First Community Health & Care C.I.C.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

The Care Quality Commission (CQC) carried out a comprehensive inspection of First Community Health and Care C.I.C between the 20 and 22 March 2017.

We inspected this core service as part of our comprehensive Wave 2 pilot community health services inspection programme.

We rated First Community Health and Care C.I.C as Outstanding overall.

Whilst all services were very good and delivered in a truly caring and compassionate way, the children’s services were exceptional at providing services adapted to meet the needs of the community being served.

The organisational culture was open, trusting, caring of the employees and there was a tangible commitment to supporting staff to deliver high quality services. Staff were encouraged to be shareholders and this ownership led to innovation and a real ‘can do’ attitude. All staff we spoke with were positive about the leadership, supported and knew the vision and were very proud ambassadors for the organisation.

First Community Health had a clear vision and strategy that was well understood and supported by staff. Staff were involved in its design and committed to its successful implementation. Staff were loyal to the organisation and excited by, and welcomed the challenges ahead in terms of having a bigger impact on care provision to a larger demographic as part of the STP.

There was a very strong holistic person-centered focus. It was also an outward looking culture in terms of knowing exactly what external services were available and how best to access these services. Staff were empowered to build strong networks with other local healthcare providers, support groups, and charities. Staff also displayed a commendable drive to continuously improve the service through innovation, balanced with meeting people’s social, cultural and individual needs. This ensured that teams were creative in overcoming obstacles to delivering care.

We saw several notable examples of where the senior managers had flexed to ensure that the staff needs were met. Staff knew their executive team well and there was a genuinely open door policy. Many staff worked from the office where the executive team were based, which coupled with the small size of the organisation, led not only to personalised care for patients but also to personalised care of the workforce.

We saw an exceptionally strong commitment to equality and diversity across the organisation, modelled by a part-time Chief Executive Officer and two administrative staff with learning disabilities who were employed on the same terms and conditions as other staff but given high levels of support to fulfil roles they told us, “Had transformed their lives and was the best job ever”. We met with BME staff but were told that each of them felt they were simply members of staff doing their jobs in a supportive organisation. The organisation had considered the Workforce Racial Equality Standards (WRES), was monitoring and considering how best to meet the needs of BME staff but also felt it was more about meeting each member of staff’s individual needs. There was role modelling with a BME Deputy Chief Nurse who had been supported to join a BME Aspiring Director of Nursing Network to enhance their development opportunities. A WRES audit had been carried out and there was an action place to address areas where improvements could be made.

The Board were particularly strong and well informed. They were led by a very confident but collaborative chair. It was clear they understood their roles and could differentiate between operational and strategic management. We saw a real depth and breadth of understanding from the non-executive directors, some of whom were recruited following a skills gap analysis review.

Our key findings were as follows:

• The service encouraged openness and transparency about safety. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence of learning from incidents and a positive incident reporting culture.
• The service assessed, monitored and managed risks to patients who use services on a day-to-day basis. This included daily checking for signs of deteriorating health, medical emergencies or challenging behaviour.
• Staff received up-to-date mandatory training, including information governance and infection prevention and control, to allow them to keep patients safe. There was a high level of compliance with mandatory safeguarding training. The service gave safeguarding sufficient priority and staff knew how to recognise and report concerns to keep patients safe.
• The service planned and delivered care and treatment in line with current evidence-based guidance, standards, best practice and legislation.
• All staff were actively engaged in activities to monitor and improve quality and outcomes. There was a dedicated audit lead in place and a healthy audit culture had been developed in the service.
• First Community had more harm free care than the national and median figures during 2015/16
• During the reporting period the provider supported an average of 96% of people at the end of their lives to die in the place that they choose.
• First Community had also implemented a live performance dashboard that staff could access at any time. This promoted ownership and responsibility of the team performance, facilitated the celebration of success, but easily identified areas for improvement.
• The service routinely monitored and collected information about patient outcomes. The service used this information to improve care. Benchmarking data, where available, showed patient outcomes were similar to national averages.
• Staff, teams and services were committed to working collaboratively and had found innovative and efficient ways to deliver more joined-up care to people who used services. This included strong links with other health care providers, local charities and support groups. They embraced new technology to improve the quality of the service.
• Patients felt involved in their care and treatment and the service encouraged patients to be partners in their care. Staff respected patients' wishes and preferences.
• People’s emotional and social needs were highly valued by staff and were embedded in their care and treatment. Whilst this was evidenced across all services, it was most striking and a prominent feature of the work undertaken by the homeless team.
• The service made reasonable adjustments and took action to remove barriers for patients who found it hard to use or access services. This included patients who had communication difficulties, disabilities and those in vulnerable circumstances.
• Volunteer-run services such as bingo and chair-based exercise classes helped meet patients’ social and rehabilitation needs.
• First Community predominantly used an electronic records system. This was accessible by a wide range of health care professional outside of the organisation and promoted safe continuity of care. The records we viewed were accurate, up to date and fit for purpose.
• The average Friends and Family Test Score for 2016/17 was 4.8 out of 5 stars (96%).
• Across all metrics captured by the staff Friends and Family Test that First Community were better than the national average.
• There were effective processes to take account of comments and concerns. People who used services were confident the organisation would respond positively to any concerns raised. Data demonstrated there were very low levels of complaints in the service. No complaints were escalated to the Parliamentary Health Service Ombudsman (PHSO), this demonstrated good local resolution.
• There was appropriate and effective governance, risk and quality measurement processes. These were widely understood by staff and influenced practice and service delivery. Staff were given direct access to outcome dashboards so they could share the success and identify areas for improvement.
• First Community’s Information Governance Assessment Report overall score for the reporting period was 70% and was graded Green (Level 2). They had an action plan in place for 2016-17 to enable them to achieve Level 3 compliance.

We saw several areas of outstanding practice including:

• There was a commendable proactive approach to understanding the needs of different groups of people and to deliver care in a way that meets these needs and promoted equality. This was most evident in the way the service met the needs of the vulnerable, homeless, Gypsy, Roma and Traveller (GRT) and refugee communities and those in vulnerable circumstances with complex social needs.
• There was a unanimous feeling that every individual member of staff counted and was valued, regardless of their role or position. Staff felt they could genuinely effect change and have a positive impact on the service delivered and the teams they worked in. The staff survey demonstrated very high engagement scores and work satisfaction scores. Data also suggested staff were highly likely to recommend the service to others.
• There was an incredibly open culture with accessible leadership demonstrated by the ‘Floor to Board in 5 minutes’ initiative. Staff really could speak with a member of the executive management team within 5 minutes of identifying a concern or idea, if they had not managed to get local advice or resolution or if they felt their comments affected the entire organisation.
• Staff demonstrated a very high level of awareness of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff made DoLS applications appropriately and in a timely manner and senior staff were well informed and able to discuss individual applications.
• Staff connected with the community through the provider Community Forum; a network of groups and organisations linking together to provide the best possible service locally.
• The provider was proactive in ensuring every patients voice could be heard. They shared ‘live’ feedback on their website/intranet. There had been 18,500 reviews over four years via iWantGreatCare.
• We identified the pro-active care matron pilot scheme with the local acute NHS trust as an area of outstanding practice. This was because the service was taking an active role in working towards reducing emergency department admissions at the acute trust.
• The Council of Governors was an elected group of staff members who took a proactive role in representing the shareholders interests in First Community Health and Care, acting as an essential conduit between shareholders and the Board of Directors. As members of the staff group, the Council of Governors promoted and encouraged participation by the shareholders in the company’s affairs.
• First Community re-invested company savings in a phlebotomy service for local house-bound patients. It proved so successful the services have now been commissioned.
• The provider holds an ‘Outstanding’ Unicef Baby Friendly Award for their work to support breastfeeding mothers.
• The child and baby “Advice Line” innovation saved local NHS partners £130,000pa as well as reducing the need for additional face-to-face health visitor support (worth £70,000pa).
• The NHS staff survey 2016 showed an Engagement score of 4.04 compared to 3.79 for NHS Trusts nationally – putting First Community among the best in UK for engagement.
• We identified the yellow wristband system for alerting staff of patients with additional nutrition needs as an area of outstanding practice.
• The service provided by specialist nurses was frequently described as a lifeline with care widened to include support for the patient and their relatives.

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

Importantly, the provider should:

• that all areas of the Caterham Dene Hospital (particularly the physiotherapy gym) are cleaned in accordance with the national guidance.
• take action to ensure all nursing staff respond to call bells and patient requests for assistance in a way that meets patients’ needs.

Overall rating for this core service Good

• Staff protected patients from the risk of abuse and avoidable harm. A range of risk assessments were utilised by the various clinical teams to assess and manage risk and staff escalated risks that could affect patient safety. We saw robust systems for reporting, investigating and sharing learning from incidents, which included the duty of candour if necessary.
• Overall, clinics were visibly clean and there were appropriate systems to prevent and control healthcare associated infections. We saw that rooms were equipped with sufficient equipment and consumable items for their intended purpose.
• All medical equipment, including those in patient homes were serviced and maintained appropriately.
• Individual patient care records had completed risk assessments. Electronic records always matched with information kept in the patient’s home.
• Staff had a good awareness of policies and procedures, which were based on National Institute for Health and Care Excellence (NICE) guidelines and other national standards.
• The organisation participated in national audits, audits requested by commissioners and internal audits. The services used the results to monitor the quality, safety and effectiveness of care.
• There was a holistic and comprehensive approach to the assessment of patients’ needs including consideration of clinical needs, mental health, physical health and wellbeing and nutrition and hydration.
• Staff were knowledgeable about assessing patient’s mental capacity and consent was obtained in line with policy and guidance.
• Some services collected information about patient outcomes and could demonstrate the effectiveness of their service
• Care was delivered by a range of skilled workers who participated in annual appraisals, clinical supervision and had access to further training as required.
• Multidisciplinary team working was embedded throughout the service and we saw good collaborative working and communication amongst all staff
• Feedback from patients about the care they received was consistently positive. The organisation scored highly in the NHS Friends and Family Test.
• Relationships between patients, their relatives and staff were caring and supportive, and we saw a genuine rapport.
• Care that we observed was truly person centred, with patient’s wellbeing at the heart of care.
• We saw staff respected patients’ dignity and respect.
• Staff were highly motivated and inspired to offer care that made a difference to their patient’s lives.
• Staff explained and ensured that patients and carers had a good understanding of procedures before undertaking them.
• The needs of patients were taken into account when planning and delivering services. Urgent needs were catered for and waiting times and delays were minimal.
• Services were delivered in a timely way with flexibility and continuity of care. There was highly co-ordinated working between other services and teams.
• Reasonable adjustments were made for people with disabilities, learning difficulties and those living in vulnerable circumstances.
• Patients were given information about how to make a complaint or raise a concern. There was a system in place for capturing learning from complaints and we heard examples of changes to the service because of complaints made.
• Services were tailored to the needs of local populations and staff were able to access training specific to the needs of the populations they supported. There was access to interpreters and written information in different languages available.
• Staff felt able to approach their managers with concerns due to the organisation’s open and transparent culture.
• There were governance and risk management systems in place. The senior management team were visible and regularly engaged with staff.
• There was a very positive, supportive culture across all staff groups we spoke with.
• Innovation was encouraged and staff felt empowered to make positive changes. The organisation was pro-active in celebrating staff achievements.
• There was strong and visible leadership who together with the staff were committed to improving patient care.
• Staff were overwhelmingly positive about their experience of working in the organisation and showed commitment to achieving the provider's strategic aims and demonstrating their stated values.

However,

• Recruitment appeared to be a challenge across the organisation, with staff vacancies leading to staff working additional hours, staff covering additional roles and direct impact on patient pathways.
• We saw patients at high risk of pressures ulcers were not being reassessed at correct timeframes.
• There was not a truly consistent approach to pain assessment and documentation. This meant staff could not assure themselves they were managing pain effectively.
• Not all staff knew how to access the translation services and told us they would use the patient’s relatives to translate.

We have given the service an overall rating of Outstanding.

This rating was because

• There were innovative approach to gathering feedback and provide accessible services which resulted in meaningful and continuous engagement with the public and hard to reach groups. New technology was being used successfully to reach children and young people (CYP) that may not have accessed the service through conventional means. Examples of innovations included CHAT Health (a confidential school nurse messaging service for young people aged 11-19.), Advice line (telephone advice line for parents with children and young people ages 0-19), and using social media and text messaging to stay in contact with hard to reach groups and for health promotion purposes.

• Staff were going beyond what was expected of their roles to ensure a wider involvement of healthcare providers, local organisations and agencies and the local community to meet the needs of those it cared for. We met one member of staff who had been contacted by a young person who was struggling to support themselves after leaving care. The member of staff used their own money to purchase electricity on the meter key and took the young person to a local supermarket to buy essentials until proper financial support could be arranged. The member of staff returned the next day to check all was well and then took the young person to a sexual health clinic when they confided that they might be pregnant. The staff member felt anyone would have done the same – even though they didn’t know whether they would be reimbursed for their financial outlay.

• There was a very strong holistic person-centred service. It was also an outward looking culture in terms of knowing exactly what external services were available how best to access these services. Staff were empowered to build strong networks with local healthcare providers, support groups, and charities. Staff also displayed a commendable drive to continuously improve the service through innovation, balanced with meeting people’s social, cultural and individual needs. This ensured that teams were creative in overcoming obstacles to delivering care.

• Children and young people (CYP) were kept safe because there were effective systems and processes to measure harm, and learn and prevent recurrence from clinical incidents. There was an open ‘no blame’ and inclusive culture that made the investigation and learning from such incidents a success.

• There was a very proactive and engaged safeguarding team that ensured effective management and oversight of safeguarding systems and processes. The homeless team provided an exemplary person centred service to those who were classified as homeless or vulnerably housed in temporary hostel, guesthouse, or refuge accommodation.

• The electronic records system supported a multi-disciplinary and multi-agency approach to delivering care. The records we viewed were person centred, contemporaneous and fit for purpose. They also contained evidence of parental input and took account of individual’s cultural, social and diverse needs. Staff had received the appropriate amount of training to be able to do their jobs and there was adequate numbers of competent staff to ensure the service was delivered safely.

• Public feedback was unanimously positive, and there were very low levels of complaints. The quality of the service provided by First Community was recognised and much valued locally. Many parents we talked with had received personal recommendations for drop-in clinics, baby massage and other support services. CYP and their families were able to access the right service at the right time.

• The care delivered reflected national and best practice guidance and data demonstrated good clinical outcomes for those who used the service. Staff were kind, caring and went beyond what was expected of them on a daily basis to ensure every contact was a success.

• The organisation provided services that reflected local need and was continuously evolving to ensure it would meet the ever-changing health and social needs of those it cared for.

• Staff were empowered to provide care that had an multidisciplinary focus and positively engaged with other services providers, councils, Clinical Commissioning Groups(CCGs)and local charities and support groups.

• Governance and risk management systems were fit for purpose. There was very good local and board leadership. Staff felt very valued and cared for, were driven and supported to innovate and improve the service.

Overall rating for this core service Good l

Overall, we rated community health inpatient services as good.

Our findings were as follows:

• The service encouraged openness and transparency about safety. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence of learning from incidents and a positive incident reporting culture.
• The service assessed, monitored and managed risks to patients who use services on a day-to-day basis. This included daily checking for signs of deteriorating health, medical emergencies or challenging behaviour.
• Staff received up-to-date mandatory training, including information governance and infection prevention and control, to allow them to keep patients safe. There was a high level of compliance with mandatory safeguarding training. The service gave safeguarding sufficient priority and staff knew how to recognise and report concerns to keep patients safe.
• The service continually planned, implemented and reviewed staffing levels and skill mix to keep patients safe. The service used regular agency staff to provide continuity of care and we saw appropriate induction processes for temporary staff.
• There was sufficient emergency resuscitation equipment available and evidence of assurances that this was safe and fit for purpose.
• The service planned and delivered care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Regular monitoring and audit ensured consistency of practice.
• The service routinely monitored and collected information about patient outcomes. The service used this information to improve care. Benchmarking data, where available, showed patient outcomes were similar to national averages.
• Staff had meaningful and timely supervision and appraisal. All inpatient nurses had up-to-date professional revalidation.
• Staff demonstrated a high level of awareness of the Mental Capacity Act 2005 and deprivation of liberty safeguards (DoLS). Staff made DoLS applications appropriately and in a timely manner.
• Nutrition was a high priority on the ward, and patients had dietitian support if needed. The service had an effective yellow wristband system to alert staff of patients who had additional nutrition needs.
• We saw that staff respected patients’ privacy, dignity and confidentiality.
• Patients felt involved in their care and treatment and the service encouraged patients to be partners in their care. Staff respected patients' wishes and preferences.
• Volunteer befrienders supported the emotional wellbeing of patients. Visits from therapy dogs also helped improve patients’ emotional wellbeing.
• The service encouraged patients to be actively involved in setting their individual rehabilitation goals to achieve maximum level of independence.
• The provider planned and delivered community inpatient services in a way that met the needs of the local population. The facilities and premises were appropriate for the services being delivered.
• The service made reasonable adjustments and took action to remove barriers for patients who found it hard to use or access services. This included patients who had communication difficulties, disabilities and those in vulnerable circumstances.
• Volunteer-run services such as bingo and chair-based exercise classes helped meet patients’ social and rehabilitation needs.
• The service took complaints and concerns seriously and responded in a timely way. The service shared learning from complaints and took action to try to improve patient care.

However:

• Four patients told us that a small number of staff were not always kind and caring. This sometimes related to staff attitudes towards call bells, particularly at night-time. We saw staff did not always respond to patients’ calls for assistance in a timely way that met their needs. Learning from complaints about call bell responses may not have been fully embedded.
• NHS Friends and Family Test feedback was consistently worse than the national benchmark of 95% for independent community hospitals between July 2016 and January 2017.
• Some areas of the inpatient physiotherapy gym were visibly dirty, with sticky equipment. The service stored several pieces of equipment in the accessible bathroom. This made the bathroom cluttered and increased the chance of germs being spread when staff transferred equipment to other areas.
• Of the two do not attempt cardiopulmonary resuscitation (DNACPR) forms we reviewed, one did not have a review date, and staff had not specified whether the order was indefinite. This meant it was unclear as to if, or when, staff should review the DNACPR order with the patient.