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Community Healthcare Services, St Mary's Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 September 2014

Isle of Wight NHS Trust is an integrated trust providing acute, ambulance and mental health services, and community health services. Community health services are provided to a population of approximately 140,000 people living on the Island. Services include community nursing teams, community rehabilitation teams, health visiting, school nursing, community equipment services and sexual health services. These services are provided across the Island in clinics, children’s centres and patient homes. Community inpatient services include general rehabilitation and stroke rehabilitation wards at St Mary’s Hospital.

We carried out this comprehensive inspection because the Isle of Wight NHS Trust is an aspirant Foundation Trust, prioritised by Monitor. The trust community services were inspected as part of the second phase of the new inspection process we are introducing for community health services.

The announced inspection took place between 3 and 6 June 2014, with an unannounced visit on 21 June, between 4pm and 11pm.

Overall, we rated the Isle of Wight NHS Trust community services as ‘requires improvement’. The trust was good for providing caring services. The safety, effectiveness, responsiveness and leadership of the services required improvement.

We rated community health services for children, young people and their families, community adult services, and community inpatient services as 'requires improvement'.

Key findings related to the following:

  • There was a high level of patient satisfaction across community services. The majority of people commented on the caring and compassionate approach of staff . Staff were highly motivated and committed, and treated people as individuals.
  • There was good multidisciplinary working, and initiatives to support people at home, and avoid admission to hospital. The trust had taken steps to improve access to appropriate services through the development of the Single Point of Access, Referral, Review and Co-ordination (SPARRCS ) team, which was based at the Integrated Care Hub. The Community Stroke Rehabilitation team worked towards specific rehabilitation objectives for patients, and facilitated early discharge from hospital.
  • There were elements of good practice across a range of units and teams, but this was not consistent across all services. Some, but not all, teams were benchmarking themselves against other services and taking innovative steps to improve ways of working and productivity, but this needed to be implemented and embedded across all services.
  • Staffing establishments were not sufficient in all areas, and there were ongoing challenges in recruiting staff. The arrangements to ensure a safe and consistent out-of-hours district nursing service needed to improve. We were concerned by insufficient medical and nursing staffing on the community inpatient wards, and this was a particular risk when there were inappropriate admissions of more acutely ill patients.
  • Risk management systems were in place, and staff were fully aware of their responsibilities in reporting and in implementing new practice. However, the governance of risk management needed to be more robust at all levels of the organisation, as across all core services we found examples of incidents that had not been responded to promptly or adequately.
  • The trust had an ongoing programme to improve access to and use of IT across community services, and connectivity issues were a known challenge. Where implemented, the IT system was still not fully functional, and incomplete electronic records created a risk.
  • The trust had a statement of vision and values, but community services staff were not consistently aware of these. Local leadership of most community services at team level was good. But there was a disconnect between staff in community services, and the executive team and senior managers, and this impacted upon the culture within which front-line staff were being expected to deliver services. Staff perceived that the community services had a lower profile within the organisation than the acute services.

We have identified areas of outstanding practice. However, there were also areas of poor practice, where the trust MUST make improvements, and other areas of practice, where the trust SHOULD take action to improve. These are identified in this report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

August 2014

Inspection areas

Safe

Requires improvement

Updated 9 September 2014

There was an incident reporting system in place, and staff had a good knowledge of reporting of safeguarding and other incidents. We found evidence of learning from serious case reviews and other incidents, as well as complaints and concerns. However, across all core services we found examples of incidents that compromised staff and patient safety, and that had not been responded to promptly or adequately.

There was a need to review some community staff caseloads, and some community teams were stretched due to staff vacancies. Insufficient medical and nursing staffing, along with the inappropriate admission of more acutely ill patients to community inpatient wards, was compromising safe patient care. We raised concerns with the trust, and our later unannounced inspection identified that changes had been made on the general rehabilitation ward, but risks arising from staffing levels remained on both wards.

A variety of risk registers were maintained, but it was not always clear what actions had been taken and what the timeframes were. Staff were concerned that risk reporting and management mechanisms were not sufficiently robust.

Action was being taken to ensure harm-free care, and reduce the incidence of avoidable harms such as falls and pressure sores, but pressure area care and pressure ulcer prevention needed improvement. Community nursing patients were at risk when not adequately assessed before the use of compression bandaging.

The level of improvement required to ensure safety on the community inpatient wards led to a judgment of 'inadequate' for those services. All other services were judged to 'require improvement' in providing safe care.   

Effective

Requires improvement

Updated 9 September 2014

We rated adult community services as 'good' for providing effective care. Integrated sexual health services and the Community Stroke Rehabilitation team were particularly notable. National guidance was used to treat patients in adult community services, and local care pathways and care bundles were ensuring consistency of treatment.

Multi-disciplinary working was widespread across community services for adults, and for children and family services, with evidence of good joint working to ensure that individual needs were met. Excellent examples were observed in the Integrated Care Hub and integrated sexual health services.

We judged that community inpatient wards, and children and family services 'require improvement'. The Healthy Child Programme was not consistently implemented across all areas. We did not find evidence of regular audits of, for example, infection control, or documentation or participation in national audits in children and family services. Continuing issues re IT connectivity and the availability of laptop computers were also impacting on the effectiveness of services. Pressure area care was being prioritised for improvement by the trust, but we found poor practice on the stroke ward.

Whilst numbers attending appraisals and training were good, we found that nursing staff on inpatient wards and some community nursing staff did not receive one-to-one supervision.

Caring

Good

Updated 9 September 2014

We rated all services as 'good' for caring for patients.

Patients were very positive about the quality of service that they received. We saw care being delivered across a wide range of services, and staff treated patients with compassion, kindness, dignity and respect. Patients told us that they were involved in planning their care, and that they were provided with enough information to make informed decisions.Staff were passionate about the care they delivered. This was reflected in the comments made by patients and their relatives.

Responsive

Requires improvement

Updated 9 September 2014

We rated community services for children and families as good but other core services required improvement. Most services were accessible, clinics and groups were established in community locations, and services were provided in people’s home where this was needed. There were increased waiting times for some children therapies whilst recruitment was ongoing.

The trust had taken steps to improve access to appropriate services through development of the Single Point of Access, Referral, Review and Co-ordination (SPARRCS ) team. The crisis team was able to respond within four hours to urgent patient needs. We saw good examples of person-centred care and services that were adapted to meet specific needs in the community, including the stroke rehabilitation team and sexual health services. However, access to community nursing out of hours needed to improve. With one district nurse on-call, we found that there were occasions when there was no service available due to lack of staffing. GPs or the ambulance service were called for patients with urgent nursing needs.

Access to inpatient rehabilitation was restricted for some patients due to the number of inappropriate admissions to the community rehabilitation wards.

Well-led

Requires improvement

Updated 9 September 2014

Most teams benefited from strong local leadership, with the exception of the inpatient wards, which lacked strong medical leadership on the organisation of care for the wards. This led to regular inappropriate admissions of patients from other specialties.

We saw some good examples of corporate communications that were accessible to all staff; these included consultations on proposed changes, as well as social activities and staff awards. The trust had a statement of vision and values, but some the staff we spoke with were not able to identify these, and could not demonstrate understanding of the trust’s development strategy. Staff did not feel included or engaged with some of the changes in services. Almost all the staff we spoke with felt that the community services had a lower profile within the organisation than the acute services. They said that the leadership team at the trust were not visible out in the community, and that communication between the leadership team and front-line staff was not effective. This had resulted in an inward-looking culture within some community service teams.

Risk management systems were in place, and staff were fully aware of their responsibilities in reporting and in implementing new practice. In some areas, staff were not confident that incidents and reported concerns were always dealt with in a timely or appropriate manner. Although there were examples of lessons learnt, trust-wide governance and risk management were not sufficiently robust. The trust had not responded adequately to Department of Health guidance and we saw that at times patients were accommodated in mixed sex bays on community inpatient wards.

The trust had started some initiatives in partnership with the local authority, such as ‘My Life, a Full Life’ and there were ongoing plans to improve integrated health and social care across the Island. We found that there were a lot of interim management posts in community services. There were also increasing problems in recruiting key staff, and this raises questions about ongoing sustainability of services; for example, the lack of geriatricians in a trust servicing an ageing population. There was a workforce strategy and working group, and we heard of plans for an older peoples’ centre on the Island. But these initiatives were at very early stages of development, and it was not clear how immediate issues would be mitigated.

Checks on specific services

Adult solid tumours

Requires improvement

Updated 9 September 2014

We judged that safety within the adult community services required improvement. Nursing staff did not feel safe, and we found that improvements were needed to arrangements to minimise risks to patients and to staff working alone in the community, particularly out of hours. Staff were able to describe the systems for reporting incidents. There was a evidence that improvements had been made to services through sharing of lessons learned, although staff felt more could be done in response to lone working incidents. Staffing levels varied across different locations and were not matching the demand in some localities, with the risk that this would compromise safe and effective patient care. This had been identified as a risk by the trust, and although staff had been recruited for some locality teams, it was not fully resolved. Safety standards were followed for infection control, the use of equipment and medicines management.

National guidance was used to treat patients, and local care pathways and care bundles were ensuring consistency of treatment. Action was being taken to ensure harm-free care, and reduce the incidence of avoidable harms, such as falls and pressure sores, but patients were at risk when not adequately assessed before the use of compression bandaging. Multidisciplinary working was widespread, with some excellent examples observed in the Integrated Care Hub and integrated sexual health services.

Staff were caring, and patients and relatives told us they were treated with dignity, compassion, and respect. We observed staff providing compassionate care, and consulting with patients in clinics and in their homes. Patients were involved in planning their treatment. The Community Stroke Rehabilitation team worked towards specific rehabilitation objectives for patients, and facilitated early discharge from hospital. They used the goal attainment scaling to score the extent to which patient’s individual goals were achieved in the course of rehabilitation intervention.

Community services were provided in people’s homes where this was needed by patients, whilst clinics and groups were also established in community locations. The trust and local authority had initiated a ‘My life, a Full Life’ programme, for people over 65, to help people to support and care for themselves. The SPARRCS and crisis teams were established to encourage early discharge, or prevent admission if possible. The crisis team was able to respond within four hours to urgent patient need. However, the out-of-hours community nursing service (8pm-8am) was an ‘on-call’ system and required improvement. The on-call service was staffed by a lone working nurse, often inexperienced, and on occasions, we found that there was no service at all. Staff told us that the weekend and Friday evening hospital discharges were not always well co-ordinated with community services. This had led to inappropriate arrangements of care and possible readmission of these patients.

We found that leadership of local teams was good. But some of the staff we spoke with were not able to identify the trust’s vision and values, and could not demonstrate understanding of the trust’s development strategy. Most community staff felt disengaged with the senior management of the directorate and the trust. Staff told us that the trust management was acute medical-focused, and did not appreciate the complexity of community nursing and rehab provision. 

Community health services for children, young people and families

Requires improvement

Updated 9 September 2014

Community health services for children, young people and families includes safeguarding children, services for children in care, health visiting services, services for children 0-5 years, school nurse services and children’s therapy services.

There was good knowledge and reporting of safeguarding and other incidents, with evidence found of learning from serious case reviews and other incidents, as well as complaints and concerns. Information from these areas was collated and reviewed in appropriate committees, and any themes were identified. A variety of risk registers were maintained, but it was not always clear what actions had been taken and what the timeframes were. We also found an example where staff had raised a serious risk, and this was not initially responded to through the trust system; this left concerns that risk reporting and management mechanisms were not sufficiently robust.

The implementation of the new IT system had incurred increased risk. Improvements had been made and lessons learnt for the next stages of the programme. However, the system was still not fully functional, and staff were required to record information in a variety of ways, which created a risk. There was also a shortage of hardware, such as laptop computers and network cables. Some buildings were also in poor condition, and these were known and featured on the trust risk registers.

We found there was a need to review some community staff caseloads, as there was inequity in numbers and weighting in the various locations across the Island. The health visitor recruitment was on track to be achieved under the Department of Health Call for Action programme with Health Visitor students in training. However, there would not be a full staff establishment until 31 March 2015 which contributed to the inequity in numbers and weighting that we found. There were staff vacancies in therapy services with active recruitment underway, but it was not clear when this would be resolved. We found that there were increased waiting times for some therapy services, and antenatal visits were not consistently in place for all pregnant women across the Island.

We found some examples of excellent record keeping, but it was less effective in other parts of the service, and this created a risk to the safety and effectiveness of care. The Healthy Child Programme was not implemented consistently in all areas of children and family services. There was good communication and multidisciplinary working, both internally and externally, with evidence of good joint working to ensure that individual needs were met.

Parents told us that the services were accessible and that staff were knowledgeable, informative and caring. We received some negative comments regarding continuity of care, but these were in the minority. Staff demonstrated a passion for their work, and good knowledge of the families and children.

Staff reported good and accessible supervision, with good support from their managers. Some staff told us that they could access further development opportunities, but others said they could not. All staff we spoke with felt that community services did not have the same profile within the trust as the acute services. They told of feeling proud of their service and being part of the NHS on the Island, but isolated from the organisation. There was a lack of visibility by the senior leadership.

Community health inpatient services

Requires improvement

Updated 9 September 2014

We found the community inpatient wards to be clean and well maintained, with staff who were caring and kind, and involved patients in their care and goal planning. However, low medical and nurse staffing numbers and skill mix meant that safe care could not always be delivered, particularly, but not solely, at the weekend and out of hours. The routine use of the wards for patients who were moved from acute medical wards due to shortage of beds, exacerbated this problem. The nurse bank frequently could not provide the skill mix requested, and so healthcare assistants often worked in place of a registered nurse. Whilst numbers attending appraisals and training were good, we found that nursing staff did not receive one-to-one supervision.

The wards were well maintained and clean, but infection prevention and control needs to improve, as we found damaged equipment that could harbour bacteria. There was also increased need for MRSA rescreening, due to routine use of the ward for medical outliers, and this had not yet started. Some equipment needed by patients was not available, and had not been maintained as required. Some patients were accommodated on mixed sex wards, which is not in accordance with Department of Health guidance.

Staff were proud of the care they provided for stroke patients, and a national audit showed improvements made since 2010. The latest published results showed the trust had improved from the bottom 25% of all the 100 participating trusts in England to the middle half in 2012. A transient ischaemic attack (TIA) clinic was in place, but did not meet national guidelines, because it did not provide carotid Doppler assessments on Sundays. Pressure area care was being prioritised for improvement by the trust, but we found poor practice on the stroke ward.

Discharge planning and multidisciplinary working for patients leaving the wards was good. A dementia pathway was in place and followed in these wards and more widely within the trust. Therapists requested and recorded patients’ consent to treatment. However, we found that other practices in gaining patient consent needed to improve.

The staff were not able to be as responsive to the needs of rehabilitation patients as required, because patients who were medical outlier admissions took priority, and reduced the time available to treat them.

Both community inpatient wards lacked strong medical leadership for the organisation of care on the wards, which led to regular inappropriate admissions of patients from other specialties. The service was unable to follow the rehabilitation strategy due to the routine admission of medical outliers. Although low staffing had been reported, leaders on the ward had not influenced senior managers within the trust to take effective action, and a resolution had not been identified. There was a sense that the impact of the cost improvement plan on patients’ care was not understood by senior management within the trust, and we found trust-wide governance arrangements needed improvement.

Other CQC inspections of services

Community & mental health inspection reports for Community Healthcare Services, St Mary's Hospital can be found at Isle of Wight NHS Trust.