Sirona Care & Health C.I.C.

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question requires improvement. At this assessment the rating has stayed the same. Governance arrangements had been reviewed and updated; however, they were not yet fully embedded across the service. Record‑keeping practice remained variable, as it was influenced by mobile connectivity, time pressures and staff preference.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At our last inspection we found the service had systems for accountability and governance, but this did not result in sustained improvement to services. Staff did not always act on the risk to improve outcomes for patients. As a result, we issued a warning notice for breach of Regulation 17 (governance).

At our last inspection, we identified concerns with staff not completing contemporaneous records during visits. Community nursing staff did not consistently use the mobile electronic systems available and instead recorded information on paper to type up later, which was not in line with provider policy. At this inspection, we found improvement. Where mobile signal allowed, most staff completed records at the time of the visit, including taking wound photographs and entering initial details using the wound care app. Some staff continued to complete written records once back at base or at their home, which was accepted practice by the provider and in support of its flexible and hybrid working policy.

At the last inspection, there were no established key performance indicators (KPIs) for the podiatry service, including the number of patients who could be safely seen. This meant service users were at risk of reduced access due to capacity pressures and staff vacancies, and stakeholders lacked oversight of whether the service was operating safely.

Senior staff told us they still had limited contractual KPIs but had introduced internal measures and a quality lead to monitor compliance, with plans to incorporate these into a dashboard. They reported they were able to monitor some metrics, including waiting times, patient‑tracking information and National Diabetic Foot Audit data. Work was ongoing to strengthen performance monitoring across the service.

A weekly podiatry huddle had been set up to discuss overdue patients for home visits in order of their RAG rating (red, amber and green). At the huddle they also reviewed patients who were due their 12 monthly reviews. The huddle was designed to last 1 hour, and was attended by senior clinical and administration staff. Senior clinical staff were given a patient’s details and asked to make a clinical decision about the timing and type of the next podiatry contact. We were told these decisions were informed by a review of relevant clinical information, drawn from multiple sources as appropriate to the individual patient. This included podiatry clinical notes, Connecting Care records to understand any interventions underway in primary or secondary care, Healthy IO to review up‑to‑date imaging, and Sirona INT records where shared care arrangements were in place. The podiatry huddle had been implemented to support prioritisation and risk oversight, rather than detailed case review, with escalation routes available where a fuller discussion was required. However, from staff feedback and our observations, senior staff were given a patient’s details and asked to make a clinical decision. This staff member may not have seen this patient before and some staff felt this process was not given the time it deserved. This potentially placed patients at risk. At this huddle not all patients were discussed due to time. We fed this back to senior staff following our site visit as the limited time to make clinical decisions about patients they were unfamiliar with, in rapid succession, placed patients at risk.

Podiatry staff told us they had strengthened the criteria for home visits to ensure patients who were mobile attended clinic appointments. This aimed to reduce the number of home visits and increase clinic capacity.

At the last inspection, leaders used an overarching governance tool to record key risks, including podiatry staffing, capacity pressures and deferred visits. These risks had remained on the register for some time without effective action. Although we were provided with minutes of governance meetings showing that risks were discussed and actions followed up. We were only given the front page of the risk register. Without access to the full risk register, we could not be assured that risks were being monitored or reviewed consistently.The provider told us the adult and specialist services risk register provided all risks rated 12 and above.

A new BRAG (blue, red, green and amber) triage tool had been introduced to streamline prioritisation and reduce duplicated processes. Though this work was still being embedded. Staff continued to raise concerns about deferred visits. The service had revised geographic zoning to support senior staff with caseload management. Which was an improvement from the last inspection, but it required time to embed fully.

At the last inspection, we saw several notifications regarding grade 3 and above pressure ulcers where staff have failed to either recognise the wound had deteriorated or effectively escalated this. At this inspection, we saw evidence that improvements with competencies and training had improved but this was ongoing. Improvements had been made to the wound care app and more were planned to make it easier for staff to complete. Specialist wound care nurses were able to monitor wounds on the deteriorating wound dashboard and staff were able to refer to them for advice. Competencies for wound care was part of staff training, and this was overseen by senior staff. This showed compliance was improving.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.