• Organisation
  • SERVICE PROVIDER

Bromley Healthcare Community Interest Company

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

27 July, 2-6 August, 11 -13 August 2021, 1 September and 7,8 September 2021

During a routine inspection

Bromley Healthcare Community Interest Company (BHC) was established in April 2011 as a social enterprise organisation to provide out of hospital community health services in Bromley. BHC employs more than 1000 staff and over 75% of staff are shareholders in Bromley Healthcare CIC.

BHC provides community health services in four London boroughs. BHC received more than 87,000 referrals in 2020 – 2021 and had nearly 600,00 patient contacts.

BHC provides a rehabilitation/intermediate care ward with 30 inpatient beds at Queen Mary’s Hospital, Sidcup; community health services for adults in the London Borough of Bromley; community health services for children, young people and families including health visiting in Bromley, Bexley, and Greenwich, school nursing services in Bromley and Bexley, and a specialist children’s nursing team in Bromley. BHC took over the provision of health visiting services in Greenwich, at very short notice, eight weeks before the inspection.

In addition, BHC provides specialist dental services from several health centres in Bexley, Bromley and Greenwich. It also provides other services, such as dietetics in Bromley, Bexley and Lewisham, improving access to psychological therapies (IAPT) and sexual health services in Bromley.

BHC has very recently acquired a care agency with 55 staff providing 700 hours of care to people in their homes in Bexley and 200 hours in Bromley.

BHC has eight locations registered with the CQC (as of 6 September 2021). Five of these provide specialist community dental services.

We carried out inspections of three core services provided by BHC and a well-led review as part of our continual checks on the safety and quality of healthcare services. This was the first comprehensive inspection of the three core services and the first well-led review of the provider. The last inspection carried out by CQC was a focused inspection of community health services for children and young people and took place in October 2020 following the death of baby.

We carried out inspections of three core services:

Community health services for adults;

Community health services for children, young people and families; and

Community health services for inpatients.

We did not inspect the provider’s sexual health services on this occasion. CQC carried out a focused inspection of the provider’s dental services in October 2021 as part of a dental services inspection project. This inspection is reported separately and was not rated.

Regarding this inspection report it should be noted that this inspection did not include a Use of Resources rating. Although Bromley Healthcare Community Interest Company is not a NHS trust the word trust is used erroneously in several places in the report as the word cannot be removed from the standardised inspection report template.

We rated Bromley Healthcare CIC as requires improvement because:

  • We rated safe, effective, responsive and well-led as requires improvement, and caring as good overall.
  • We rated two of the provider’s three core services as requires improvement and one as good.
  • The provider had three overarching strategic aims but a lack of clarity and detail regarding how the strategy would be achieved and by when. The provider had begun to refresh the strategy for the next three years.
  • Although there was a culture of high-quality care and leaders were clear that quality was not impacted by financial decisions, from our findings in the core service inspections there was some variation in the quality of care across some services. Specialist teams and services were found to have high quality care throughout. However, in district nursing and health visiting teams there was variation in quality.
  • Assurance systems in some areas were weak. Although performance data was collected and some of it presented very clearly in the form of dashboards, other key details of service delivery were not routinely analysed leading to gaps in assurance. The provider did not have effective arrangements to ensure that all notifications were submitted to external bodies as required.
  • Clinical audits were conducted mostly annually, but in some areas, such as record keeping, this was not frequent enough to drive improvements. The board had identified concerns about the quality of some audit design, which made it difficult to learn anything meaningful from the results. Where gaps had been identified following internal and external audits these were not always addressed effectively to bring about improvements, with the same or similar issues persisting at the time of our core service inspections.
  • Focus on the development of black and minority ethnic and other staff groups with protected characteristics, and the equality, diversity and inclusion agenda more generally, was relatively recent and was developing. Indicators across several of the workforce race equality standards highlighted disparities between the experiences of black and minority ethnic (BAME) staff and white staff. Further understanding and strategies were required to improve the experience of BAME staff.
  • The provider had arrangements in place for staff to implement the Accessible Information Standard, which applies to people using services (and where appropriate carers and parents) who have information or communication needs relating to a disability, impairment or sensory loss. However, many staff we spoke with did not know what the standard was. The provider did not monitor whether or not staff implemented the standard effectively.
  • Arrangements for the Freedom to Speak Up Guardian role had been in place since February 2021 but were yet to be fully established. The service had not been widely advertised or promoted with staff although details about the FTSUGs had been shared with staff via the chief executive’s weekly briefing, and nurses’ forum.
  • Patient experience feedback was limited, especially during the pandemic. The provider largely relied on Friends and Family Test feedback and had not fully explored obtaining feedback in other ways. Patient and public engagement was taking place. For example, a children’s community nurse ran a support group for carers and young people with sickle cell disease; the sexual health service was proactive in engaging patients through social media, focus groups and questionnaires; community paediatricians obtained feedback from patients on their experience of virtual consultations; and the COVID monitoring service had used a survey to gain feedback regarding long COVID symptoms from more than 440 patients. However, this work did not sit within an overall patient and public engagement strategy that included how BHC would engage specific patient and public groups who may provide valuable feedback but might not engage through the existing channels.
  • The training and delivery of a quality improvement methodology and culture was at an early stage. BHC used a plan, do, study, act (PDSA) approach to quality improvement and a quality improvement lead had been appointed and commenced work with BHC in May 2021. Further work to develop a quality improvement approach and embed a quality improvement culture throughout the organisation was needed.
  • Although the provider had carried out fit and proper person checks on directors, they had not made basic criminal record checks with the Disclosure and Barring Service in respect of non-executive directors.

However:

  • There was a stable and full leadership team with capability in their roles. Leaders were visible and approachable across the organisation, although some leaders were very operational in their day to day roles and responsibilities. The non-executive directors (NEDs) had a variety of backgrounds with a bias towards commercial skills and expertise. The balance of NEDs on the board was being reviewed at the time of the inspection with consideration being given to the addition of a further NED with a clinical background.
  • There was good financial stability and control and a highly skilled team delivering tender bids and winning appropriate contracts. The senior leadership team had a strong commercial skill set and were highly skilled at delivering this for the organisation.
  • The provider was very responsive in its approach to health and care delivery as exemplified by the rapid mobilisation of the Greenwich 0-4 service and the setting up of a COVID-19 monitoring service at the height of the pandemic. The provider managed change effectively and minimised disruption when service provision changed.
  • The provider had largely effective arrangements for identifying, recording and managing risks, issues and mitigating actions. Risks were recorded at service level and escalated up through clear channels to the corporate risk register where they were discussed and addressed. Risks identified by frontline staff matched those articulated by board members.
  • Dashboards were available for teams and used by them to review performance. All staff said they were helpful and easy to use. Bromley Healthcare staff shared their information technology (IT) skills with the local care sector and supported GPs with IT during the pandemic.
  • The provider had very positive relationships with external health and social care stakeholders. Senior leaders took an active role in local health care partnerships. Service staff worked effectively with NHS trusts and primary care clinicians to deliver high quality services to adults and children, such as the hospital at home service and rapid response.
  • The provider was committed to the development of staff and encouraged staff engagement and an open organisational culture. Senior leaders were very accessible to staff at all levels. A number of new staff well-being initiatives had implemented over the previous year, which were valued by staff.
  • Senior leaders had clear oversight of incidents, safeguarding and complaints. Managers investigated incidents and complaints and shared the lessons with staff to minimise the risk of them happening again. Safeguarding procedures were robust throughout the organisation. Staff understood how to protect adults and children from abuse and the services worked well with other agencies to do so.

How we carried out the inspection

Our inspection teams comprised of eight CQC inspectors, one inspection manager, three specialist advisors with expertise in providing community health services and three experts by experience.

The well-led review team comprised an executive reviewer, who was a chief executive from an NHS combined mental health and community health services provider; CQC’s national professional advisor for community health services, who was also a director of nursing in a community NHS trust; three CQC inspectors, an inspection manager and a head of hospital inspection.

During our inspection of the three core services, the inspection teams:

  • visited an intermediate care/rehabilitation ward, looked at the quality of the ward environment and observed how staff were caring for patients
  • visited six community team bases
  • spoke with 21 senior leaders in the services including a matron, associate directors, team leads, and heads of service
  • spoke with 56 other members of staff including nurses, nursing rehabilitation assistants, therapy rehabilitation assistants, occupational therapists, administrators, nursing associates, advanced nurse practitioners, district nurses, central coordination centre staff, health visitors, school nurses and nursery nurses
  • spoke with 38 patients and six families who were using services or their carers/relatives
  • reviewed 82 patient care and treatment records
  • reviewed four safeguarding supervision records
  • reviewed five patient and carer feedback cards
  • observed seven telephone consultations with adult patients and four child clinic appointments with the consent of the parent or carer,
  • observed five shift handover meetings, one multidisciplinary team meeting, one child development clinic and one infant feeding clinic
  • sent an online survey to Bromley Healthcare staff eliciting more than 200 responses
  • looked at a range of policies, procedures and other documents related to the running of the services

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the services say

On the inpatient rehabilitation ward based at Queen Mary’s Hospital, Sidcup, patients and carers told us that staff treated them with compassion, kindness and dignity. Patients and carers said staff were attentive, non-judgmental and were responsive to their needs. Carers told us that they were offered emotional support and advice when needed and that staff were very kind and caring with the patients. One patient commented that the ward felt like a hotel.

We spoke with six families using the community services for children, young people and families. Most people reported a positive experience and said their allocated health visitor had been caring. We heard positive feedback about the infant feeding team and how they supported mothers with breastfeeding. Families were very keen to resume face to face appointments.

Most patients using the district nursing service said that staff treated them well and with kindness, and were friendly, supportive and responsive when other professionals needed to be contacted. However, some patients told us that appointments were rushed, particularly with agency nurses, and sometimes staff would arrive without the correct medical supplies, or knowledge about their care needs. Patients and carers described unpredictable timing as a particular issue, with some experiencing missed or delayed visits. All patients we spoke with who used the specialist nursing teams were satisfied with the care they received and felt involved in making decisions about their care.

5-7 October 2021

During an inspection of Community dental services

We found:

  • The provider did not demonstrate that they had effective governance systems and processes in place to ensure risks to the service were assessed, monitored and mitigated. Systems and processes for managing radiation protection were unclear, and audits were not conducted regularly enough to identify potential gaps and drive improvements.
  • Dental staff had not completed paediatric immediate life support training, despite treating children, and were overdue for immediate life support training for adults. The provider had booked the required training for staff and it was due to take place in November and December 2021.
  • The provider had not carried out an annual radiography audit since 2015 in line with legal responsibilities under Ionising Radiation (Medical Exposure) Regulations 2017.
  • There were some recommended items missing from emergency equipment including airways and paediatric inflating bags. Although not mandatory items the service should consider their relevance given the number of children seen in the service.
  • Patient care and treatment information was not stored consistently. Some records were held electronically and some on paper. During the inspection staff could not show us the full range of information held about patients or confirm that the necessary checks related to conscious sedation had been recorded.
  • Some staff felt they were not treated equitably and others felt the provider could do more to address staff well-being.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. Staff kept equipment and the premises visibly clean.
  • The service had enough staff with the right qualifications, skills, and experience to provide the right care and treatment. Managers reviewed and adjusted staffing levels and skill mix, and gave locum staff a full induction.
  • The service used systems and processes to safely prescribe, administer, record and store medicines.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • Dentists, dental nurses and others worked together as a team to benefit patients. They supported each other to provide good care. Staff gave patients practical support and advice to lead healthier lives.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out inspection of community dental services at three locations.

Overall we:

  • Spoke with 15 staff including dental officers, dental nurses, a dental therapist and senior managers
  • Spoke with seven patients or carers by telephone
  • Reviewed 22 patient care and treatment records
  • looked at a range of policies, procedures and other documents relating to the running of the service.

What people who use the service say

All service users and carers we spoke with were able to able to contact professionals or teams when they needed to speak to someone. Patients and carers felt they were respected and valued as individuals. All knew how to make a complaint if they needed to.

Patients and carers felt staff involved them in decisions about their care and treatment. They told us that staff understood their needs and supported them to understand and manage their care, treatment and condition.

June 2015

During an inspection of Community health inpatient services

This service has not been rated. This inspection was a focused unannounced inspection in response to information and concerns we received about the service. These concerns related to poor infection prevention and control practices and general cleanliness of the unit, nutritional standards, therapy provision and environment, unsafe staffing levels, high numbers of complaints and patient falls.

Staff knew how to report incidents and safeguarding concerns on the electronic reporting system. They told us they received feedback on the incidents they had reported and participated in debriefs as and when required. Feedback was given in team meetings on a monthly basis and information pertaining to incidents was uploaded to the intranet following the publication of a monthly report compiled by the risk management team.

From information received prior to our inspection concerns were raised about staff training. We found that not all staff were up to date with their mandatory training. The suitability of the therapy gym was not conducive to maximising a patients rehabilitation potential.

Information received prior to our inspection showed their had been an increased number of falls. During our inspection we saw records that demonstrated patient falls had been investigated and changes made to reduce the risk of further falls occurring. Patient records were stored securely and were of aan appropriate standard. Planned staffing levels were not always met and there was a high useage of agency and bank staff. This was noted on the provider risk register. Recruitment was underway to fill some nursing and therapy positions.

The community inpatient service followed national guidance and staff had access to policies to ensure best practice. There was access to specialist nurses in tissue viability and infection control.

The service participated in national audits to improve service provision. Pain relief was provided as appropriate by GP’s and by the consultant geriatrician who attended the unit weekly. Palliative care specialist nurses were available to assist with pain management for patients at the end of their life.

Patients’ were provided with meals which were cooked on site in the building’s kitchen area. Patient feedback regarding the food was varied. Evidence of fluid and nutrition intake was recorded in patient records. Referrals were made by nursing staff if a patient required assistance from external therapists, such as speech and language therapist or dietician. There was good multi discipliniary team (MDT) working practices, with all specialities involved to ensure a safe discharge home for patients.

The referral to admission key performance indicator (KPI) target of 90% was not being met. The service was achieving 85% for this KPI. Staff were unclear about their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). There was no training provided in relation to this. The one DNACPR (do not attempt cardiopulmonary resuscitation) proforma were saw was not completed correctly.

Staff provided kind and compassionate care. Patients had their dignity and privacy respected in most areas apart from the therapy gym which was largely due to a poor environment. Most patients and relatives/carers felt involved in care planning from admission to discharge. Patients were emotionally supported by staff and pre discharge visits were arranged to offer emotional and practical support to patients.

Discharge planning was managed in a timely manner from first point of admission into the unit to ensure the correct equipment and care provision was available for people to return home safely. Links were being made with the local Healthwatch service to encourage patients to become involved in service planning and delivery. There was no reasonable adjustments made for patients living with a learning disability and no easy read information was available. New dementia champions were being trained to support staff in caring for patients living with dementia. An interpreter service was available. Most staff were not aware of the process for arranging an interpreter. A community psychiatric nurse (CPN) was available to support vulnerable patients within the service. Patients told us that they were unhappy with the lack of “things to do” at weekends. There were no televisions or radios available in patient rooms and therapy sessions were only available during the week.

There was vision for the future of the community inpatient service and although most staff did not know what the provider wide strategy was, they could tell us what the vision was in relation to patient care and experience. Senior managers told us that they would like to provide patients with a better environment to optimise their rehabilitation.

Bi-monthly governance meetings were held with most disciplines being involved. There was a transparent and open culture within the service and staff felt able to raise concerns or issues with senior managers and felt that they would be listened to. Staff felt well supported by their line management team. There was good communication links between managers and staff.

Local links were being made with Healthwatch to encourage patients to become involved in planning the service for the future and the friends and family test results showed that 87.5% of patients would recommend the service. Staff questionnaires were conducted based on the NHS model. As a result of the mock Care Quality Commission (CQC) inspection by an external consultancy, action groups had been tasked with improving services.