City Health Care Partnership CIC

Letter from the Chief Inspector of Hospitals

We inspected CHCP CIC from 19 to 22 November 2016 and undertook an unannounced inspection on 22 November 2016. We carried out this inspection as part of the CQC’s independent community health services inspection programme. The core services inspected were:

• Community Health Services for Adults
• Community Health Services for Children, Young People and Families
• Community Services for End of Life Care
• Urgent Care Services
• Termination of Pregnancy Services

Although we regulate termination of pregnancy services we do not currently have a legal duty to rate them. For these services, we highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

The following services operated by the provider were not inspected as part of this visit, prison health care, GP services, dentistry, public health and social care.

This report only comments on what we found in relation to the community health services that we inspected. We have not rated City Healthcare Partnerships CIC as a provider for each of the five key questions or as an overall rating because we did not inspect how well-led the organisation was in relation to all the services that it provides.

Our key findings were as follows

• Feedback from patients and their relatives was consistently positive about the care they received. All staff consistently communicated with patients in a kind and compassionate way, treated them with dignity, and respected their privacy.
• There were processes for being open and honest when things went wrong and patients given an apology and explanation when incidents occurred. However, some staff did not fully understand when duty of candour would be applied.
• Most staff understood their responsibilities to raise concerns and use the mechanisms to record safety incidents and near misses however staff understanding of what incidents to report and sharing of lessons learnt were not consistent in all services.
• All areas inspected were clean. Most staff followed the ‘arms bare below the elbow’ national hygiene guidance; however, some staff in community health services for children, young people and families were not following this guidance.
• There were some excellent examples of multidisciplinary team working particularly in end of life care to ensure that quality of care could be maintained closer to home and prevent unnecessary hospital admission.
• Staffing levels were planned and reviewed and any staff shortages were being managed adequately.
• Services were planned and delivered to take account of people with complex needs. There were arrangements to enable access to the service for people in vulnerable circumstances.
• People could access care and treatment in a timely way. Action was taken to minimise the time people had to wait for treatment and care.
• There were systems for the management of complaints, and evidence of improvements following complaints.
• Information showed that most intended outcomes were being achieved for people who use services.
• There were processes to consider risk and quality management however, areas such as clinical audit, effectiveness, and measures to identify escalating risks required further improvement.
• Senior and local site managers were visible to staff. Staff were proud to work in the organisation and spoke highly of the quality of care provided.
• There were good levels of constructive engagement with users of the services and staff, including equality groups.

We saw several areas of outstanding practice including:

• Urgent care services participated in a falls response pilot scheme with the ambulance service, fire and rescue and other health services. Emergency care practitioners (ECPs) based in urgent care provided clinical input and had trained ten fire officers involved in Hull FIRST. Where a clinical assessment or medical treatment was needed following a fall, ECPs worked with other clinicians at the patient’s home or at the scene of the fall to help avoid unnecessary transfer to hospital.
• The End of Life Academy attracted staff from a variety of specialisms and services in the area to increase their skills and understanding of needs at the end of life. The service has received enquiries from around the UK about end of life educational delivery.
• The End of Life service had established one of six national pilot sites of integrated community end of life services based on the Motala model in Sweden. This model sought to provide direct care and support to patients in the last 12 months of life to prevent unnecessary hospital admissions and enable them to live at home and die in the place of their choice. This was achieved through early referral, home-based clinical intervention and joint working with community based services including primary care.
• The sexual health service was piloting a Skype clinic with community gynaecology patients and was planning to include the service for male sexual dysfunction and HIV clients. This reduced the need to attend face-to-face appointments and lowering barriers to access.

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

Importantly, the provider must:

• Ensure that there is assurance processes for Abortion Notification Forms HSA1 completion and HSA4 submission to the Department of Health within the legal timeframe of 14 days.
• Implement a surgical safety checklist for vasectomy patients.
• Ensure patients are informed that their anonymised data from HSA4 (notification for pregnancies terminated) forms is shared with the Department of Health (DH) for statistical purposes.

The provider should:

• Ensure there are processes to formalise arrangements for access to a specialist palliative care consultant 24 hours a day.
• Review the Incident and Near Miss Policy to ensure that it clearly defines the triggers for implementing duty of candour; and that staff are aware of the triggers to implement duty of candour.
• Ensure effective systems and processes so that lessons learnt from incidents are shared with staff groups consistently.
• Review assurance and clinical auditing systems to effectively identify, monitor and mitigate risks.
• Ensure that all services are undertaking audits to assess compliance with evidence based guidance from the National Institute for Health and Care Excellence.
• Review arrangements to ensure that there is appropriate board level representation for children’s services, as recommended by the National Service Framework for Children (2003).
• Ensure that all staff have completed the level of children’s safeguarding training relevant to their role.
• Review how wait times for termination of pregnancy patients are monitored against DH requirements of 5 working days from referral to consultation and 5 working days for consultation to treatment to provide assurance that extended waiting times are due to patient choice or appropriate clinical delay.
• Consider providing patients attending for medical abortion a time alone with the assessing nurse or consultant to give them a private opportunity to disclose any concerns regarding abuse or coercion.
• Continue to work with social care to ensure that processes are in place to meet the statutory requirement of providing an initial health assessment to all looked after children within 28 days.
• Ensure consultation rooms in urgent care services have signage to show when rooms are occupied.
• Ensure that lone worker applications for staff during home visits are used consistently and in line with organisation policy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall we rated community health services for adults as good because:

• There were systems in place for incident reporting, staff had received training in these systems and staff we spoke with were able to describe how they reported incidents. Managers were able to describe examples where they had carried out the duty of candour. Staff we spoke with could describe how they would report safeguarding concerns.
• Record keeping data was positive across the services and staff we spoke with told us they had access to the equipment they required.
• Staff were able to describe how they assessed and responded to patient risk and deteriorating patients in their services.
• Evidence based care guidance and treatment was used in the services and staff could describe the national guidance and protocols they used and had access to. Technology and telehealth was taken into account in community health services for adults and there was a telehealth service available for patients.
• We found staff to be competent in the services visited and staff told us of the training opportunities offered and the additional training they had undertaken to increase staff competency and skills.
• Compassionate care was provided to patients and staff made sure patient privacy and dignity was respected in the services visited. Friends and family test results were positive for the services. Patients, families and carer’s we spoke with during our inspection were positive about the care they received.
• Services were planned and managed in order to meet the needs of patients. Community nursing operated 24 hours a day, 7 days a week. Telehealth services had been introduced in cardiac and respiratory services to provide care through technology from a distance.
• Referral to treatment indicators were mostly positive across the different services and were meeting national indicators.
• The services had plans to become an integrated care service and develop a single point of access system to all services offered. Managers were able to describe the future plans and vision for the services.
• The service had a risk register in place and this was regularly reviewed. Managers were able to describe the risks to the services and the action taken to mitigate the risks.

Overall rating for this core service l

Overall, we rated the service as good.

• During the inspection, we observed staff delivering care to children and their families in clinic settings and in their own homes. We saw staff treat children and families with dignity and respect, demonstrating kindness and compassion. We observed good relationships between staff and patients and their carers.
• The service acted on lessons learnt from safeguarding investigations. There was a safeguarding team to deliver and support training and supervision to practitioners.
• Community children’s services used a range of evidence based systems and risk assessments to deliver appropriate care. There was evidence of services working with other organisations to develop competencies and deliver evidence-based practice, which supported enhanced care at home.
• The community children’s nursing team were involved in a practice development project to improve care practices.
• The service used an electronic record keeping system. This provided staff with up to date information about children, including safeguarding concerns. It allowed staff to share information with other practitioners in a timely way.
• Staff had additional training opportunities, regular appraisal and were supported to re-validate their professional registration.
• Staff felt valued and listened to, and had access to supportive management.

However:

• Not all looked after children received their initial health assessment by 28 days as required by statutory guidance because of late notification of children in the looked after system from social care. This was on the corporate risk register and the provider was meeting with the local authority each month to improve the timeliness of notifications from the local authority when children became looked after.
• There were a number of information governance issues and although managers were aware of these it was not clear that an action plan was in place or that, the issues were included in the services local risk register.
• Governance processes were not fully developed for identifying, recording and managing risks, issues and mitigating actions.

Overall rating for this core service OUTSTANDING

We have rated this service as outstanding because:

• There was a good safety record with no never events and no severe harm incidents reported. Staff were familiar with the incident reporting system and received feedback on lessons learned.
• Medicines were well managed and records in patients’ homes were organised with information easy to access including assessments for areas such as mobility, pain management and nutrition.
• Staff were familiar with the safeguarding systems in place to protect adults and children from harm and knew how to escalate concerns.
• The nursing staff we spoke to felt their caseload was manageable and that they had sufficient time with their patients. The post of palliative care consultant had remained vacant for some time and the failure to recruit had been escalated to the Care Group Director. Arrangements were in place to access palliative care medical input but these were informal.
• A new advance care planning document provided a record of the patient’s wishes for advanced care including their choice of environment, comfort and symptom management and support. Patients and relatives told us that pain was well managed and that staff were accessible to manage symptoms in a timely way. The service worked with four local care homes to increase education, skills and the quality of care given to end of life residents and to reduce emergency admissions. There was a holistic approach to discharge planning from hospital which was facilitated as quickly as possible when required. Arrangements fully reflected individual circumstances and preferences. The continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring high quality care evidenced by the success of the End of Life Care Academy which provided a structured programme of educational sessions to internal and external staff. Multidisciplinary working was a core element of the community end of life service. This was to ensure that quality care could be maintained closer to home and to prevent unnecessary hospital admissions.
• We observed a very caring and compassionate approach from all staff during their interactions with patients and family members. Patients were addressed appropriately and their dignity protected. We saw how family members were supported in understanding and managing symptoms by being involved in discussions with members of the specialist palliative care clinic team during their assessment of the patient at home. Patients and their families were encouraged to call the team for emotional support whenever it was needed. A widow told us how the Macmillan team and community nurses always returned calls within a reasonable time and spent a good amount of time with her and her husband during his illness.
• Staff were clear that patients' individual needs and preferences were central to the planning and delivery of end of life services. One hundred per cent of all patients referred to the end of life services in April to August 2016 achieved their preferred place of care where stated. The involvement of other services and organisations was integral to how services were planned and delivered. There was a proactive approach to understanding the needs of different groups of people and the service was extending its support to hard-to-reach groups by liaising with specialist healthcare services. People could access the service at a time that suited them through the single point of access service which operated 24 hours a day. Very few complaints were received by the service. Each was dealt with in a timely manner and actions taken where appropriate.
• The end of life service had a clear vision of the quality of care that it wished to provide and collaborated with multiple agencies to deliver it. Staff we spoke to described the chief executive as being visible, accessible and approachable and their managers and lead specialist palliative care clinical specialists as very supportive. Staff were very aware of the strategy and the aims of the service and gave examples of how integrated working assisted the patient to achieve their preferred place of care. There were effective governance systems in place to monitor patient safety and the quality of care and there was an open culture. Staff told us they felt most proud of the difference that they made to people’s lives and how well the disciplines worked together to achieve this. There were regular activities to engage the public to talk about and plan for end of life care.

We rated urgent care services as good because:

• Patients received friendly, compassionate care and treatment which was well directed to meet their needs and access standards were consistently achieved.
• Patients presenting with high risks and deteriorating patients were identified and escalated appropriately. Staff understood their responsibility to safeguard patients. Staff followed consent procedures and evidence based guidance to ensure the effectiveness of treatment.
• Public and staff engagement was well developed and levels of patient satisfaction compared well with similar services nationally.
• Directors of the care group which included urgent care and senior managers of the service provided clear and reliable operational leadership. The culture was positive and patient focussed.
• Staff competence was supported through regular training, supervision and appraisal. Staff felt valued and supported by managers and were proud to work for the service. Staff were recognised for improvement and innovation.
• Staff were trained in incident reporting, encouraged to report incidents and learning was shared. Duty of candour was considered.
• Equality and diversity was reflected in delivering services. Facilities were designed for disabled access and patients with a learning disability were supported. An integrated urgent care service was being introduced in response to people’s needs.
• Equipment was maintained and medicines were stored and administered safely. Infection control and hygiene procedures were followed and a high standard of cleanliness was maintained.
• Urgent care liaised effectively with other health services. Electronic patient records were easy for staff to use and were linked with primary care. A resilience and business continuity plan was in place for adverse events in collaboration with external organisations.
• The vision and strategy was embedded and governance, risk management and quality measurement were in place. Items identified for action were followed up. Although the service did not receive many complaints, they were investigated and learning was shared.

However

• The clinical audit programme required development.
• For one subject area, moving and handling, mandatory training was not fully completed but this was being addressed with a change of training provider.

City Healthcare Partnership CIC was contracted by Hull and East Riding clinical commissioning groups (CCGs) and city councils to provide an integrated sexual health service for patients from the areas of Hull and East Riding. Sexual health services were provided as part of Care Group Two, which also provided community paediatrics and public health services.

Services were provided under the name of ‘Conifer Sexual and Reproductive Healthcare Services’, which provided the range of contraception and sexual health (CASH), HIV and gynaecology services and medical abortion up to 9 weeks gestation. The service also provided pre and post termination counselling as well as contraception advice and screening for sexually transmitted diseases. Staff referred any patients requiring surgical abortion or medical termination of pregnancy of greater than 9 weeks gestation to alternative termination of pregnancy providers. The service also provided vasectomy.

The premises were situated at a large treatment centre in the town centre and were easily accessible by public transport or car. Facilities were modern and suitable to meet the needs of the service. The services were open from 8am until 8pm Monday to Saturday and 9.30am to 4.30pm Sundays.

The termination of pregnancy service assessed and treated patients of all ages, including those aged less than 18 years and could treat young people and children as young as 12. Seven hundred and forty four patients had accessed this service between October 2015 and September 2016, 13 of these were under 16 years. No children under 13 years had accessed the service during this time. Staff caring for patients less than 18 years of age followed strict safeguarding and management processes. The service was provided in an integrated manner with the local acute trust to allow women access to abortion services up to and including 9 weeks. Women who were more than 9 weeks pregnant were referred to other providers of later termination services. The majority of patients treated were NHS funded and lived within the boundaries of Hull and East Riding.

The integrated sexual health service employed 4.43 whole time equivalent (wte) consultants, 0.75 wte GPs with special interests, and 2 wte specialty and associate specialists. Two of the consultants were involved in providing the termination of pregnancy service including; clinical assessment, confirmation that the lawful grounds for abortion were met, and prescribing of abortifacient medicines.

The integrated sexual health service employed 17.12 wte registered nurses at band 5 and above, 1.8 associate practitioners at band 4 and 8.01 wte support staff at bands 2 and 3. There was an additional 0.19 band 6 vacancy and 1.06 band 3 vacancy, which had been recruited to but staff were not in post yet.

The service was also support by an administration team, which included 7 wte receptionists.

We carried out an announced comprehensive inspection of the termination of pregnancy service between 8 – 11 November 2016 and an unannounced inspection on 22 November 2016. The staff and services we inspected were those delivered from Wilberforce House.

We spoke with 3 patients and carers, and 15 staff, including managers, doctors, nurses healthcare assistants and receptionists. We attended a number of focus groups and we observed staff deliver care. We looked at 10 sets of medical records for termination of pregnancy patients and three vasectomy patients and reviewed the service performance data.