Sirona Care & Health C.I.C.

Updated 9 February 2022

Established in October 2011, Sirona Care and Health Community Interest Company are the sole provider of NHS and local authority funded adult and children’s community healthcare services across Bristol, North Somerset and South Gloucestershire (BNSSG). Sirona is a not-for-profit social enterprise committed to serving its communities and funded by the NHS and local authorities. Sirona does not have shareholders and does not pay dividends; any surplus is re-invested back into the community.

Initially providing adult health and social care in the Bath and North East Somerset region, Sirona took over provision of the community learning disability service in South Gloucestershire in October 2013, and later community health services in April 2014. In addition, the service took over the provision of community children’s services in Bristol and South Gloucestershire in April 2016. This service is jointly provided by Sirona, Avon and Wiltshire Mental Health Partnership NHS Trust, University Hospital Bristol NHS Foundation Trust, Barnardo's and Off the Record, as part of the Community Children’s Health Partnership.

In April 2020 Sirona took over the provision of services previously provided by Bristol Community Health and North Somerset Community Partnership and the children’s community paediatric services in Weston Area Health Trust.

Services span across all ages from birth to end of life and range from preventative and pro-active support to keep people as well and independent as possible through to complex care and support in individuals’ own homes to prevent admission to hospital or to support people following discharge. Sirona services are provided across 100 different locations as well as in individual’s homes and in schools.

Sirona provide the following core services:

• Community mental health services with learning disabilities or autism
• Community health services for adults
• Community health inpatient services (four inpatient rehabilitation units)
• Community end of life care
• Community health services for children, young people and families
• Urgent care services (two minor injury units and one urgent treatment centre)

Sirona are registered for the following regulated activities:

• Accommodation for persons who require nursing or personal care
• Diagnostic and screening procedures
• Personal care
• Treatment of disease, disorder or injury

Between October and November 2016 we undertook a planned announced inspection as part of our comprehensive community health services inspection programme. We inspected all core services and rated the provider as good overall and in the effective, responsive and well led key questions. We rated the provider as requires improvement in the safe key question and outstanding in the caring key question.

We carried out this unannounced inspection of two of the community health core services provided by Sirona as part of our continual checks on the safety and quality of healthcare services.

We also inspected the well-led key question for the provider overall.

Our comprehensive inspections of organisations have shown a strong link between the quality of overall management of a provider and the quality of its services. For that reason, we look at the quality of leadership at every level. We also look at how well a provider manages the governance of its services – in other words, how well leaders continually improve the quality of services and safeguard high standards of care by creating an environment for excellence in clinical care to flourish.

Regarding this inspection report it should be noted that this inspection did not include a Use of Resources rating.

Although Sirona Health & Care Community Interest Company is not an 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.

Services inspected

We did not inspect community mental health services with learning disabilities or autism, community health services for adults, community end of life care or community health services for children, young people and families at this time. The provider had recently started providing a wider range of services across the geographical area and continued to be in a period of transition, so it was not appropriate to inspect these services at this time. Each of these services are currently rated good, apart from community end of life care, which is rated as outstanding.

We inspected the community inpatients and urgent care services. These had not been inspected since 2016. We wanted to follow up on issues raised at the previous inspection for community inpatients and in response to the new services not previously inspected. We also inspected urgent care in response to the recent additional pressures on the service during the Covid-19 pandemic.

Sirona has four community-based rehabilitation services (community inpatients):

• The Henderson Rehabilitation Unit is a 20 bedded inpatient rehabilitation service on the top floor of The Grace Care Centre in Thornbury. The service specialises in the provision of services for persons who require nursing or personal care, diagnostic and screening procedures and treatment of disease, disorder or injury.
• Skylark Rehabilitation Unit is a 30 bedded inpatient rehabilitation service located on the top floor of The Meadows care home. It opened in February 2018 and is run in partnership with North Bristol NHS Trust and South Gloucestershire Council. Access is available to all adults over the age of 18.
• Elton Rehabilitation Unit is an eight bedded unit in North Somerset Community Hospital for patients who no longer require acute hospital care but are unable to safely return to their usual place of residence.
• South Bristol Rehabilitation Unit is a 60 bedded inpatient rehabilitation service situated across two wards in the South Bristol Community Hospital. On 1st April 2021, the management of the wards was transferred to Sirona from University Hospitals Bristol and Weston NHS Foundation Trust (UHBW). Ward 100 currently provides 30 beds, including for people post stroke and for people requiring intensive rehabilitation following an acute inpatient stay. Ward 200 was not fully opened due to staffing shortages and the future purpose of the unit will depend on the needs of the local region.

Sirona Care & Health CIC provides urgent care services through a minor injuries service for people in South Gloucestershire, a minor injuries service in Clevedon, and an urgent treatment centre in South Bristol.

In rating the provider, we took into account the current ratings of the four services not inspected this time. Following this inspection we rated safe as requires improvement, effective, responsive and well-led as good, and caring as outstanding.

Our rating of services stayed the same. We rated the organisation as good because:

The organisation had a leadership team with a range of skills, abilities, and commitment to provide high-quality services. They recognised the training needs of managers at all levels, including themselves, and worked to provide development opportunities for the future of the organisation. They had identified a need to further develop and add to the leadership team, for example, a Digital Director was being recruited.

The organisation had worked flexibly and with a commitment to patient safety through the pandemic to keep patients and staff safe and well. Their commitment to patient care was at the heart of all their work. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care. The commitment to working flexibly and putting patients at the centre of everything they do was recognised and commended by system partners.

Senior leaders visited all parts of the organisation and fed back to the board to discuss challenges staff and the services faced. The organisation made sure that it included and communicated with patients, staff, the public, and local organisations.

The organisation was committed to improving services by listening and learning when things go well and when they go wrong, promoting training, research and innovation and using this learning to improve practice. Staff managed safety incidents well. There was learning from incidents to prevent any reoccurrence.

Staff felt respected, supported and valued by their line managers. They were clear about their roles and accountabilities and focused on the needs of patients receiving care.

Staff treated patients with compassion and kindness, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

Staff were focused on the needs of patients receiving care and were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services to meet the needs of local people. All staff were committed to improving services.

However:

The organisation had undergone considerable change and growth at the start of the pandemic. While they had a clear strategy and vision for developing and bringing the organisation together, this had been inevitably delayed due to the pandemic. The organisation now needed to move forward, at pace, with their new strategy and transformation of the organisation.

The organisation had identified that it needed to improve governance arrangements and plans were in place to revisit these. The board assurance framework was still in development, and further work was required to ensure it gave the board a high level of assurance. In addition, further improvements were needed to improve the quality of data, some improvements had been made but local managers needed increased oversight of information to ensure they were monitoring services to drive improvement.

The organisation had a structure for overseeing performance, quality and risk, with board members represented across the divisions. However, not all senior leaders were confident that the senior leadership team had oversight of all the key risk areas. While the risk management software used within the organisation had been updated, it was acknowledged that around 50% of the risks on the risk register were overdue for review as a result of the pressures on capacity and resources.

While the service had an open and supportive culture, there was work still to be done to bring the organisation together as one. Some staff, whose services had recently joined the organisation told us they did not always feel valued and felt that senior leaders were not visible or involved in their services.

While the urgent care service had the required staff numbers for the contract to care for patients and keep them safe, the increased demand on the service due to the pandemic meant that staff were not always able to see patients in the required timescales to keep them safe.

Staff at the urgent care services did not consistently assess risks to patients in a timely manner. At South Bristol Urgent Treatment Centre we found that some patients were not being triaged for long periods of time which increased the risk of a condition deteriorating. Staff were not consistently using recognised tools to monitor patients at risk of deterioration. Staff provided patients with pain relief but did not consistently monitor pain levels to support patients.

Storage facilities in Henderson rehabilitation unit were limited. Stocks of continence aids, equipment, gloves and furniture were kept in the lounge, corridors and bathrooms. There was limited space for therapies. Medicine systems on the unit were not safely managed. Stocks of needles and syringes were accessible to visitors and patients. Medicines were administered from an unlockable trolley which created a potential risk.

Patients’ privacy and confidentiality of information was not respected in Henderson and in South Bristol Rehabilitation Units. Personal details, health and care needs were accessible to visitors and staff on bedroom doors or whiteboards.

How we carried out the inspection

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

Before the inspection visit, we reviewed information that we held about the services and reviewed a range of information.

During the inspection visit to urgent care services, the inspection team:

• visited two minor injuries units and one urgent treatment centre
• looked at the quality of the environment
• spoke with 25 people who were using the service
• spoke with four managers
• looked at 31 treatment records of people including medicines records; and
• looked at a range of policies, procedures and other documents relating to the running of the service.

During the inspection visit to community inpatient services, the inspection team:

• visited Henderson, Skylark, Elton and South Bristol rehabilitation services
• spoke with ward managers at all locations and in South Bristol Rehabilitation Unit the team spoke with the registered manager
• carried out a tour of the environment and checks of clinical areas in all locations
• spoke with 12 people who used the service and a family member
• participated in and observed organised activities
• spoke with 15 staff including nursing staff, agency, support workers and reception staff
• spoke with a hotel service manager, operations coordinator and discharge coordinator
• spoke with a GP, occupational therapist and physiotherapist and pharmacy technicians
• reviewed 26 care records and 21 treatment records
• reviewed a number of meetings minutes and
• looked at a range of policies and procedures related to the running of the service.

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.

Updated 28 March 2017

Overall rating for this core service

We rated community health services for adults as good because:

• There were effective incident reporting systems in place and staff reported they received feedback and learning from these.
• Staff had good knowledge of safeguarding procedures and felt supported in raising any safeguarding concerns
• Good medicines management protocols were in place to keep patients and staff safe.
• Equipment was available, had been checked and was serviced regularly.
• The needs of patients were assessed, planned and delivered in line with best evidence based practice using recognised assessment tools in most cases.
• Multidisciplinary team working was embedded throughout the service and referrals to different healthcare professionals were coordinated and efficient.
• Feedback from patients was consistently positive, patients went to great lengths to tell us about their positive experiences.
• We saw patients who were active partners in their care, and were encouraged to speak about their opinions of their planned treatment.
• Care that we observed was truly person centred, with patient’s wellbeing at the heart of care.
• Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.
• Staff were fully committed to working in partnership with people and made this a reality for each person.
• Patients were given information about how to make a complaint or raise a concern. There were systems in place to evaluate and investigate complaints.
• There was strong local leadership in place. Staff felt able to approach their managers.
• There were governance and risk management systems in place.
• There was a very positive, supportive culture across all staff groups we spoke with.
• The organisation listened to staff and looked to ways to improve and be innovative across their services.

However:

• Individual care records did not always have risk assessments reviewed and electronic records did not always match with information kept in the patient’s home.
• Staff did not always update records contemporaneously due to connectivity and confidentiality issues.
• Not all staff were compliant with mandatory training in safe systems, processes and practices.
• In some teams staffing levels were below established numbers which meant substantive staff had to work extra hours to cover the workload. The organisation was continuing to advertise and recruit to posts. In some clinic based services, despite being staffed to commissioned levels, there were long waiting lists. the shortage of staff had led to long waiting lists that were The lists were triaged to ensure patients with urgent needs were prioritised.
• The service did not always monitor the completion of timely assessment of risks to patients.
• Some bespoke services that needed specialist staff to run them were not able to be offered if that person was on leave or off sick. Although patients were offered another appointment with an alternative appropriate service.
• There was inconsistency across the two local authority patches in which Sirona worked. This meant different systems were in place in different areas making it difficult to provide consistent and meaningful audit data and an overview of risks across the services.

Updated 28 March 2017

We rated children young people and families services, overall, as good because:

• There was a positive culture around incident reporting which helped promote learning and service improvement for children and families. Staff said they received feedback from reported incidents when this was appropriate and were told what actions were taken.

• There were arrangements in place to safeguard children from abuse that reflected the relevant legislation and local requirements. Staff understood their responsibilities and were aware of the provider’s policies and procedures.

• People’s needs were assessed and care and treatment was delivered in line with legislation and evidence based guidance. We saw numerous examples of best practice being identified, shared with colleagues and delivered.

• There were some outstanding examples of the planning for transition being undertaken. This included the Lifetime service who undertook planning for transfer to adult services and the Bath & North East Somerset (B&NES) speech and language team who were providing transition reports for people with autism moving into further education or going on to university.

• The provider encouraged innovative practice. One of the school nurses had developed an app to help young people make informed choices regarding sexual health and contraception.

• We observed care, support and advice being delivered by a variety of staff in a compassionate and caring manner at all the locations we visited. We had feedback and comments from children and families that was positive about the staff they received a service from. People told us that staff took the time to explain and ensure they understood the care and treatment they were involved in providing.

• The services which Sirona were commissioned to provide were planned to meet the needs of the local population. For example Sirona, as part of the Community Children’s Health Partnership, had worked with a charity in developing a participation strategy. This strategy outlined how children, young people and their families could be involved with service feedback, development and improvement.

• The Lifetime service provided specialised, highly valued care and support to approximately 250 children with life limiting conditions and their families over a wide geographical area. This included some outstanding practice around advance care planning for children and families.

• Sirona had a vision and set of core values that were well promoted and known to staff. Staff were proud of the organisation and the services they were involved in providing. Because the transfer of the Community Children’s Health Partnership had only taken place on an interim basis, Sirona and the other partners had not introduced a new service vision and strategy. Instead, they were focusing on continuing to deliver the service while the contract tender process was being completed.

• There were numerous examples of staff engaging with the users of services to gain feedback and use this information to influence service development.

• We saw examples of teams and individuals engaged in improving their services and its delivery through research and the sharing of learning and participating in innovative projects.

• However:

• There were some shortfalls in the safeguarding training updates being completed by some teams.

• The support staff working within the Lifetime service were being trained to safeguarding level two when the national recommended level for staff lone working in this type of situation is level three.

• We saw examples where staff were not following the required infection control protocols.

• There were shortfalls in the systems for storing of medication used by the sexual health nurses working in the schools.

• There were inconsistencies in the use of risk registers and the understanding of the process for escalating concerns.

Updated 9 February 2022

Updated 28 March 2017

Overall, end of life care and treatment was rated as outstanding because:

High quality, effective and responsive treatment and care was evidenced as established in practice and provided to patients and those people close to them. National guidance and best practice was seen to be understood and followed. Staff at all levels were well supported and encouraged to develop their knowledge and clinical skills.

The majority of Sirona end of life care was provided in patients’ homes by district nursing teams, most of who were based with GP surgeries. End of life care was also provided within the three community hospitals located in Bath (St Martin's Hospital), Paulton and Thornbury.

There was a truly holistic approach to care and support to patients and those people close to them. Pain and symptoms were regularly reviewed and management plans put in place. Staff proactively and consistently looked for ways to ensure wherever possible, that patients and families hopes and wishes were achieved. Across the services we observed numerous examples of staff who worked in partnership with patients and collaboratively, flexibly and effectively with other professionals, teams and services to provide coordinated care.

Processes were in place to promote equality of access to end of life treatment and care regardless of each patient’s individual differences or personal circumstances. This included the development of end of life care plans for patients with particularly complex or vulnerable needs, and staff training to provide this.

There was a clear end of life strategy in place which was based on service user feedback, national strategy and with local commissioners input. Identified goals and action plans were seen to be kept under regular review. The service was well led and staff were proud of the end of life treatment and care they provided.

Care was safe. Patients had risks assessed, reviewed and actions put in place. Medicines to manage pain and other symptoms were prescribed and provided in advance of requirement. Staff had access to a range of end of life training and were well supported in their roles.

The culture was ‘can do’ and positive. Patients and those people close to them were consistently highly satisfied, with reports that the level of care and attention to detail far exceeded expectations. Practice was truly holistic, patient centred, compassionate and sensitive at all times.

Some improvements were required to the detail recorded on treatment escalation plans and to systems and processes used to monitor and evaluate risks and quality information specific to end of life patients. Improvements were required to the compliance level of staff with safeguarding children and vulnerable adults training.

Updated 9 February 2022

Updated 28 March 2017

Sirona is a community interest company that provides community health and adult social care services and was established in October 2011. Sirona provides a number of services to people with a learning disability including health services and social care.

This inspection focussed on the health services that Sirona provided to people with learning disabilities. The complex health needs team in Bath and north east Somerset (B&NES) and the community learning disability service in south Gloucestershire both provide multidisciplinary services to work with people who have a learning disability who require support for complex health needs including mental health care.

The south Gloucestershire service has a hydrotherapy service attached to it.

The complex health needs team is commissioned by B&NES clinical commissioning group and the south Gloucestershire community learning difficulties team is commissioned by south Gloucestershire clinical commissioning group. Each service is commissioned separately with specific service requirements.

We rated Sirona community mental health services for people with learning disabilities as good because:

• Service users told us that staff were supportive and caring, treating them with dignity, respect and kindness. Service users felt that staff listened to them. Carers commented that staff were interested in them and the service users as people. Staff displayed warmth and genuine interest in people using the service. This was evident for all staff within the teams.
• The service used interventions in line with National Institute for Health and Care Excellence (NICE) guidance delivered by a diverse and skilled multidisciplinary team.
• Service users were seen within four weeks from referral to the service. Service users, their carers and social care providers all said that staff were accessible quickly when they needed them.
• There was clear leadership evident from team leaders and the divisional manager that was respected and valued by staff within the service. Staff we spoke with were very complimentary about the team managers and the support and direction they give the teams.

However,

• Care records were stored on multiple systems and this meant that important service user information was not easily available to staff. Although daily record entries were of a good standard, staff were not readily able to identify where risk assessments and care plans were kept.
• In B&NES there was a lack of oversight of each service user’s care (other than for those receiving care under the care programme approach) as community nurses did not undertake the care coordination role as in south Gloucestershire. Staff told us that this provided some risk for service users and left staff feeling that they worked in isolation