Locala Community Partnerships C.I.C. Also known as Kirklees Community Healthcare Services

We inspected Locala Community Partnerships Community Interest Company (“Locala”) from 11-14 October 2016. We undertook unannounced inspections on 27 and 28 October 2016 and 4 November 2016. We carried out this inspection as part of the Care Quality Commission’s (CQC) comprehensive inspection programme.

We inspected the following core community health services:

• Community adults services
• Community inpatient services
• Community dental services
• Community services for children, young people and families

In relation to each core service that we inspected we asked if the service was safe, effective, caring, responsive and well-led.

We sampled services provided from a range of locations across the Kirklees and Calderdale areas.

We did not inspect GP services, sexual health services or primary dental services provided by Locala during this inspection.

As a result of this inspection, we have rated the four core services that we inspected. We have not rated Locala as a provider for each of the five key questions or given 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:

• Locala’s systems for identifying, investigating and learning from incidents were not robust. There were several examples of this, including an incident that was not identified as a serious incident until several months after it occurred and that was incorrectly deemed to have been unavoidable.
• The duty of candour requirements were not embedded across the services that we inspected and compliance with the duty of candour requirements had not been monitored by the Board until September 2016.
• The organisation had safeguarding policies and procedures in place for safeguarding vulnerable adults and children. Safeguarding training rates were variable across the core services we inspected. A serious safeguarding adults incident had occurred in June 2016 which highlighted that some staff in the community adults team had not recognised safeguarding concerns that had been raised by patients and subsequently had not known what action to take. This had resulted in a delay in the organisation taking the appropriate action.
• We identified significant concerns regarding assessing and responding to risk on Maple Ward. This included falls and venous thromboembolism risk assessments not being completed and national early warning scores not being calculated when it was clinically appropriate to do so.
• We were not assured that governance and risk management arrangements were robust and we were concerned that there was an insufficient focus on quality within the organisation. Revised governance and risk management arrangements had been introduced shortly before our inspection. However, many of these changes were not fully embedded and it was too early to see whether they would lead to improvements. We saw several examples of serious patient safety issues not being identified or escalated through the governance structures appropriately.
• We found a mixed picture in relation to the culture of the organisation. This was reflected in the variation in responses in the June 2016 staff survey across the four business units.
• Mandatory training compliance rates were variable across the four core services that we inspected.Locala had a trajectory that Nurses in the integrated community care teams were not being provided with individual clinical supervision.
• Appraisal rates were low in the community adults and community inpatient services.
• Staffing levels were appropriate in the majority of services that we inspected. However, staffing shortfalls were a significant issue in the integrated community care teams, which delivered planned and unplanned care to patients. Staffing issues had been particularly acute in these teams in the period August to October 2016.
• A number of the infection prevention and control (IPC) policies and procedures were out of date. There were capacity issues in the infection prevention and control team, which meant that the IPC audit schedule hadn’t been followed in all the services that we inspected. We observed staff following IPC practices during the inspection.
• Care and treatment was evidence based across the services that we inspected. Staff had access to policies and procedures and other evidence-based guidance via the organisation’s intranet. Policies, procedures, assessment tools and pathways followed recognisable and approved guidelines.
• There was an agreed clinical audit programme in place for 2016/17. Locala had identified that there were gaps in required levels of quality assurance and clinical governance that may lead to poor standards of clinical quality and had commenced a programme of work to address this.
• The services we inspected participated in a number of audits to measure patient outcomes. We generally saw evidence of good patient outcomes in the services that we inspected, with the exception of Maple Ward where national audit data had not been completed during the reporting period for this inspection. In some instances we did not see evidence of action plans in the community dental service to address the outcomes of audits.
• Across the services staff used technology to enhance the service they provided to patients, however there were issues with the connectivity of mobile technology which meant that information was not always available to staff when they needed it..
• Throughout our inspection the majority of patients and relatives informed us they felt involved in care options, decision making and planned treatment. Staff took time to explain the care being administered and to ensure that patients and relatives understood what was happening.
• Patients were generally able to promptly access care and treatment in the services that we inspected. There were waiting lists for patients to access some services in the integrated community care teams and some visits were being delayed as a result of staffing shortfalls.
• There was no dementia or learning disability strategy in place. However, Locala had received an award in 2015 from a local voluntary group specialising in dementia care in recognition of the work to become dementia friendly. We saw some good examples of staff and services responding to the needs of people in vulnerable circumstances.

There were areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that there are robust procedures in place to ensure that incidents, including serious incidents and never events are correctly identified and reported and are comprehensively investigated and reviewed at an appropriate level within the organisation.
• Ensure that learning from incidents and complaints is shared and embedded across the organisation.
• Ensure that the duty of candour process is effective and embedded in practice across the organisation.
• Ensure that at all times there are sufficient numbers of suitably skilled, qualified and experienced staff, taking into account patients’ dependency levels.
• Ensure that all staff have completed mandatory training and role specific training.
• Ensure that infection prevention and control policies and procedures are reviewed and in date.
• Ensure that the infection prevention and control audit programme is followed and actions are identified and implemented in a timely manner when issues are identified through the audit programme.
• Ensure that staff are up-to-date with appraisals and staff attend clinical supervision as required.
• Ensure that there are in operation effective governance, reporting and assurance mechanisms.
• Ensure that there are in operation effective risk management systems so that risks can be identified, assessed, escalated and managed.
• The provider must have systems in place, such as regular audits of the services provided, to monitor and improve the quality of the service.
• Ensure that staff have undertaken safeguarding training at the appropriate levels for their role.
• Ensure that there are appropriate systems in place in the community adults service to ensure that patients are prioritised and seen promptly in accordance with clinical need. In addition, the provider must ensure that the governance and monitoring of such systems is operated effectively to enable the identification of any potential system failures, and to take action so as to protect patients from the risks of inappropriate or unsafe care and treatment.
• Ensure that staff competency is robustly assessed in the community adults service.
• Ensure that timely clinical risk assessments are undertaken and recorded and care plans are developed and recorded that are reflective of the patient’s needs for patients on Maple Ward.
• Ensure that clinical risks are promptly identified and appropriately monitored on Maple Ward, including the calculation of National Early Warning Scores, as clinically appropriate.
• Ensure that patients who self-medicate on Maple Ward have been appropriately risk assessed.
• Ensure that patients having venous thromboembolism prophylaxis on Maple Ward are appropriately assessed as per current best practice guidance.
• Ensure that a paediatric nurse is available to provide recovery care for children receiving dental treatment under a general anaesthetic, as recommended by the Royal College of Nursing.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall, we rated this service as inadequate because:

• There were significant nursing and therapy staff shortages in the integrated community care teams, which were having an impact on patient care. There were concerns about the lack of robust governance, oversight and monitoring of this situation. There was also a lack of robust governance in relation to incidents and concern about the lack of learning from incidents. The service demonstrated some evidence based care in the various teams and performance against some national and locally set targets was good. However, there was a lack of benchmarking of performance both within the organisation and externally. There was no clinical supervision of nursing staff within the integrated community care teams and the appraisal rates were low. The systems for checking staff competencies were not robust.

• There were a number of services with waiting lists of patients requiring assessment and treatment. There was no dementia strategy and there was a lack of provision for people who did not have English as their first language. However, the service had a range of specialist services to meet the different needs of people in the locality.

• Risk management and governance processes were not robust and plans to improve services were often not in place or lacked deadlines for actions to be achieved. There had been a lack of staff engagement at a time of significant change in the service. Planning for the changes had not been robust and action plans for this did not include actual or potential risks. There were gaps in policies and guidance for staff and there was little oversight or audit to ensure policies were followed. The recovery plans to address waiting lists were not robust and in some situations there were no plans in place to recover the position. Senior managers were not visible to staff and many staff felt they were not listened to. However, there were positive messages from some staff who enjoyed working for the organisation. There were some innovations in working with the third sector.

However:

• Staff in all teams were working very hard to provide a quality service to patients and their carers or families. We saw examples of outstanding care in some services. We saw patients and relatives were treated with dignity, respect and compassion. We observed staff reassuring patients and relatives and there was an empowering approach to patient care in some services. Feedback about the staff and the service from patients and families was mostly positive.

Overall, we rated this service as inadequate because:

• The timing and pace of change within the organisation and intermediate care unit had a negative impact on the quality of care provided.
• Patient’s risks were not consistently assessed and monitored to ensure that they were safe and received appropriate intervention and support. This included the risk of falls, venous thromboembolism (VTE), diabetes and epileptic seizures. We could not be assured that these patients were consistently receiving safe care.
• A computerised patient care record system had been introduced before staff had completed training on the system, which had resulted in staff not having access to the information that they needed to assess and monitor patient care. There were gaps in records and inconsistencies in the care documentation. The ward staff were experiencing difficulties in sustaining a safe and effective service that met people’s needs.
• Staff did not follow the correct procedure when carrying out an investigation into a fall. They graded the fall as unavoidable. A further investigation was undertaken several months after the incident and the correct process was followed. The fall was graded as avoidable. This meant that the service had missed opportunities to address patient safety concerns in the period between the first and second investigation.
• Systems were in place to report safeguarding incidents. However, staff had not identified or taken action about a patient who may have been at risk of self-neglect.
• There had been several staff and local management changes, which had meant that staff had not had formal supervision or appraisal.

However:

• There were infection prevention and control systems in place to help reduce the spread of infection.
• Staffing levels had recently been reviewed and had been determined using National Institute for Health and Care Excellence (NICE) guidance.
• Multidisciplinary assessments were also carried out prior to the patient going home. This ensured patients’ needs were met and they were not delayed.
• The service had started to use a monitoring tool for pain and four patients we asked told us they received pain free care.
• The service scored higher than the national average in the ward PLACE audit for maintaining the privacy and dignity of patients.
• They positively made changes following feedback from people who used services.

Overall, we rated this service as good because:

• There had been no never events or serious incidents reported between April 2015 and August 2016. Incidents were investigated and reported in line with policy. We saw evidence of the service sharing learning with staff and there was evidence of changes to practice in response to serious case reviews. There was a broad understanding of the duty of candour and evidence of it being implemented. Staff were experienced in safeguarding children and recognising risk, and safeguarding supervision took place on a regular basis. Staffing levels and caseloads were appropriate for the services provided and were in line with commissioned levels. However, there had been problems recruiting staff in children’s therapy services resulting in capacity issues. The risks had been mitigated by temporary actions.

• Staff practised evidence based care and treatment and there was good evidence of effective multi-disciplinary working within the service and with external partners. There were clear and accessible routes into other services. Information technology supported mobile working and a single electronic patient record that was accessible to the multidisciplinary team. Immunisation rates and health visiting performance indicators met the expected targets. We saw optimum completion rates of health assessments for vulnerable children including looked after children and youth offenders. Most staff groups in the service had appraisal rates of between 90% and 100% and the overall rate for the service was 88%. Staff were aware of the principles of consent and we observed this in practice when attending clinics and home visits.

• We observed compassionate care being delivered in clinic, school and home settings. Children used the word ‘kind’ frequently in their feedback on care. Parents told us that they felt they could ask for advice and trusted the information that they were given. The Family and Friends test results demonstrated that children, young people, carers and parents were extremely likely or likely to recommend the service.

• Staff we spoke with had a clear focus on the needs of children, young people, carers and parents. The service planned and delivered services that met the requirements of current child health programmes. Therapy services including physiotherapy, occupational therapy and speech and language therapy, achieved 100% of assessments and interventions starting within 18 weeks. We saw that there was consideration of the diverse communities and public health needs. There was access to translation and interpreting services and staff were aware of local links into services for new migrants and the lesbian, gay, bisexual and transgender community. Services were easily accessible for children and their families and there was flexibility in how these were provided to suit individual need. There were minimal complaints about the service and these were dealt with in a timely manner.

• The service vision and aims were aligned with the corporate vision and staff were passionate about delivering a high quality service. The governance structure had been revised and was in the initial stages of implementation. Executive and service level leadership was visible and open to staff engagement. There was evidence of surveying staff regularly and acting upon negative feedback. Staff were involved in decision-making to support the significant changes planned to integrate health visiting and school nursing services. There was strong engagement with families and children in the community and evidence of acting upon feedback.

However:

• We noted and reported safety and cleanliness issues in the child development centre to management, which were acted upon immediately. There were no child-friendly furnishings or decorations except in the playrooms. Alternative accommodation was being sought at the time of inspection and this issue was listed as a service risk.
• We observed medicines for several children being prepared for administration at the same time in a clinical area. This was highlighted at the time of inspection and procedures were changed immediately as a result. We confirmed that practice had changed during the follow-up unannounced inspection.
• Lack of capacity in the therapy services meant that follow-up appointments could be delayed.
• The escalation route for risks from front-line staff to the board and the criteria for submitting a risk for escalation were not clear.

Overall, we rated this service as good because:

• Dental services were effective and focused on the needs of patients and their oral healthcare. We observed examples of clinicians and teams working together effectively in the service. The service was reviewing its referral system and integrating a triage process to ensure patients received care by the appropriate clinician and at a clinic that met their needs.
• Systems for identifying, investigating and learning from patient safety incidents were in place. There was evidence that lessons learnt from incidents and complaints were shared across the teams.
• Infection control procedures were in place and audits had been carried out. The environment and equipment were clean and well maintained.
• Staff told us they felt supported by their managers, they were informed of the future strategy of the service and had the opportunity to participate in the planning. There were governance systems in place.
• The focus of staff was to provide a positive and caring environment, where patients were at the centre of all they do.
• Patients told us they had positive experiences of care at each of the clinics we visited. Patients, families and carers felt well supported and involved with their treatment plans and staff displayed compassion, kindness and respect at all times. We saw examples of staff caring for families and not just the patient. Patients and their families were appropriately involved in and central to making decisions about their care and the support needed. Staff used imaginative ways to engage younger patients in care.

However:

• The service provided treatment in a hospital setting under general anaesthetic to children, but did not provide paediatric nursing staff to support children’s recovery from anaesthetic in the recovery area in all of the hospital settings. This is recommended by the Royal College of Nursing (2013) to ensure safe paediatric care.
• Staff are required to undertake level two safeguarding children training, however overall only 19% had received this training as of August 2016. The organisation had a trajectory to achieve 100% compliance by 31 March 2017.