Sirona Care & Health C.I.C.

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from avoidable harm. At our last inspection we rated this key question as requires improvement. At this inspection, the rating has remained the same as requires improvement. This meant people were at risk of avoidable harm and we found not all staff had the competencies, knowledge and skills to recognise deteriorating patients and/or their wounds.

The service was in breach of the legal regulation regarding staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff we spoke with understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally. However, not all staff were reporting incidents for example, recognising when a wound was deteriorating and completing an incident form. Whilst these incidents had been investigated and actions taken, some incidents were still happening with similar themes still occurring.

The organisation had a clear process for the reporting of, feeding back and identifying learning from adverse incidents. We spoke with staff who had varying levels of responsibility within this process. It was clear that the system was embedded, and staff were confident in its use. There were systems whereby themes that were captured were fed back to teams in meetings and the shared learning discussed. Staff told us they were confident in the effectiveness of the system. However, we found incidents where deteriorating patients wounds were still not being identified quickly resulting in harm to patients.

Staff in podiatry had reported a series of incidents where they believed patients had come to harm because of delays in care. A patient safety investigator had carried out a thematic review of 5 incidents and determined 1 needed to be thoroughly investigated and was upgraded to a patient safety incident investigation (PSII). The 4 remaining incidents were reviewed using the providers other processes as 2 of the 4 were possibly related to staff competencies.

One incident in podiatry showed 1 patient had come to avoidable harm from multiple failings across the system including nursing care and podiatry as well as from other local NHS providers. The final report showed there had been systemic failure on the part of the podiatry service and community nursing teams, coupled with a lack of process to monitor on going follow ups and referrals. Capacity issues within the podiatry service meant follow ups were late and community nurses who attended the patient as part of shared care, lacked the skills and knowledge to identify when diabetic patients’ feet were deteriorating.

Action taken following this incident included the introduction of a weekly safety and review huddle attended by all podiatrists and administration staff from across all 3 regions. Staff reviewed all patients based on risk and review times and checked both their Sirona and other electronic care records to ensure the patient was given the appropriate risk rating. Staff explained these had been a recent development but were assured it was an effective way of making sure patients were being allocated the correct level of staff member within the correct time frame. This ensured patients were being followed up for care on a risk basis and in a timely manner. However, staff explained they often attended this meeting whilst on their lunch breaks as there was no other time in the working day to accommodate it. Staff told us this impacted on their well-being.

We reviewed a sample of 29 incidents in podiatry. Of these incidents, we saw 19 incidents that highlighted multiple delayed appointments, failure to escalate concerns through shared care and unactioned podiatry referrals. Of the 4 incidents graded moderate or above, only 1 was investigated through Patient Safety Incident Investigation (PSII) and after-action review.

Of the 29 incidents we reviewed, we saw 4 incidents where it was specifically mentioned as grade 2 or above pressure ulcers. (pressure ulcers are graded to determine the damage to the skin and surrounding tissues, 2 and above mean they are open wounds and starting to extend deeper than the skin). Within the incident report we saw evidence of delayed Waterlow score (pressure ulcer risk assessment tool) and Malnutrition Universal Screening Tool (MUST) (risk assessment for malnutrition) assessments.

The podiatry service had several similar incidents centred around delays in patients receiving follow up care. A patient had shared care with the community nurses as and the podiatry service. Staff in podiatry explained there had always been a focus on patients who needed to be seen at 1 and 2 weeks which often left other patients waiting longer and, in some cases, up to 4-6 weeks which meant delays in their care. Shared care between these 2 services was supposed to act as a safety net, but there was also evidence that community nurses were failing to pick up on patients with deteriorating wounds to their feet.

A safety huddle had been introduced weekly to review all patients (including those who had delayed visits), but in the meeting we attended, the team did not manage to get through all the patients who were experiencing delays. We were not assured there was any other review of patients. All patients were RAG (Red, Amber, Green) rated, (this is where patients were assessed by a set criteria based on red, amber and green to determine their risk) but as demonstrated in the 29 incidents we reviewed, podiatry patients can deteriorate very quickly and longer if follow up patients were not having their RAG rating reviewed. There was no assurance they were not deteriorating while awaiting either a review or a follow up appointment.

There was some evidence lessons had been learnt because of serious incidents. However, we were not assured lower harm incidents and near misses were being reviewed as part of a wider, larger view of the podiatry service. Reports identified actions which needed to be taken but did not evidence that actions were being taken forward. The podiatry service action plan incorporated actions from the previous peer review and service transformation actions. This was overseen by the Quality and Outcomes Committee. Following the PSII this action plan was incorporated with the recommendations in the PSII to create a larger Quality Improvement Programme of work. We reviewed the draft quality initiative plan and saw 48 separate actions. At the time of our assessment, 20 of these actions had not yet been started. None of the 28 actions referred to reviewing all patients who had their care and treatment delayed. Since the inspection the provider had further developed this programme with action plans in task and finish groups. Progress was planned to be reported and monitored through the providers project management system from quarter 2, 2025/26.

The service had dedicated patient safety incident investigators who oversaw the assessment and any subsequent serious incident investigations. Staff explained that following the sudden increase in reported harm incidents in the podiatry service, the team had identified and grouped together 5 incidents as part of a thematic review. This review showed the 5 incidents selected highlighted a multitude of problems that were not necessarily linked. However, in the case of 1 incident, it was determined that despite significant delay in follow up (4 months), the deterioration of the wound was not down to these delays.

There were arrangements for reviewing and investigating safety and safeguarding incidents, and events when things went wrong. The patient safety investigators met weekly to review all reported incidents and determine which should go to after action review or on to full PSII. These meetings involved the family liaison officers as well as the clinical teams, and the families involved in any investigation, to ensure they understood the process and any subsequent report. The family liaison officer also ensured the patient, and their family were able to ask questions and oversaw the gathering of responses for them.

Staff were able to tell us of improvements to practice following a safety incident. For example, making sure the date of opening was always written on insulin administration pens to prevent out of date insulin being administered again.

We reviewed the notifications the provider had sent us for 12 months prior to our assessment regarding serious injuries. We looked at ones relating to community health services for adults and these related to pressure ulcers. We identified themes relating to community staff not recognising deteriorating wounds, and / or patients, and not completing paperwork at the time of the visit. We also saw learning from another incident where the provider had identified several issues. These included staff not acting on a deteriorating wound, the incorrect wound care pathway followed, the wrong dressing was used, and staff didn’t understand the process to flag a deterioration of a wound to the wound care service. The wound care team had put on additional training for staff but at times these were poorly attended, and this was due to the demand on their services. The wound care app had been brought in to help community teams with the ongoing monitoring of wounds. By using this wound care app, staff were able to take pictures, and the wound care app would be able to tell them if the wound was improving or deteriorating. Staff were still able to use their professional judgement in this wound care app. Staff told us the wound care app was time consuming to complete all the sections of it and therefore they did not always do this at the visit. Following the inspection the provider shared with us an audit which showed a 50% reduction in the time it took to compete documentation associated with wound care. Also, if the patient had more than 1 wound, they had to complete the whole process again which then meant it was more time consuming when staff were busy. Since the inspection the provider had offered training to staff on mapping of multiple wounds at once and completion of the assessment on the wound care app itself.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not have enough qualified, skilled and experienced staff. Not all staff received effective support, supervision and development. Staff worked together but some lack the skills and experience which meant people’s individual needs were not always met and placed them at risk of harm.

Cover was provided for staff absence where possible, such as for planned or on-going sickness and annual leave. The provider used a tool to determine the number of staff required to meet the needs of patients within the integrated network teams. This was the recognised tool ‘community nursing safer staffing tool’, provided by NHSE. Short term and last-minute sickness were harder to cover, but where staffing levels dropped below a safe level, agency and bank staff were utilised. Staff numbers were discussed twice daily, and shift leads discussed staffing 48-72 hours in advance so that agency or bank staff could be booked ahead of time.

Senior staff planned visits for staff in advance at the twice weekly planning calls, however these could be changed due to more urgent visits being required on the day. All referrals to community services were RAG rated from red to green and each risk decided if patient’s visits could be deferred if demand was higher than the service’s capacity. This meant that some patients visits were postponed accommodating all the red rated (higher priority) visits. Not all patients were informed when their visits were postponed. We saw evidence of harm to a patient from a patient safety incident where there was shared care between podiatry and community nursing where visits were postponed due to more urgent visits to other patients being required.

In Weston, Worle and surrounding villages, the risk register stated they were deferring on average 70 scheduled visits per day. This included wound care putting patients at risk of harm due to deterioration of wound not being identified quickly enough.

For community nursing, a ‘response’ nurse had been recruited to cover all urgent care visits. These were where patients rang on the day and were RAG rated. If red, they were seen within 2 hours, if amber or green they could be seen up to 48 hours later. Staff told us at times, the number of visits were too high which meant they did not get time to complete their records.

Arrangements for using bank, agency and locum staff mostly kept people safe. All staff underwent a skills review by senior managers before beginning work. Managers were also able to request nurses with specific skills from the staffing agencies they used. Records of staff training were held centrally by the agency and prospective staff had their curriculum vitae (CV) sent to managers before beginning work.

Handovers for shift changes ensured that people were kept safe. We observed several handovers and saw all staff gave updates for every patient they had seen and were planning to see. However, the provider had on their risk register there was no allocated time for handover of patients from the night team to the day teams. This meant night teams were late off their shift due to this. This impacted on their wellbeing.

In addition, teams held a twice daily staffing call to assess the number of unallocated red RAG rated patients across all teams. In the afternoon call, we saw teams actively utilise all available slots to accommodate outstanding high risk red visits.

The service took account of staff competencies and skill mix in most cases when planning visits. In the twice daily staffing calls, skill mix was discussed in relation to the outstanding red visits. We also saw this was done as part of handovers to ensure staff with the right skills saw the right patients. However, this was not always the case. We saw one patient who had been visited by a nurse who had declined to dress their wound as they did not feel they had the necessary skills to do this.

Across adult services, the provider had 108.8 whole time equivalent (WTE) vacancies with the most being in the integrated team covering the Bristol area. The provider was actively recruiting to fill these vacancies. For specialist services, they had 48.8 WTE vacancies with the most being in podiatry and long covid service. The provider was also actively recruiting to fill these vacancies. Two services had over the allocated number of staff, and these were neurology and bladder and bowel service (these 2 services were linked together by the provider) and medicines management.

The turnover rate from January 2024 to December 2024 for all community services including children varied from 11.4% to 15%. This was monitored monthly.

In podiatry, there was a 20% vacancy rate across the whole service. This led to significant capacity issues and high caseloads for staff. For example, staff told us they did not have enough time within 30-minute allocated face to face appointments, to complete their clinic notes. Staff reported being challenged for recording details about patients’ preferences in their case notes. Staff explained they viewed their patients holistically and used notes to remind themselves of patients likes and dislikes to ensure compliance with treatment in the future. Following the inspection, managers told us appointment timings had been discussed at the southwest workforce meeting and were comparable with other similar services. Staff had also been supported to streamline note taking, for example including more concise information on patients’ preferences that could be easily understood and used by other staff. Clinical administration tasks had also been reviewed to reduce the burden on staff. This included digital optimisation training and administrative team availability to assist clinicians.

In the podiatry service caseloads and staff numbers did not match the demands of the service. In South Gloucestershire, there were 126 ‘over due to be seen patients’ at the time of our assessment. Meaning these patients were already on the caseload, but capacity was such they could not been seen within their allotted follow up time frame. Staff explained there was a focus on seeing new patients within the 18-week target and there had also been a historical focus on 1- 2 week wait patients. The majority of new patients referred and reportable under an 18-week target were triaged as requiring an urgent or soon appointment. Prioritisation of new appointments was based on clinical urgency at the point of triage. Prior to the inspection the provider had introduced a specialist service wide weekly review meeting of Patient Tracking Lists which alternated between new and follow up waiting lists to provide equal focus.

Mandatory training was aligned to each role. For example, every role and banding had currently been through or was going through a competency review panel to align competencies across the whole organisation. At the time of our assessment, we saw several band 5 and 6 roles including physiotherapists and podiatrists had already been ratified. However, we identified staff who had recently joined the provider as a band 6 podiatrist and had limited experience of dressing wounds and there were plans for them to be lone working in clinics. This was listed as a core part of the band 6 podiatrist role in clinic. This had been escalated but we were not told of the outcome. Following the inspection the provider gave us assurance that the individual was now working independently without any concerns around competency or capability and continued to be supported and received clinical supervision.

Some staff reported they did not always get time to complete their training requirements, and supervision was not always happening at arranged times. Senior staff told us about some training for the out of hours staff which involved trainers coming out, out of hours to help those staff address their training requirements. The learning needs of staff were identified through regular structured, one to one conversation with line managers. For example, data showed for the South Gloucestershire out of hours team, staff were receiving clinical peer to peer supervision, but it was not clear from the data submitted, if the staff list represented the whole establishment. It was clearly recorded when staff, were new in the service or required additional supervision.

Following the inspection, we were sent copies of some of the services supervision records. The policy for clinical supervision for qualified staff and supervision of unqualified staff states it should be 4 times per year either as an individual session or part of a group. These sessions were not monitored by the provider only by each service; therefore, the provider would not know if these were taking place as per their policy. The records showed this was not happening for all staff. For example, in the heart failure team, not all staff had received 4 supervisions session for 2024, 2 staff had only 2 sessions. One of the integrated teams the majority of staff had either 1 or 2 sessions for 2024. However, there where several staff who had more that the recommended 4 sessions. It was clear that the majority of staff were not having supervision sessions as per the providers policy but they were not monitoring this as part of their governance arrangements. Since the inspection the provider had looked to incorporating data on clinical supervision within their electronic system which also stored staff training records and competencies.

Staff received training in safety systems, processes and practices. However, some staff reported there were sometimes lengthy delays between face to face and online elements of the same training course. For example, in compression training delivered to community nurses, they were not identified as competent until both elements of the training had been undertaken, and they had completed 5 compression dressings under supervision.

Following the inspection, senior staff sent us a list of mandatory training and the percentage of completion by staff. The target was 90% except for information governance which was 95%. Out of the 26 mandatory training topics all but 5 were at the target or above for staff working in community health services for adults.

At the last inspection we issued a requirement relating to safeguarding training for staff in adult and children as the figures for completion were below target and patients were at risk of abuse. At this assessment we found the provider had met this requirement.

One patient’s family member we visited, disclosed some possible safeguarding concerns. This was escalated to the management team who agreed it was a safeguarding concern; however, the nurse did not initially recognise this but had noted it in their case notes for the patient.

Staff told us they felt supported with training and competencies by the practice education facilitators. The practice educators assisted with training of staff and could review and sign off their competencies. Following the inspection the provider sent to us copies of competency assessments used for wound care for band 5 and above. We found that despite these competency assessments, issues were still being identified with staff not recognising a deteriorating wound and following the correct wound care pathway.

Poor or variable staff performance was identified and managed in a positive way which supported staff to improve. Managers explained they approached situations holistically taking account of factors external to work which may be affecting a staff member’s performance. For example, if a member of staff was struggling to make certain shift start times, flexible working arrangements were considered to support that staff member to be on time for work.

Feedback from patients and those close to them was consistently positive about the care the staff provided and there were many examples of when patients thought staff had gone the extra mile to support them. However, all patients commented they never saw the same nurse twice which meant there was no continuity, and they never got to know staff. Following the inspection the provider told us this had been recognised by the service as an area of improvement and the provider had subsequently implemented zonal working and named nursing. Both of these improvements were intended to support continuity of care and improvement in patient and clinician relationships.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Safety and safeguarding systems, processes and practices were developed, implemented and communicated to staff through online policies and standard operating procedures. All staff were aware of the IPC principles they needed to adhere to when delivering care and treatment in patients’ own homes.

Policies and procedures relevant to infection control practices were available to staff on the organisation’s intranet. Staff were able to find these when we asked to see them. We saw staff adhering to handwashing procedures and being bare below the elbows during clinics and home visits.

Aprons and gloves were readily available, and we saw staff using them when attending to patients' dressings. Where able in patients’ homes, staff asked to wash their hands before undertaking any care and treatment.

Staff managed infection control in patient homes as best they could and tailored their care to take account of specific infection risks, such as pets or other environmental factors. All staff we saw cleaned their hand by washing them or using hand gel both before and after delivering care and if necessary, during the episode of care as well.

In the outpatient clinical sites we visited, standards of cleanliness and hygiene were maintained though regular cleaning and documented on standardised checklists. All areas we visited were visibly clean and all cleaning checklists we reviewed were complete.

In the integrated network team, there were some reliable systems in place to prevent and protect people from a healthcare associated infections. All the nurses we spoke with understood the importance of looking for the signs and symptoms of sepsis.

Staff could describe instances where infection control was a particular issue, and we saw one nurse give advice to a bed bound patient about the infection risks associated with not cleaning and drying areas of skin on their body.

Staff undertook IPC and hand hygiene checks in patient homes and the data submitted from the podiatry service for example, showed 100% compliance between February 2024 and February 2025.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.