed. In March 2018 compliance with the standard was 75%, there was 60% compliance within the imaging sub-standard (7 days) and 75% compliance within the memory assessment standard to review findings (7 days). A re-audit following an action plan to work with the imaging provider to improve audit times and with the memory assessment service to improve availability of clinicians to review findings showed evidence of improvements. Improvements included 100% compliance with the 14-day standard and 95% compliance with both the imaging and memory assessment service review sub standards.
  • The service participated in national benchmarking, for example through the Memory Services National Accreditation (MSNAP) scheme. This showed that the service performed better than 80% of services recently visited by the MSNAP team.
  • Individual practitioner competency was routinely monitored using a clinical dashboard against patient outcome measures. This was used to inform performance review and development.
  • A specific quality goal for the service was to improve the approach to clinical audit, ensuring repeat audit cycles were planned and that audits were designed to promote improved patient outcomes as well as quality assurance.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff. The service used an ‘onboarding’ work sheet for new employees and those transitioning into new roles. The worksheet included activities for the first day, week, month and quarter the staff member was in post. The work sheet had categories that included aspects of the organisation such as purpose and beliefs, key relationships, tools to carry out their role, opportunities for development and progression and training and standards.
  • All staff had completed mandatory training relevant to their role and training compliance was appropriately monitored.
  • The musculoskeletal service ran an annual conference for staff working within the Sussex wide musculoskeletal pathway. The conference focused on a number of areas of development including lifestyle and mental health factors, clinical reasoning and team work.
  • Clinical staff attended an annual ‘away day’ to discuss clinical topics.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. Learning needs were identified and met through a system of meetings, appraisal and training. Staff had access to regular individual and group supervision. For example, nursing staff carrying out assessments within the memory assessment service had quarterly clinical supervision with a psychiatrist. All staff had received an appraisal within the last year.
  • There were competency assessment frameworks in place within the service. For example, within the musculoskeletal service advanced practitioners completed a regular competency assessment. This included an assessment of their triaging and prescribing skills as well as specific skills relating to clinical interventions such as joint injections.
  • Within the musculoskeletal service a clinician dashboard was in use. This showed activities such as the type of appointment, appointment outcome, transfer of care/referral to other service, the type of diagnostic investigations requested and the average ‘did not attend’ rate for each clinician. Managers had oversight of the dashboard and it was used to identify areas for further review as part of supervision and appraisal processes within the service. Reviews of clinical decision making were carried out as part of the regular multidisciplinary meetings to identify and share learning and good practice.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. This included the delivery of the service as a whole within a partnership framework and working closely with other service providers within each clinical pathway. We saw evidence of communication with GPs and other primary care practitioners, as well as onward referral to other services such as secondary care, mental health, social services and pain management services. Patients were signposted to services such as those providing health and wellbeing and weight management support, and programmes to support physical activity for those with musculoskeletal conditions.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • Where patients agreed to share their information, we saw evidence of letters sent to the patient detailing their treatment plans also being copied and sent to their registered GP in line with GMC guidance.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services. This included mental health and social services. For example, patients assessed in the memory assessment service who were identified as vulnerable were supported to access services to help them to manage at home. There were clearly established relationships with local services and staff had a good understanding of the referral pathways involved.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice, so they could self-care. The service model for both the memory assessment and musculoskeletal services was based on improving self-care and quality of life for patients.
  • Within the memory assessment service memory support workers provide support to patients to maximise their independence from the point of referral. This included referral to other support services and care planning around strategies to help them enjoy life.
  • Within the musculoskeletal service a shared decision-making model was in operation, where staff would assess patient needs holistically and an agreed plan of care would be developed. Staff took account of the patient’s needs, wishes and preferences, as well as supporting them with ways to manage their mobility and pain through activities such as exercise.
  • Where patients need could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately. Patients were asked for consent to referral and investigation. We saw evidence that consent for joint injections was documented in patient records.

Caring

Good

Updated 3 September 2019

  • People were respected and valued as individuals and were empowered as partners in their care.
  • Feedback from patients was positive about the way staff treated people.
  • People who used services were active partners in their care. Staff always empowered people who used the service to have a voice.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people. We spoke with five patients and four carers in the memory assessment service who told us that staff were good at listening and were focused on finding solutions to their concerns. They told us that staff were approachable and gave the impression of having unlimited time for them, that staff were supportive and treated them with dignity and respect. They reported good continuity of care and described the service provided as ‘brilliant’. We spoke with three patients within the musculoskeletal service told us staff were ‘caring and delightful’, describing relationships that were productive and valued.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients. Assessment processes were holistic and considered the totality of patient’s needs.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. Patient information was available in different fonts and ‘easy read’ formats to make it easier to read and staff were able to access information in different languages as needed.
  • Patients told us that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them. Changes to services in recent years included earlier assessment processes of patient needs for those accessing the memory assessment service. Assessments, care plans and letters of communication were undertaken with clear processes for involving patients in decisions about their care and treatment. Within the musculoskeletal service a model of shared decision making was in operation and data showed this approach had resulted in a more holistic way of treating patients and a reduction in elective surgery.
  • Relationships between staff and patients were highly valued by staff and actively promoted by managers and leaders. This was apparent within the model of governance and operations within the service, where patients and carers were seen as partners in care. This was particularly embedded within the musculoskeletal service where patients were recruited and paid in honorarium as a voluntary payment for their input into the services. In addition, the service had appointed a patient director as one of three directors across the service. Patients were actively involved in their care and in the review and development of the service.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Curtains were provided in clinic rooms to maintain patient’s dignity. Clinic room doors were closed, and conversations could not be overheard.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 3 September 2019

  • People could access the right care at the right time.
  • Waiting times, delays and cancellations were minimal and managed appropriately. There was evidence of action to reduce waiting times and delays.
  • People who use the service and others were involved in regular reviews of how the service managed and responded to complaints.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

Memory Assessment Service

  • The memory assessment service was delivered in a number of locations across Brighton and Hove such as GP practices and other care settings. The facilities and premises were appropriate for the services delivered and were accessible for patients with different levels of mobility. Where necessary patients could also be seen at home.
  • The provider understood the needs of patients and improved services in response to those needs. The service responded to patient feedback which was actively sought. A particular example of this was in relation to feedback from patients that a focus on diagnosis was less important than a focus on ongoing support. This had led to a review of the service and the development of memory support worker roles where support and care planning was provided at the point of referral rather than at the point of diagnosis.
  • The service had made reasonable adjustments so that people in vulnerable circumstances could access and use services on an equal basis to others. Specific examples of this included working with the local homelessness GP practice to develop a memory assessment pathway that meant homeless patients could be seen and assessed in a location of their choice. Other pathways had been developed including those for patients with a learning disability and for those who identified as Lesbian Gay Bisexual Transgender Questioning (LGBTQ). Pilots were underway to improve access to memory assessment for people living in care homes and one within primary care to identify and support GP practices in relation to dementia diagnosis and support.

Musculoskeletal Service

  • The musculoskeletal service was delivered in a number of locations across Brighton and Hove including GP practices, clinical and diagnostic centres. The facilities and premises were appropriate for the services delivered and were accessible for patients with different levels of mobility.
  • The provider understood the needs of their patients and improved services in response to those needs. This included improvements to shared decision making within the service. A key performance indicator was the measure of the patient experience of shared care decision making. This included a measure of patients feeling sure about the best choice for them, knowing the benefits and risks of each option, being clear on which benefits and risks mattered to them most and having enough support and advice to make a choice. Scores on this measure had increased by 12% since 2016 to reach 98% in 2019.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

Memory assessment service

  • The most recent audit data showed that patients having scans received these and had the results reviewed within the 14-day service standard. This was an improvement on previous findings.
  • The service had been benchmarked against other services and the average time for patients to be seen within the service was 17 working days which was better than 70% of similar services. The average time from referral to diagnosis was seven weeks which was better than 80% of similar services visited by the national audit team.
  • Patients reported that appointments were accessible, and we viewed records that showed initial contact was made with patients within the five-day standard.

Musculoskeletal service

  • A change to the model of working within the service included improvements to shared decision making which in turn impacted on a 7% reduction in unwarranted referrals to secondary care. This in turn resulted in a stable or reducing referral to treatment time for incomplete treatments within secondary care. Further impact included improved access times for patients who wanted or needed surgery due to the overall reduction in referrals. An improvement in waiting times for patients living in Brighton was evident with a reduction from 8.8 weeks in 2016 to seven weeks in 2018.
  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way. The service worked in partnership with other providers to ensure clear pathways of care. There was evidence of action to improve on the timeliness of care across pathways of care.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, a complaint about access to appointments within the musculoskeletal service led to additional training for administrative staff, including observed clinical appointments so that they had a greater understanding of appointment processes to be able to provide information and guidance to patients.
  • Patient partners were involved in reviews of complaints in order for the service to consider the patient view more fully when taking action to improve.

Well-led

Outstanding

Updated 3 September 2019

  • There was strong collaboration, team-working and support across all functions and a common focus on improving the quality and sustainability of care and people’s experiences.
  • Governance arrangements were proactively reviewed and reflected best practice. A systematic approach was taken to working with other organisations to improve care outcomes.
  • There were consistently high levels of constructive engagement with staff and people who use services. Rigorous and constructive challenge from people who use services, the public and stakeholders is welcomed and seen as a vital way of holding services to account.
  • Services were developed with the full participation of those who use them, staff and external partners were viewed as equal partners.
  • Improvement was seen as the way to deal with performance and for the organisation to learn.
  • There was a clear, systematic and proactive approach to seeking out and embedding new and more sustainable models of care. There was a strong record of sharing work locally and nationally.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • There was a staff owned approach within the services with leadership at every level. Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care

and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities. The service was founded on three key principles; do least harm first through intervention, extend the skills of others, and only use specialist skills where they are needed. The service aimed to create possibilities for care in every moment by asking patients ‘what matters to you?’
  • There was clear evidence of the service delivering high quality care and promoting good outcomes for patients. This was done through the development of partnerships to deliver care, integrated governance structures, common information technology platforms, and quality built into the front line of the services.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant). Staff across the services were able to articulate common beliefs, purpose and commitments.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service. Evidence of this was seen in monthly staff recognition awards where staff members were nominated by colleagues in situations where they had gone above and beyond expectations in their daily work.
  • The service focused on the needs of patients and had developed services that were truly patient focused. Service redesign work across both the memory assessment and musculoskeletal services had been carried out with comprehensive input from patients and carers and had led to improved outcomes for patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. Communication with patients following an incident or a complaint included action taken to address the issue and minimise the risk of it happening again. Patients were encouraged to engage with the service to address any concerns and there was a culture of addressing concerns at the earliest opportunity, including asking patients what could be done to address the issue at the point of the concern being raised. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour, including regular audit of compliance.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. Staff had all received appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where appropriate. Clinical staff, including nurses and physiotherapists, were considered valued members of the team. They were given protected time for professional development and evaluation of their clinical work. Regular audits of clinical consultations were carried out and the results used to encourage open discussions and learning to improve outcomes for patients.
  • There was a strong emphasis on the safety and well-being of all staff. The service had developed a wellness group that was run by a group of staff with an allocated budget to deliver their ideas on promoting staff wellbeing and support. Support for staff included the availability of twice daily meditation sessions, a monthly masseuse, and subsidised sports and yoga classes after work in one of the meeting rooms. This meant that staff were supported to provide patient care and a stable workforce was established.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally and that there was a culture of diversity in the workplace. We heard from staff that the work environment was inclusive and that flexibility and support for a good work-life balance was available. There was a culture of ‘bringing your whole self to work’ and the service had produced a video series aimed at exploring and celebrating diversity at work. Videos available on the service website included discussions group with working dads and with members of staff who were part of the LGBTQ+ community.
  • There were positive relationships between staff and teams.
  • The service had developed key practice resources that were aimed at supporting staff to ‘realise our purpose to create more possibilities for care in every moment’. This included resources aimed at ‘creating impact together’ and learning such as ‘having courageous conversations to share information and ideas that enable greater team and partnership working.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • The integrated service governance structure was based on a ‘bottom up’ approach, where each service worked as an organisation in their own right, and where each service area had an understanding of what good looked like and had systems and processes in place to check themselves against that.
  • The governance structures were designed to provide assurance as close to the front line as possible, where team meetings, work plans and projects, patient and carer feedback and finance and performance information was fed into service clinical quality groups. This in turn fed into a partnership board, quality assurance board and the organisational board of directors. The quality assurance board (QUASAR) served to provide additional oversight to pick up themes across services, and as a resource to pose questions, gain advice, and work through different approaches to service delivery and development.
  • Clinical quality and governance meetings were held within each service. Minutes of these meetings showed a representative attendance and agenda items included operational updates, risk registers, policies and procedures, national guidance, pathway development, safeguarding, complaints and incidents, patient satisfaction and audit updates.
  • Staff were clear on their roles and accountabilities
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety. Risk registers were maintained and reviewed, with an emphasis on action to eliminate or reduce the risk. Risk assessments were routinely carried out in each clinical area and these were updated based on changes and incidents.
  • A patient safety group was in operation. Minutes showed that meetings were held within an approach that included reflection and enquiry and the identification of learning and themes. Reviews included how the learning was shared. For example, one set of meeting minutes showed the review of an incident that had occurred because learning from a previous event had not been shared properly. Examples of why this might have been included situations where the impact of the incident rather than the learning had been shared. Action included a review of repeat incidents and discussions with staff as to the cause of this, including that learning may not have been shared widely enough. The service had developed the role of patient safety champions and there were representatives in each team responsible for ensuring shared learning across the service. Patient carer partners were involved in internal reviews to share and promote learning and improvement.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Organisational and service level performance was routinely reviewed. Key performance indicators were identified, measured and monitored, with information about performance shared with commissioners and other stakeholders.
  • Both services agreed quality goals on an annual basis. Within the memory assessment service a quality goal was agreed in relation to developing a better understanding of care and support needs within the LGBTQ+ community. This led to the development of a champion within the service and support for a ‘bring dementia out’ initiative by a national dementia service. Within the musculoskeletal service a particular goal was to implement 10 improvements projects with involvement from patients within the service. Examples of this included patient involvement in improving the availability of accessible information. This included work on the service website, improvements to patient communication through letter and improvements to the waiting areas within the service.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account, including key performance indicators.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. Any breaches to data security standards were appropriately reported and learning was shared to ensure improvements, including with external and partner organisations as appropriate.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. Within the musculoskeletal service a patient carer partner system had been developed. The system engaged with patients/carers affected by life-changing illness, injury or disability, or affected by a long-term condition and worked collaboratively with service providers to improve local healthcare. A patient/carer partner (PCP) was a paid role, where the individual worked alongside clinicians, leadership teams and staff by drawing on their personal experience to provide insight into the design, improvement and delivery of the local musculoskeletal services. PCPs were involved in areas such as the clinical quality group where they contributed the patient view to clinical and governance processes. They were also involved in service development activities such as the development of the shared decision-making model of care within the service. Within the memory assessment service, patients and carers were routinely asked for their feedback and contribution to the service. Ongoing relationships were developed through group activities and formal feedback was gathered. A monthly newsletter was published and shared with staff and patients.
  • Service stakeholders including staff, patients, partner organisations and local GP practices were invited to attend the Annual General Meeting and were encouraged to contribute and share feedback and ideas with the service.
  • Staff could describe to us the systems in place to give feedback. This included formal feedback processes and meetings. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. There was a culture of continuous improvement across the services which was supported by improved outcomes. Learning was shared and used to make improvements. There were structured governance systems, including patient safety champions and patient carer partner input into internal reviews to share and promote learning and improvement.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work. This included full system reviews of both the memory assessment and musculoskeletal services to identify ways of working that would improve patient outcomes. This practice was shared with other services to promote shared learning. The service participated in external accreditation schemes and had received recognition for their work. They had been awarded the 2019 Health Service Journal Partnership Award within the musculoskeletal service for their collaborative work to improve the patient experience, reduce unwarranted variation in patient outcomes and improve access times for patients who wanted and needed surgery. Learning from this was shared with other services through the development of case studies and presentations. The service enabled visits from other providers to share their work and create opportunities for learning from their experiences outside of the organisation.
  • The service was a finalist in the 2019 patient safety education and training award, working in collaboration with other services within the Sussex Musculoskeletal Network and other NHS Trusts in raising awareness of cauda equina syndrome (a serious condition caused by compression of the nerves in the lower portion of the spinal canal).
  • Other awards and recognition of the services provided included a Social Enterprise of the Year award in 2017 and Employee Ownership Association award for innovation in 2017.