You are here

Provider: Your Healthcare Community Interest Company Good

Reports


Inspection carried out on Announced visit between 15 and 17 November 2016. Unannounced visit on 30 November 2016.

During a routine inspection

Letter from the Chief Inspector of Hospitals

Your Healthcare Community Interest Company is a not for profit social enterprise, delivering health and social care community services for residents in Kingston and Richmond. Your Healthcare has around 620 staff in post. The organisation’s healthcare services employ around 427 WTE staff.

Your Healthcare is commissioned to provide health services to all patients registered to a Kingston CCG GP (203,854 NHS Digital October 2016). This exceeds the resident population by 17.5%. Some patients resident in a surrounding borough are registered to a Kingston GP.

Our key findings were as follows:

Safe

  • The duty of candour was understood and implemented by staff. The process was appropriately followed and actioned.
  • The provider had up to date safeguarding policies and procedures. Staff understood their roles and responsibilities with regards to safeguarding and could tell us how they would escalate any concerns.
  • There were effective policies and procedures to manage the storage and administration of medicines. Patients received their medicines on time and when they needed them. They knew if their medicines had been changed and could ask for pain relief when they needed it.
  • Community nursing staff had no problems getting equipment such as standard pressure relieving cushions and hospital beds, pressure relieving mattresses and commodes in a timely manner. The provider maintained and safety checked equipment.
  • Most staff washed their hands appropriately between patient contacts and adhered to the ‘bare below the elbows’ policy and had access to personal protective equipment (PPE). Staff were observed following infection control procedures and protocols in patients’ own homes.

  • There were suitable arrangements for the handling, storage and disposal of clinical waste, including sharps in clinic and home environments.

  • Staff knew how to recognise incidents and mostly recorded and reported appropriately. However, due to lack of equipment or IT connectivity issues in the community, staff could not always access on-line reporting in the community, but had to return to a hub office to do so. This could cause delays in reporting incidents.
  • The Cedars Unit had not reported any deaths within the last year; although five patients had died on the unit. Providers must report all deaths as a statutory notification to CQC and therefore this should have been completed.
  • The Cedars Unit did not carry out mortality reviews and when we raised this with the provider, we were told that it wasn’t required within the community setting. In the absence of any local mortality review process, it is difficult to understand how the provider would be assured that the death of the service user was attributed to the course of the illness or medical condition that treatment was being provided for.
  • There were high vacancy rates especially for nurses and speech and language therapists across all services, which impacted on the delivery of care. Senior staff reported difficulties in recruiting nursing staff and recruitment was ongoing. Nurse staffing was listed on the directorate risk register as a high risk and was being looked at strategically.
  • Extra space and storage was highlighted by staff as a concern on The Cedars Unit. Beds were close together in bays and there was no space, apart from manager’s offices for speaking to patients and relatives in a private environment. The lack of communal areas meant that patients spent a large amount of the day sat by their beds.
  • A number of staff reported that there were issues with the electronic records system and said that sometimes it crashed and did not save the data. The electronic system migration was recorded as a very high risk on the directorate risk register.
  • All staff we spoke to said they were up to date in their mandatory training. Community staff in the different teams described good access to mandatory training. However, mandatory training was highlighted by senior staff as an area of risk of non-compliance due to lack of oversight and this was listed on the organisational risk register. Action being taken as result.

  • Staff could access and book training through an online system, but there was no means for line managers to be able to check completion rates. 

Effective

  • There was no care plan and pathway widely in use that was specific to patients who were dying, during the inspection.
  • Some staff working with end of life care patients were not confident about what process they should follow if patients did not have capacity. However, Mental Capacity Act processes were mostly followed and used appropriately when required. It was clear that when there were concerns about a person’s ability to make specific decisions relating to hospital treatment and everyday decisions, mental capacity assessments were carried out. The patient’s family and multidisciplinary team was involved.
  • There were gaps in MUST nutritional assessments for patients receiving end of life care, either they were not available in patient records or not completed thoroughly.
  • There were no personalised care plans on nutrition and hydration for patients receiving end of life care, to ensure that the patient and their family’s views and preferences around nutrition and hydration at the end of life were explored and addressed.

  • The number of young people attending drop in sessions at some schools were fewer than 10 in some schools, but there was no target.
  • Community nursing staff told us the specialist palliative care team from the local hospice would measure patient’s outcomes.
  • The provider arrangements for end of life care services to achieve the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People, was in draft and being consulted upon. Timescales for implementation of the care plan were not provided.
  • There was an audit programme, which was agreed by the audit and assurance board. The provider carried out internal audits such as ‘bare below elbows’ and anti-biotic prescribing. It also took part in external audits such as the sentinel stroke national audit programme.
  • The Cedars Unit had taken part in the National Audit of Intermediate Care (NAIC) in 2015. This audit aimed to assess progress in services for older people aimed at maximising independence and reducing use of hospital admission and look at national trends.
  • Policies and procedures were consistent with National Institute for Health and Care Excellence (NICE) guidance where appropriate such as NICE CG50 relating to responding to the deteriorating patient. Patient’s needs were assessed and care and treatment was delivered in line with NICE quality standards relating to the assessment and prevention of pressure ulcers.

  • The neuro gym service provided a range of specialised sessions to support patient rehabilitation as well as maintenance of movement, based on latest evidence. The service undertook action research on measuring a patient’s arm recovery following their recovery programme. The results showed a good recovery for patients in terms of time and duration taken for recovery.

  • The Barthel Activities for Daily Living (ADL) score was used to measure patient’s performance in their rehabilitation

  • Staff used outcome measures to monitor patient progress. Key outcome measures were Braden Assessment of pressure ulcer risk and nutrition scoring. However, in most of the records we reviewed, these assessments were not completed accurately, and there were no results provided to the inspection team.
  • We found opportunities to participate in bench marking, peer review, accreditation and research were proactively pursued by the service provider. Information about the outcomes of people’s care and treatment were routinely collected and monitored to improve patient care.
  • There was no data on the number of children and young people achieving their treatment goals through speech and language therapy.
  • Multidisciplinary team (MDT) working was well established on The Cedars Unit and formed an integral part of the wards.
  • All staff were very positive about the weekly MDT meetings in the community, which involved a full range of staff providing care and treatment including a GP, nurses, therapists and social workers.
  • Patient’s we spoke with told us staff always gained their consent prior to providing care or treatment. We observed nursing staff explained procedures to patients and gained verbal consent to carry out the procedures.

Caring

  • Patients received compassionate care which was centred on them, whether inpatients or in the community.
  • Patients were mostly positive about their care and treatment.
  • The results from a service user engagement survey over the period January to October 2016 showed all of the respondents would be extremely likely or likely to recommend the unit. However, the response rate for both wards was extremely low, with only eight responses for Chestnut Ward and six for Elm Ward.
  • Staff told us that the lack of therapeutic activities on the unit had been identified as an issue, and provision of an activity co-ordinator discussed, however funding was not available.
  • On Elm ward at night, the Zimmer frames of each patient were put out of their reach, to prevent them using them and potentially falling. However, this did not encourage the patients to mobilise independently
  • Call bells on The Cedar Unit were very loud and disturbing to patients.
  • Community nurses delivered respectful and compassionate care with attention to their patient’s privacy and dignity.
  • The majority of families using the services that we spoke with were very happy with the services provided by Your Healthcare.

  • Although there were only small numbers of mothers attending the feeding clinic, mothers at these clinics said staff were 'relaxed and friendly'.

  • Staff involved patients in their care; they communicated well with them and provided them with simple information on how to manage their condition and options of treatments available.
  • When patients asked questions, these were responded to appropriately and where further information needed to be obtained by a nurse patients were informed in advance.
  • Relatives told us that they had been consulted about decisions and understood what was happening and why.
  • Staff communicated with children and young people in an age appropriate way and involved them in decisions about their care.
  • Staff in all services used written information to supplement verbal information, which was good practice.
  • Staff met the emotional needs of patients by listening to them, by providing advice when required, and responding to their concerns.
  • There was not a routine chaplain visit to The Cedars Unit; however senior nurses told us that they could contact a local chaplain if it was required.
  • Patients and carers felt emotionally supported and reassured by the community nursing visits.
  • Health visitors sensitively discussed mothers’ feelings and emotional well-being during home visits.

Responsive

  • Patients’ needs were assessed and care planned accordingly. Where appropriate, care planning involved joint visits with staff from other specialties or GPs.
  • Patients with complex needs including those who were housebound were discussed between services and a co-ordinated multi-disciplinary plan of care was agreed. Service users could access community nursing services directly and request visits and appointments.
  • Staff worked closely with their local hospice to ensure end of life care needs of their patients were met.
  • A Tongue Tie Release Clinic had been set up in January 2016, after midwives at the local hospital stopped doing this and instead referred cases to outpatient appointment at another hospital.

  • There was a dementia nurse specialist to support patients living with dementia.
  • The Cedars Unit used a ‘forget me not’ sticker to identify patients living with dementia. There had been some effort to make the unit a dementia friendly environment such as the use of pictures and word signs on toilets.

  • In the community, nursing assessments identified patients living with dementia or learning disabilities and care was provided to meet their needs. The neurodevelopmental services assessed people attention deficit hyperactivity disorder and autism and worked closely the local acute and hospital social services. They provided learning disability awareness training to staff.
  • We saw evidence of easy read documents and pictures for people living with a learning disability.

  • People were generally seen in a timely manner, with some exceptions and had their individual needs met.

  • The average wait for patients to access The Cedars Unit between October 2015 and August 2016 was three days for Chestnut Ward and four days for Elm Ward.
  • There was a single point of access to the nursing service. Referrals were triaged immediately and the workload allocated accordingly.
  • Waiting times were variable across the community services. Referrals for community nursing visits are often received in advance therefore representing a lead time for discharge home for example rather than a waiting period. Community nursing provides a daily priority based response and in consequence there is no waiting time to access this service. However, therapy services had a triage system in place to identify urgent and non-urgent appointments.
  • The SALT service did not hold a traditional waiting list, but described a risk managed monitoring list. Different staff told us that the wait for routine assessment by a therapist was between six, eight or 10 months, so were not meeting the 18 week referral to treatment times.
  • Face to face and telephone interpreting services were available. There were also a number of staff on The Cedars Unit that spoke a second language and would assist when it was suitable for them to do so. However, some staff reported that they would often use family if interpretation was needed which is poor practice. The unit had a menu that contained photographs of food choices that could be used for patients who may not be able to read English.
  • Staff treated patients with respect regardless of their race, religion and sexual orientation. Relatives confirmed that they and their loved ones were shown dignity and compassion throughout their care.
  • The SALT service produced leaflets for parents on the development of speech sounds, stammering and modelling correct speech which gave parents tips on how to help their child.
  • There was a complaints policy and staff were trained on handling complaints.
  • Staff understood the process for receiving and handling complaints and were able to give examples of how they would deal with a complaint effectively. Managers discussed information about complaints during staff meetings to facilitate learning.
  • Our review of records found that there were no formal risk assessments for complaints that would determine how they should be dealt with and we did not see a record of how the learning would be shared. There was also inconsistent evidence on whether complainants were asked whether they were happy with the response.

Well led

  • The managing director did not have a formal appraisal of her performance and was the only person in the organisation not required to have one. This was not good practice and must be addressed.
  • There was a flowchart which described the governance structure and process. However, this was neither signed nor dated.
  • It was clear that the governance process was understood internally, but the flowchart could be improved to demonstrate the overall governance framework. For example, there was no formal policy or procedure setting out the governance framework in narrative to back up the flowchart.
  • The board lead for Foundation is on the membership of the Kingston CCG End of Life Care Steering Group, which acted as a forum for the commissioner to ensure collaborative working between their providers.

  • Systems or processes were not sufficiently established or operated to effectively ensure the provider was able to assess, monitor and improve the quality and safety of end of life care services.
  • There was no documented vision for the children and families service delivered by Your Healthcare.

  • The organisation was not clear about its risk tolerance, or had definitive SMART plans with clear milestones for managing risks.
  • The provider had developed a manifesto to support their vision. There were clear priorities to help deliver the vision. The manifesto highlighted the status of the provider as a social enterprise with the freedom to use their resources to improve patient care.
  • How the organisation is governed is outlined in its articles of association registered with Companies House.
  • Risk registers were kept by separate departments and committees, which were amalgamated to inform to organisational risk register.
  • The organisation took the health and well-being of its workforce seriously. It worked closely with the Public Health Department.
  • Most staff told us they enjoyed working for the organisation.
  • We saw an action plan which was agreed by the board, aimed at making progress against the WRES indicators. One desired outcome for the organisation in assessing its progress against the WRES indicators, was improving the percentage of BME staff in senior positions.
  • There was active staff and public engagement.
  • The multiple sclerosis support group generates income and run exercise classes for themselves. This came about as a result of the provider listening to the service users, to improve the service delivered.
  • The Cedars Unit had recently bought a new piece of equipment called the ‘Hover Jack’. This allowed the nursing staff to safely lift patients from the floor whilst keeping them flat so that they could then be transferred to a bed. This reduced manual handling for staff and a better patient experience.

We saw several areas of outstanding practice including:

  • The multiple sclerosis support group was recognised as an example of good practice. This group generates income and run exercise classes for themselves.
  • The provider re-invested surplus money in its services. This included the appointment of a tissue viability nurse, reduction of waiting times and purchasing of gym equipment.
  • The Cedars Unit had a ‘Hover Jack’. This allowed the nursing staff to safely lift patients from the floor whilst keeping them flat, so that they could then be transferred to a bed. This reduced manual handling for staff and a better patient experience.
  • The Cedars Unit had a bariatric training suit for manual handling training. This allowed staff to better understand the problems of mobility and routine activity associated with bariatric patients.
  • Schwartz Rounds were conducted in the organisation; this is a forum in which staff can openly and honestly discuss social and emotional issues that arise in caring for patients. The provider had supported staff to participate in the “Rounds”.

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

Importantly, the provider must:

  • Ensure the managing director receives a formal appraisal of her performance.

In addition, the trust should:

  • Ensure there is a formal policy or procedure setting out the governance framework in narrative to back up the flowchart.

  • Reduce the risk related to the electronic system migration.
  • Correct the electronic data inaccuracy related mandatory training.
  • Carry out formal risk assessments for complaints that would determine how they should be dealt with.

Professor Sir Mike Richards

Chief Inspector of Hospitals


CQC inspections of services

Service reports published 9 June 2017
Inspection carried out on 15 -17 & 30 November 2016 During an inspection of Community health inpatient services Download report PDF | 385.97 KB (opens in a new tab)
Inspection carried out on 15 – 17 November 2016 During an inspection of Community health services for adults Download report PDF | 331.73 KB (opens in a new tab)
Inspection carried out on 15 - 17 November 2016 During an inspection of Community health services for children, young people and families Download report PDF | 377.17 KB (opens in a new tab)
Inspection carried out on 15 – 17 November 2016 During an inspection of End of life care Download report PDF | 315.8 KB (opens in a new tab)
See more service reports published 9 June 2017