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 good. At this assessment the rating has decreased to requires improvement. This meant there were shortfalls in management of risks and implementation of actions to reduce these. Local leaders supported staff and encouraged services to continuously improve.

The service was in breach of legal regulation in relation to the governance of the service.

This service scored 61 (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.

The service had inclusive local leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Local leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff were complimentary about their local managers and found them approachable and supportive. Staff agreed there was an open-door policy with their managers. Staff said they did not see managers from a “higher” level very often, they did not see this as a problem as they were confident in their line manager’s ability to communicate clear messages.

Not all staff felt leaders were visible and approachable and commented they were rarely seen at clinic locations, but did acknowledge they were present and visible at staff meetings and other forums.

Specialist services, such as the physiotherapy interface service were managed by people with both clinical and managerial skills. This had the effect of simultaneously providing clinical knowledge and managerial support to staff within those teams.

Local leaders understood the challenges to quality and sustainability, and they could identify the risks to their services.

Staff told us about a new multi- disciplinary meeting to discuss patients who displayed challenging behaviour during visits. A risk assessment was completed to determine how many staff need to attend to maintain their safety and to discuss other options. For example, a senior manager can accompany staff and issue a warning to the patient under the yellow card system. This was part of the well-being strategy for staff and to protect their safety from bullying, harassment and violence from patients and members of the public.

The provider’s 2024 staff survey result showed there were no improvements from the previous year’s result and of the 119 questions 57 were rated as worse. One of the 3 main questions was “care of patients/service users is my organisation top priority”’ Sixty-nine percent was positive, but this was 7% lower than the previous year. Another question was “would I recommend my organisation as a place of work” and 50% agreed but this was 11% lower than the previous year. There were some improvements which related to staff experiencing less bullying, harassment and violence from patients and members of the public.

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.

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.

The service had systems for governance and risk management which monitored and identified risks to service provision. However, several risks on the provider’s risk register had been on there for some time with limited change to the risk despite actions to minimise these. Some risks had actions which the provider had taken but the risk remained for example, clinical competencies especially relating to deteriorating wounds and the management of these.Since the inspection the provider had taken measures to improve the oversight and management of staff competencies. Specific work had been carried out in particular teams such as Podiatry and Integrated Network teams to focus on identification and recognition of deteriorating wounds.

The provider uses a daily situation report or sitrep to monitor what was happening across each location. For example, up to date staffing figures to show where they had gaps due to sickness and how they can cover this. They generated an ‘integrated operational pressures escalation level’ (OPEL). NHS England introduced the national OPEL framework in 2016 to standardise local and system escalation processes, encourage wider co-operation and improve regional and national oversight of operational pressure. The provider was rated as OPEL 2-3 (OPEL 2 indicated enhanced coordination of services and level 3 is about major pressures on the services) during our site visits. The sitrep was updated throughout the day to enable senior managers to have oversight of their service provision and patient safety.

We observed a daily call where all leads from adult services across the provider met to discuss demand against capacity. This included information about local NHS trusts and their OPEL rating. Senior staff reviewed unallocated visits and looked to move capacity to meet their shortfall. On some days this was followed by a system wide meeting which included other providers of services which covered same geographical locations. We saw good evidence of all providers working together to respond to demands for services.

Integrated care teams assessed patients using a prioritisation matrix system based on their clinical need. They were assessed as red, amber or green and this was used to plan allocations of visits. If demand was high and out stripped capacity, visits rated as amber or green could be deferred. Deferred visits data was monitored.

Urgent community response patients were assessed as being within 2 hours or non 2 hours. National target for 2 hours was 70%. The provider was over this target at 78.7% within 2 hours. There was no national target for non 2 hours, but the provider had set themselves a target to see patients within 48 hours. Year to date they were at 93.3%. They told us this was despite demand being above the commissioned target.

In the single point of access, action was taken to minimise the length of time people had to wait for calls to be answered and had achieved and were maintaining their target of under 10% of calls being abandoned. All calls were recorded, and these were used for quality assurance, training and if any complaints are received, they were reviewed.

We saw from minutes of team meetings across the community health services for adults where complaints and concerns were a routine agenda item, and each complaint was discussed with outcomes and learning shared with all staff.

Peer review of several adult community services was commenced in 2024. Each service was assessed using the 5 key questions from Care Quality Commission guidance and a score resulted in a rating. The ones we saw were all rated as good but had areas of good practice and areas for improvement. The actions were to be addressed by the senior manager for the service. Not all services had been assessed as this was a new initiative and action plans were to be followed up.

The provider monitored waiting time for each of their services as not all patients were seen within the 18-week target. The provider sent us information post site visits which showed some patients were waiting longer than 18 weeks for planned therapy. For example, in South Gloucestershire, they had the most patients waiting at 386 and of those, the longest wait was 40 weeks.

Managers were aware of their risks and any actions to help minimise these. These were recorded on their risk registers. For example, some services had longer waiting times. Weekly huddles had been introduced for staff to discuss any patients of concern and look at how they could bring their appointment forward.

The risk register included the risk, initial risk rating score and the review score. Actions were included to help reduce the risk and review date. We saw for example, risks relating to podiatry staffing and patients, staffing across integrated teams, deferred visits on the register as these remained high especially in one location. We also saw deteriorating pressure ulcers and the number of insulin visits as risks on the register. Despite actions being taken for these risks they were still remaining.

We reviewed minutes of several governance meetings where we saw for example, quality and safety, adverse events and key issues and concerns for that month were discussed. Any actions were documented and followed up at next meetings.

Wound care was being monitored by a dashboard which included average number of visits for wound care each month. Whilst some of the data was positive as they had rated themselves as green in their RAG rating tool for overall progress, we saw the number of deferred wound care visits was high. The baseline was based on the average number of wound care visits deferred from January to March 2024 for each location. When we looked at individual locations and the number of deferred visits per month, we saw in some cases this exceeded the baseline.For example, Weston, Worle and surrounding villages baseline was 1160, which was a high number of wound care visits being deferred and patients were at risk of potential harm with this high number. In June 2024 they had 2023 deferred visits, which was the highest on the dashboard. Some months were less than the baseline at 156 for August 2024. Reasons for deferred visits included staffing levels and demand on service provision which was above capacity.

The risk of deferred visits for Weston, Worle and surrounding villages was recorded as a risk on its own on the register as they averaged about 70 scheduled visits per day being deferred. This placed patients at risk of potential harm.

The provider told us in their incident reports, in line with the service’s Patient Safety Incident Response Framework (PSIRF) plan, pressure injury incidents were not chosen as a PSIRF priority. This meant they did not routinely have a PSIRF learning response. This was despite the number of pressure ulcers where staff had failed to identify they were deteriorating and placing patients at risk of harm. They told us they had a pressure injury strategic plan and continued to review their progress against this. Pressure injury incidents received a local managers review, and local actions were taken accordingly, and these were documented on the incident. However, these incidents were still occurring.

We were sent a copy following our site visit of the pressure injury strategic plan which was due to come into force from April 2025. This was building on the previous one from 2023-2025. The aim of these was to reduce the number of pressure ulcers especially at grade 3. Updated training and care and treatment documents will be shared with staff to help achieve the required outcome.

There were arrangements to ensure that data or notifications were submitted to external bodies as required, however some staff were not clear how decisions around this were made. For example, 2 incidents had been reported where a patient had undergone an amputation.

We saw the provider acted following receipt of notifications. Staff told us about a project to review bedrails following a Medicines and Healthcare products Regulatory Agency (MHRA) notification. The provider was working through the list of actions, and this was on their risk register.

People’s individual care records, including clinical data, were not always written and managed in a way that kept people safe. Nurses used note pads to make notes during their visits and typed up care notes when they returned to their base. Staff using the wound app were able to take pictures whilst on the visit but did not have time to complete the assessment/records whilst on site. This meant these were not always contemporaneous records. They explained they could not always access the electronic systems on their laptops when out in the community. Some staff said they did not always have time to complete their records due to the number of visits they had to complete. Senior managers explained this was a longstanding known risk and there were plans to introduce a mobile phone/tablet-based version of their record keeping system which would enable nurses to fill in records at the time of the visits.

We attended a full staff briefing where paper notes usage was raised with staff as an issue and a reminder was given to all staff about the importance of storage and destruction of all paper records.

There were systems to manage and access patient care records, particularly when delivering care in patient’s homes. Staff across the service used both an electronic system and wound app as tools to document both care delivered, future care plans and to photograph and document wounds and injuries to monitor both healing and/or signs of deterioration.

The quality of people’s care records was regularly audited. The service used a comprehensive multi point tool to assess the quality of notes. This included ensuring standardised ways to documenting patients’ history using specific templates, not using abbreviations and referring to best practice.

All the information needed to deliver safe care and treatment was available to relevant staff in a timely and accessible way. As part of the weekly safety huddle for example in podiatry, staff reviewed nearly all patient care records including hospital records to give them the most up to date risk rating for each patient. Some meetings ran out of time meaning not all patients were reviewed.

Other services, such as GPs or community services and the local NHS trust had access to the information which was stored electronically.

If a patient had changes made to their case management by the hospital, staff could access these records as part of their preparation for visits and as part of safety huddles in podiatry.

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.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contributed to audits and research.

Leaders and staff in some services strived for continuous learning, improvement and innovation. In physiotherapy the service was involved in a Department of Work and Pensions sponsored Getting It Right First Time (GIRFT) initiative focused on holding community-based clinics to explore and help people return to work faster. It was hoped having physiotherapists alongside health promotion initiatives and other social support networks, would support people with long term problems to access support and return to work faster.

Leaders in the podiatry service had overseen a pilot involving a specialist nurse who was seeing patients who were assessed as being lower risk. This project had concluded at the time of our inspection and leaders were waiting the outcome data from the project to assess its success.

The Musculoskeletal (MSK) physiotherapy service was involved in a GIRFT project to look a capacity and demand utilising community based one stop events where services such as physiotherapy would be available alongside other services such as weight management and smoking cessation. The service was also looking into working with charity services as part of social prescribing.

The wound care team had introduced a wound care app to help monitor the progress of wounds using AI technology. This helped staff to assess and determine if the wound was healing or deteriorating.

Due to delays with ambulances and the pressure on the NHS urgent care services, the provider had a project where they purchased 40 raiser chairs to assist care homes to lift patients up from falls which showed a reduction in ambulance attendances.

The single point of access service had plans to help with admission avoidance and reduce the number of call the ambulance service were getting by taking some of their less urgent calls.

In the North Somerset area staff, were trialing a ‘skin tear’ pilot which supported care home staff to manage skin tears without the need for community nurse involvement. Care home staff were being supported with training and how to escalate to the community nurses. This was being trialed to help reduce the number of visits by community nurses.

The Integrated Network Teams in conjunction with the Diabetes Specialist team had completed a trial where home care staff were taught how to administer a patient’s insulin under a delegation framework (aligned to the national delegation framework) which had been developed with support from Local Authorities and Care Homes. This framework provided a base from which other delegated tasks such as skin tears could also be managed, which had been rolled out and was another proactive way to prevent deterioration of a wound.

To ensure all people had access to the same community services an overarching health equalities service was being set up. This was to make sure people were aware of what services were available to them and how to access them. This would include existing services for example, the Haven which provided support and services for refugees and asylum seekers.