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Provider: Sirona Care & Health C.I.C. Good


Inspection carried out on 18,19, 20, 21 October 2016 and 1 November 2016

During a routine inspection

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

We undertook a planned announced inspection as part of our comprehensive community health services inspection programme between 18 and 21 October 2016. We also carried out an unannounced visit on 1 November 2016 and inspected the following core services:

  • Community health services for adults
  • Community health services for children, young people and families
  • Community inpatients
  • Community mental health services for people with learning disabilities or autism
  • Urgent care services
  • End of life services

Sirona Care and Health CIC also provide adult social care through a number of residential units. These did not form part of this inspection but have been inspected and reported on separately.

During the inspection we visited a variety of locations including all three community hospitals and both minor injuries units. We visited health centres and children’s centres to inspect services for children, young people and families. To inspect the community adults’ services, we went to a range of health centres, went out with district nursing teams to people’s homes, visited health centres and clinics, and met with staff delivering palliative care, accompanying them on visits to meet the patients and families they were supporting. We spent time with the executive, non executive and leadership team, conducting interviews, held focus groups and observed a board meeting.

Staff were cooperative, open, helpful and supportive to us at all stages of the inspection.

Our key findings were as follows:


  • Compliance with training for both adults and children’s safeguarding was variable and not all staff received training at the correct level.
  • The premises at Thornbury Hospital was not fit for purpose. The ward was cramped meaning there was not suitable room for equipment, patient chairs, or adequate space around the beds to perform day to day duties. However, it is recognised that the organisation did not own Thornbury Hospital.
  • There were issues with maintenance of the building at Ash House at St Martin’s Hospital in Bath including delays in issues being rectified. For example, there was no working door bell, paint peeling from walls in toilets, stains on the carpets and the ceiling in the manager’s office had recently collapsed.
  • Within the learning disabilities service, interview rooms did not have alarms at any of the sites. Staff relied on administrative staff being aware that they were using rooms and for them to call for help if needed.
  • Notes were not always stored securely in community hospitals. Notes trolleys were left open and unattended and one trolley did not lock at all.
  • National guidance was not fully followed with regard to patient treatment escalation plans (TEP).
  • Compliance with mandatory training was variable though shortfalls were being addressed by the organisation through the development of a full days training to ease staff release from the work areas. However, compliance varied from 66-91%.


  • There was a good culture among staff for reporting incidents. There were systems in place to report incidents and near misses that staff were familiar with and competent in their use.
  • Staff had a good understanding and knowledge of when to apply the duty of candour.
  • There were adult and children’s safeguarding systems in place to keep patients safe. Policies were in place and staff were aware of their responsibilities in relation to safeguarding.
  • The majority of medicines were stored and administered safely.
  • There were reliable systems in place to prevent and protect patients from healthcare associated infection.
  • Staff assessed and responded to patient risk. Staff completed risk assessments and where patients presented with high levels of risk, an embedded system of multi-disciplinary working meant teams were able to seek specific support .
  • There were business contingency plans in place to respond to emergencies and other major incidents.


  • Patients’ care and treatment were delivered in line with relevant legislation, standards and evidence-based guidance. Staff followed evidence based and current practice when assessing and planning care
  • Where documentation existed we saw that pain assessment and management was integral to patient care and treatment.
  • In most instances, information about people’s care and treatment, and their outcomes, was collected and monitored and was used to improve care.
  • There was participation in relevant local and national audits
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was adherence to the Mental Health Act 1983 and the Mental Health Act Code of Practice
  • A strong multi-disciplinary working approach ensured co-ordination of care pathways and transition arrangements.


  • Services within the community did not consistently document the assessment and management of patients’ pain.
  • Whilst consent to care and treatment was, in most cases obtained in line with legislation and guidance, some staff within the minor injuries units were not entirely familiar with the way in which consent was handled for people who could not make their own decisions and within the children’s services, not all staff were clear about the implications of the age of a child in relation to consent.


  • People were respected and valued as individuals and were empowered as partners in their care. Partnership working, led at all times by the patient and family was observed to be embedded, and routinely applied.
  • Feedback from people who use the service, those who are close to them and stakeholders was continually positive about the way staff treated people. People were truly respected and valued.
  • Staff were often described as going the extra mile and the care people received exceeded their expectations. Relationships between people who used the service, those close to them and staff was strong, caring and supportive.
  • Throughout, people were provided with care that was dignified, respectful and compassionate. Staff took people’s personal, cultural, social and religious needs into account and provided truly holistic care.
  • People were active partners in their care. They were supported to manage their illness whenever possible and were involved in all care decisions.
  • Staff adapted how they provided end of life care to fit around people, so that at all times, patients were involved as much as they wanted to be and were treated with dignity and respect. Staff skilfully balanced humour, honesty and compassion with each situation.
  • People and those close to them were given appropriate and timely support and information to cope emotionally with their condition.


  • Services were planned and delivered to meet the needs of the local communities
  • The equality and diversity needs of people who used the services was met at all times.
  • Services were planned, delivered and coordinated to take account of people with complex needs and those in vulnerable circumstances.
  • There were different approaches to ensure access to the right care at the right time for most people
  • There were systems and processes in place for handling complaints and sharing learning as a result. A dedicated customer care service had been established to ensure the smooth handling and follow up of all complaints and concerns, no matter how they were raised.


  • Waiting times for some services exceeded the NHS England targets of 18 weeks from referral to start of treatment
  • The minor injuries unit in Yate, although providing the service it had been commissioned to deliver, was not able to meet the demand from patients at times. This resulted in frequent early closure of the service.


  • There was a clear vision and set of values in place that were developed with staff and demonstrated by staff at all levels.
  • Throughout the organisation, quality and safety were top priorities and were taken into account whenever financial decisions were made.
  • Progress against strategic objectives were measured through ongoing audit
  • There was strong and well established leadership of the organisation. Reports received at board meetings were subject to scrutiny and challenge. Members and non executive directors held the executive team to account.
  • The organisational ethos of ‘taking it personally’ was developed in conjunction with staff at all levels and was demonstrated wherever the inspection teams went.
  • Staff were empowered to suggest change and develop their own services.
  • Public and staff engagement occurred in all areas of the organisation. Patient feedback was welcomed and encouraged. Patient stories featured prominently at board meetings.
  • The loss of a significant and sizable contract had just been announced. The executive team recognised the impact this would have on staff, services and the remainder of the organisation and were developing plans to mitigate risks and ensure continuity.
  • A quality impact assessment was undertaken for all cost improvement programs with the impact of the saving reviewed throughout the year. Where the saving was felt to affect quality, it was not approved.
  • Services were empowered to be innovative and progressive.


  • Although there were systems and process in place which ensured the governance and risk management of services, in places these required strengthening, most notably in relation to the management and oversight of lower level risks.

We saw several areas of outstanding practice including:

  • All staff in the minor injuries units had been provided with a review of their practice and competence in the last year (annual appraisal). Staff also had monthly meetings with their line manager, clinical supervision, and were supported with training and development.
  • The matron at the minor injuries unit at Yate had been supported over a two-year period to help establish minor injury services within 29 GP practices in South Gloucestershire. This relieved pressure on this already high-demand service and more widely for the healthcare economy in that area.
  • We saw evidence that care provided to end of life patients and those people close to them across the Sirona services was outstanding. Holistic and person centred support was embedded in practice and patients and family were fully involved and informed about all aspects of treatment and care. Relationships were highly valued by both patients and families and staff. The attention to detail and level of care, treatment and support provided by staff far exceeded expectations.
  • Patients with end of life care needs were prioritised at all times and care and support was provided 24 hours a day, seven days per week. Partnership working with patients, families and other professionals and services was evident throughout the service, and this enabled coordinated and responsive care to be provided. Staff at all levels were actively supported to develop their end of life knowledge, skills and practice in order to deliver a high quality service.
  • Staff positively looked for ways to engage patients and those people close to them with the planning and delivery of services and a range of resources had been developed to promote equality of access to the service. Staff worked above and beyond their roles to ensure wherever possible that patients and families achieved their hopes and wishes.
  • The use of reminiscence pods and other activities to stimulate patients living with cognitive impairment within the community hospitals.
  • The community adults service demonstrated outstanding multidisciplinary working across services, with GPs and other external health care providers.
  • Feedback from patients was consistently positive; patients went to great lengths to tell us about their positive experiences.
  • Patients were active partners in their care, and were encouraged to speak about their opinions of their planned treatment. Care 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 and were fully committed to working in partnership with people.
  • The organisation provided a number of bespoke services across their adult community services such as the active ageing service, falls service, emergency care practitioners and blood transfusion and intravenous service all of which had led to positive outcomes for patients.
  • Within the community adults service, staff regularly went the extra mile when caring for patients.
  • The transition planning for young people being undertaken by staff in the Lifetime service was outstanding as was the planning of advance care plans and the support of families in completing these.
  • Sirona provided placements for people with disability or autism who were often previous users of their services. People were offered roles for a period of time to help them to gain skills in the job market and to boost their confidence.
  • The learning disabilities service proactively managed risks for service users who could be detained under the Mental Health Act with other agencies. This had resulted in no admissions to hospital in four years
  • In Bath and North East Somerset staff working in the learning disabilities service had a communication passport in a grab bag that they carried with them to all new assessments, designed to ensure that staff communicated with people when they first met them before they had the opportunity to assess any communication needs.

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

Importantly, the provider must:

  • The provider must improve its compliance rates for level two and level three adults and safeguarding training and ensure that safeguarding training is received at the right level for the role.
  • The provider must ensure that the care records system/s it has in place within the learning disabilities service do not pose unnecessary risk for staff and people who use the services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

CQC inspections of services

Service reports published 28 March 2017
Inspection carried out on 19, 20, 21 October 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 18-21 October 2016 and 27 October 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 19 & 20 October and 1 November 2016 During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on 18 19 20 & 21 October 2016 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 19 & 20 October and 1 November 2016 During an inspection of Reference: Urgent care services not found Download report PDF (opens in a new tab)
Inspection carried out on To Be Confirmed During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
See more service reports published 28 March 2017