East Coast Community Healthcare 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.

Letter from the Chief Inspector of Hospitals

The Care Quality Commission (CQC) carried out a comprehensive inspection of East Coast Community between the 1st to 4th Novmeber2016, with an unannounced inspection on 17th November 2016.

This community enterprise company provides a number of NHS community services to the people of Great Yarmouth, Lowestoft and surrounding areas as well as some services across Norfolk and Suffolk. During our inspection we visited the a number of registered locations as well as a number of small clinics and services run across the provider.

Prior to undertaking this inspection we spoke with stakeholders, and reviewed the information we held about the provider. The provider had undergone change since its inception in 2011 including the reduction of the number of inpatient beds it provided alongside an increase in the provision of GP services. We visited the Beccles Minor Injury Unit (MIU) and found that this service was operating as an extension to primary care rather than an MIU as laid out in guidance. There was an ongoing consultation about the service.

We inspected three core service; community health services for adults,

Our key findings were as follows:

• An organisation that was changing to meet the needs and commissioning environment of healthcare in Great Yarmouth and Waveney and surrounding areas.
• Staff engaged with the organisation they worked for with over 70% owing a share of the company, above the average for a community interest company.
• There was an open culture for reporting incidents. Learning from incidents were identified and actions taken to reduce the chances of them reoccurring. However, we found that not all staff were made aware of learning from incidents.
• Good infection control, practices were evident across the services. Staff were aware of safeguarding principles and had the appropriate level of training.
• Mandatory training was above provider target in almost all areas.
• Care was evidence based and followed national guidance and best practice.
• There was effective multidisciplinary working throughout the services both within the organisation and with external professionals, services and partners.
• We found staff to be very caring. Patients were always treated with dignity and respect. We saw some examples of staff offering flexibility in their services to meet the emotional needs of patients.
• Friends and Family Test scores were positive across the series though sometimes on a low response rate.
• Services were designed to meet the needs of local people. Staff frequently flexed their service to meet individual needs of patients on an ad hoc basis.
• Access to services was good. There were drop in services for some clinics and other services such as Hospice at Home and community nursing seeing many patients within 24 hours of referral.
• Staff respected local leadership and felt well supported. They all spoke highly of senior management during the inspection though staff survey results showed they felt a lack of engagement from the executive team.
• There was a governance structure in place that enabled directors and senior leaders to monitor and manage risk, plan and strategise and provide assurance to themselves as well as stakeholders.
• There was a clear vision and strategy for the provider and its services. Senior leaders were aware of the risks facing the organisation which the strategy reflected.

We saw several areas of outstanding practice including:

• There was an increased use of self-management programmes in some services with a focus on patient outcomes.
• Staff in the hospice at home service demonstrated a sensitive, compassionate and caring approach to patients in their care. Staff gave us examples of how they went ‘the extra mile’ to meet each patient’s individual needs and preferences.
• There was increased integration of services particularly in palliative care and partnership working with acute trusts. The diversification into other services such as GP’s offered greater scope for the integration of services.
• Free baby life support training was offered by the health visiting teams.
• There was a breast feeding peer support team which offered support out of hours via telephone.

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

The provider should:

• Ensure there is documentation regarding the distribution of multivitamins in line with the Governments “Healthy Start Programme”.
• Ensure completion of the child’s health record, “red book”, and note taking procedures when on home visits are consistent.
• Ensure the waiting area for children attending speech and language therapy (SaLT) at Shrublands is child friendly and children do not have easy access to stairs through a set of unsecured double doors.
• Ensure LAC are meeting targets for initial health assessments and annual reviews.
• Ensure staff were aware of audit outcomes such as harm free care.
• Ensure that all patients risk assessments are properly reviewed.
• Ensure all equipment is properly checked and calibrated.
• Ensure all staff are aware of incidents which have occurred across the CYP team and evidence sharing and learning from incidents.

Professor Sir Mike Richards

​Chief Inspector of Hospitals

Overall, we rated East Coast Community Health as good for Adult Community Services because:

• Patients were protected from harm with effective infection prevention and control processes in place and there was evidence of robust investigation of incidents and good dissemination of lessons learned.

• Staff had the appropriate skills and knowledge for their roles and received regular mandatory training and supervision. The organisation actively supported staff to develop and extend their knowledge and competencies, and supported staff with external training and secondments.

• Patient treatment was evidence and national guidelines based and staff met key performance indicators ensuring patients received the right care at the right time.

• There was excellent demonstration of multidisciplinary working within the organisation and with external agencies such as local acute care providers and adult social care.

• Staff treated patients with kindness and compassion and respected patient’s dignity at all times. We saw staff involving patients and their families in decision making about their care and providing emotional support with great depth of understanding.

• We saw staff in the hospice at home team completing care visits for patients near the end of their life with kindness, sensitivity and compassion. Staff tailored assessments and treatment to each patient’s individual needs and made sure that each patient’s wellbeing was their priority.

• The staff covered a diverse geographical area but had a good understanding of the differing needs of the communities they served. They made adjustments and allowances to account for patient preferences.

• The hospice at home service provided visits to patients that were flexible dependent on patients’ needs and preferences.

• Complaints were investigated and managed appropriately in a timely manner with learning identified shared with staff.

• Staff were supported with strong local leadership in the community nursing and OOH teams and felt valued by their teams and the organisation.

• The organisation was pro-active in celebrating staff achievements with several members of the adult community teams receiving awards recently.

However:-

• We had concerns regarding patient safety following the temporary suspension of twilight shifts for the community nursing service due to staff shortages. This was being monitored daily. There were six whole time equivalent qualified community nursing vacancies and one band seven post vacant. There was also a high level of sickness which had impacted on workload.

• Individual risks to staff were attached to the patient’s electronic record and there was no local risk registers to monitor local risks, therefore we were concerned that there was limited oversight of these risks. There was a lack of oversight of risk assessments relating to individual patients.

• We found three items out of 14 pieces of equipment in use that were not fit for purpose because they had failed or were out of date for maintenance testing.

• There were rural areas where staff did not always have connectivity to the live electronic patient records system and they were unable access or update patient information. Patient risk assessments were not always completed or reviewed appropriately.

• There was a disconnect between the junior staff and the executive team due to poor cascade of information. Junior staff had little or no knowledge of audit or process managed by the executive team, although all the staff we spoke to were aware that they could attend governance meetings, none of them had done so.

• Hospice at home staff were not engaged in interpretation of audit at a local level and there was limited audit of patient outcomes. We did not see evidence of audit being used to drive improvements in the service. However, we acknowledge that the hospice at home service had only recently been set up.

Overall, we rated East Coast Community Health as good for Children’s and Young People’s services because:

• Services delivered by the provider were safe. There were procedures in place to protect vulnerable service users, record keeping was safe and secure and registers of “at risk” children ensured they were easily identifiable. There were good infection control procedures in place and staffing levels were close to establishment.

• Services were effective, evidence based and focussed on the needs of children and young people. We saw examples of good multidisciplinary work. Care and treatment was evidence based, and there were policies and procedures in place to support staff and ensure that services were delivered effectively and efficiently. Parents told us that staff displayed compassion, kindness and respect.

• Services delivered by the provider were caring. Staff were dedicated to the families they supported and worked hard to ensure that patients received the best treatment and support possible. Patients were involved in decisions and understood the services being delivered to them. Staff undertaking home visits were dedicated, flexible, hardworking, caring and committed often going the “extra mile” to support the families in their care.

• We found the service was responsive to needs of children and families. Multidisciplinary team working, including external partners, ensured children and young people were provided with care that met their needs.

• Overall the children and young people’s service was well led.The board and senior managers had oversight of the reported risks and had measures in place to manage these risks. Staff felt well supported by their local managers and felt being a shareholder was something that enabled them to take more control of their organisation.

However,

• Policies and procedures to keep staff safe at the end of the working day were not embedded, completion of the child’s health record “red book” and note taking on home visits was inconsistent. There was little evidence of learning from incidents at team level and mandatory training levels were not meeting provider target.

• The numbers of people who responded to the Friends and family test were low and none of the people we spoke with were aware of how to raise a complaint. There was little or no feedback and sharing of incidents, audits, performance and local risks at team level and none of the staff we spoke to were aware of risks in their areas for their service. Staff satisfaction and morale within the service was low and 20% of staff we spoke with said they felt stressed.

Overall, we rated community inpatient services as good. Safe, effective, caring, responsive and well-led all received good ratings, This was because:

• Clinical areas were visibly clean and staff complied with infection control procedures.

• Medicines were stored securely and staff completed appropriate checks of controlled drugs.

• Staff understood their responsibilities in terms of duty of candour (a regulatory duty that relates to openness and transparency) and in terms of reporting incidents and safeguarding concerns.

• Mandatory training compliance was good. We saw records to show that mandatory training for inpatient staff in October 2016 was 95.98%.

• Staff gave us examples of national guidance that was relevant to their practice and implemented these guidelines. For example, nursing staff completed a falls history for any patient over the age of 65 admitted to the ward. This was in line with National Institute of Health and Care Excellence (NICE) clinical guideline CG161 Falls in older people: assessing risk and prevention.

• Patients told us nursing staff managed their pain well. Nursing staff completed intentional rounding, which meant that patients were asked about their comfort and well-being a minimum of every four hours and more often if needed.

• Staff compliance with supervision and appraisal was good. We saw records to show that 100% of nursing staff on the ward had completed an appraisal in the last year.

• There were positive working relations between different members of the multidisciplinary team. There were formalised meetings in place for the multidisciplinary team to share information on patients’ care.

• Results from the NHS Friends and Family Test were positive. From September 2015 to August 2016, there were nine months where there were sufficient patient responses received to calculate results. In six out of these nine months, the inpatient service scored 100% for the question “Would you recommend this service to friends and family?”

• Staff worked with other teams in the organisation and with the local acute hospital to improve patient flow and to make sure that patients received the right level of care in the right place. For example, senior staff told us how they worked with the local out of hospital team to ensure that patients were triaged appropriately to either the community hospital or to be supported at home.

• There was a robust process in place for handling complaints. Senior staff gave us examples of learning from complaints and shared this learning with staff at team meetings.

• There were governance processes in place for sharing information with staff on the ward and escalating information to executive level through the integrated governance committee.
• We saw a local risk register, which included identified clinical risks and actions to mitigate them.

However:

• There was no clear documentation of safety checks for the resuscitation trolley before 27 October 2016. Senior staff were aware of this and had put a new safety checklist in place to ensure that staff documented safety checks clearly. We followed up on this at our unannounced inspection on 17 November and found that staff had consistently completed the new safety checklist every day.

• The temporary inpatient ward (Laurel ward) was originally designed for patients with mental health needs. This meant that there were some features of the environment that were not ideal for patients using the community inpatient service. The layout and size of the ward also meant that there was very limited space to store equipment. We saw several pieces of equipment stored in corridors, including two transfer aids. This meant that there was limited space for patients and staff to move through corridor areas. Senior staff were aware of the limitations of the environment and had put measures in place to reduce risks.

• The root cause analysis for a serious incident on the ward lacked a detailed analysis of the underlying causes of the incident. This meant that we were not assured that learning from serious incidents was always robust.
• Staff told us that there was a lack of engagement from senior leaders in the organisation.