• Organisation
  • SERVICE PROVIDER

Your Healthcare Community Interest Company

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

30 - 31 May 2023, 8 June 2023, 4 July 2023

During an inspection of Community health services for children, young people and families

Our rating of this service improved. We rated it as good because:

  • Safeguarding processes and follow up were very robust and thorough. There was good evidence of comprehensive and regular safeguarding supervision
  • The service had enough staff to care for the children and young people and keep them safe. Staff had training in key skills, understood how to protect children and young people from abuse, and managed safety well.
  • Staff treated children, young people and families with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children and young people, families and carers.
  • The service planned care to meet the needs of local people, took account of children and young people’s individual needs, and made it easy for people to give feedback.
  • Families gave overwhelmingly positive feedback about the service. They praised staff for their help and support. They felt listened to, informed, and involved in their children’s care.
  • Managers ran services well using reliable information systems and supported staff to develop their skills.
  • Staff gave very positive feedback about the service. Staff said the service fostered a good culture, they had very supportive management, and excellent staff wellbeing support.
  • Staff understood the service’s vision and values, and how to apply them in their work.

However:

  • The timeliness of some of the five health visitor visits within the universal offer of the Heath Child Programme (HCP) fell below national averages for the 6–8-week, 1 year and 2-2.5 year check
  • The service provided an enuresis (night-time bedwetting) service for children however this had a waiting list
  • Consent was not always recorded in patients care records
  • Equipment used by staff was not always within date

Background to inspection

Your Healthcare Community Interest Company (YH) was established as a mutual cooperative social enterprise on 1st August 2010. Staff formerly worked for the community services of Kingston Primary Care Trust (PCT).

YH provided some of the community nurse-led, children and families’ services in the Royal Borough of Kingston upon Thames, in south west London (SWL). Your Healthcare provided a universal health visiting service to children and families which includes the provision of well-baby clinics and breastfeeding support. Your Healthcare also provided, school health services and Child Speech and Language Therapy (CSLT) services. The school health service delivered two universal provisions: the National Child Measurement Programme (NCMP) and the School Health Surveys, it also provided health promotion activity within all the borough’s state maintained mainstream schools, one Special Educational Needs (SEN) school, and Kingston College. Referrals were accepted from schools, children and families, and social care for supportive input. The child continence clinic did not sit within 0-19 services, but within the urology and colorectal service. The uncommissioned tongue tie clinic was no longer offered. Their contraception and sexual health service included a service for under 19s. All services supported children with SEN and/or a disability and CSLT provided specialist interventions.

Other universal and specialist services for children such as vision checks, immunisations, physiotherapy, occupational therapy, dental services and the integrated service for children and young people with special educational needs and disabilities and their families, are the responsibility of other local providers. Child and Adolescent Mental Health services are provided by the local mental health organisation.

The health of people in Kingston is generally better than the England average. Re-infection rates for sexually transmitted Infections (STI) are worse than the England average.

CQC last inspected the service in November 2016. We rated the service Good for Safe, Caring and Well-led, and Requires improvement on Effective and Responsive. We rated the service Requires improvement overall.

There is a registered manager in place.

The service is registered to provide the regulated activities:

  • Treatment of disease, disorder or injury
  • Diagnostic and screening procedures

What people who use the service say

We spoke with 12 families and carers. The feedback we received was overwhelmingly positive. Parents told us they received comprehensive and helpful information from the beginning. They praised all of the staff, including clinical and administrative staff, and said they were supportive, proactive and responsive. Parents said they felt involved in the care for their child and knew who to contact in an emergency.

Direct comments from parents, which were representative of this feedback, included: “Staff are supportive, lovely, professional”, “they are responsive, helpful, providing support whenever you need”, “if I had any concern, I could go back to them”, “my daughter is on medication, they were very clear in giving me all the instructions including all the side effects”.

07 August 2022 to 11 August 2022

During an inspection of Community health inpatient services

We carried out an unannounced comprehensive inspection of this service in line with our inspection methodology. This inspection included a follow up on our previous inspection in 2016 to see if improvements had been made at the service.

Cedars Ward at Grace Anderson Unit has 25 beds and provides nurse / therapy-led rehabilitation for adult patients registered to a Kingston GP. The ward is run by Your Healthcare Community Interest Company (CIC) and is based at Teddington Memorial Hospital.

The ward provides sub-acute care, treatment, and rehabilitation, including neurorehabilitation for adults which focuses on maximising the functional and physical abilities of the patient before they return home.

Patients are either admitted from home or a local acute hospital and include patients who require further therapy input and / or short-term care such as complex wound management or medication management. Admissions are open to patients over the age of 18 who are registered with a Kingston GP and who are suitable for the nurse-led rehabilitation the unit provides.

Our rating of this service stayed the same. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Managers monitored the effectiveness of the service and made sure staff were competent.
  • Staff assessed risks to patients, acted on them and kept accurate care records. The service recognised and recorded safety incidents and learned lessons from them. Staff collected safety information and used it to improve the service. The service controlled infection risk well.
  • Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. Staff gave patients enough to eat and drink and gave them pain relief when they needed it. They provided emotional support to patients, families, and carers. The service made it easy for people to give feedback about their experience.
  • The service planned care to meet the needs of local people and took account of patients’ individual needs. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems. Staff felt respected, supported, and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. All staff were committed to improving services continually. The provider was committed to promoting research.
  • There was an effective system of governance that enabled the escalation of information upwards and the cascading of information from the management team to frontline staff. The service used regular audits to monitor and drive improvements in care. There was a good understanding of risks affecting the service and how these were being managed and a strong safety culture.
  • Staff felt respected, supported and valued. There was a strong culture of teamwork

However:

  • There were challenges with space on the unit. This meant the privacy of patients receiving physiotherapy was sometimes compromised and there was a lack of space for staff because of limited office space. The lack of storage space meant broken equipment had to be kept on the corridors until it could be removed.
  • Patients on the ward were unable to access a gym that was located on the same floor as this was reserved for patients in the other ward within the hospital, run by a different provider. Access to the gym was currently outside of the lease agreement held.
  • There was a general lack of activities available for patients. The provider had recognised this and recruited an activities coordinator who was due to start on the unit. Most patients were dressed in hospital issued nightgowns throughout the day, even though they were encouraged to bring in their own clothes to wear.
  • The ward had identified the need for environmental modifications to make it more accessible and suitable for patients with dementia and cognitive impairment, but these had not yet been implemented.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

To fully understand the experience of people who use services, we always ask the following 5 questions of every service and provider:

  • Is it safe?
  • Is it effective?
  • Is it caring?
  • Is it responsive to people’s needs?
  • Is it well led?

Before the inspection visit, we reviewed information that we held about this service.

The team that inspected the service consisted of 1 inspector, 1 inspection manager, a 1 specialist advisor, with experience working in community inpatient services and an expert by experience, someone who has experience of caring for an older adult.

During the inspection visit, the inspection team:

  • Carried out structured observations of how staff were caring for patients
  • Attended multidisciplinary meetings on the wards
  • Spoke with the ward matron.
  • Spoke with 15 staff members including registered nurses, health care assistants, physiotherapists, occupational therapists, non-medical prescribers (NMP) and the registered manager.
  • Spoke with 10 patients and 2 carers and relatives
  • Looked at the quality of the environment on each ward.
  • Reviewed 7 patients’ care and treatment records
  • Reviewed documents related to the running of the service
  • Reviewed feedback provided by the GP practice who provides medical support to the service Monday to Friday.

What people who use the service say

We spoke to 10 patients, 2 carers / relatives and reviewed feedback the provider had gathered through the most recent ‘service users engagement survey’ in June 2022.

Feedback we received was overwhelmingly positive about the service. Patients told us they were happy with the care and treatment they received, that staff treated them kindly and compassionately. They said that the food was good, and the environment was clean. The survey results indicated 100% of patients said they were treated with dignity and respect and 87% rated their overall experience as ‘very good’ or ‘good’.

26 April and 27 April 2022

During an inspection of Community health services for adults

Your Healthcare CIC provides adult community health services to all patients registered to a Kingston GP. This inspection focused on community nursing, the matrons team, rapid response team, and tissue viability services.

The community nursing service provided skilled nursing care to adults aged over 18 years in their own homes, residential homes or in a clinic setting. The community nursing teams were attached to GP surgeries, working as part of their integrated teams. The community nursing team supported people with a disability or long-term condition to live independent lives. They provided a range of services and treatment to enable individuals to avoid unnecessary hospital admissions and to facilitate early discharge where hospital admission was necessary. Community nurses also provided care to patients requiring palliative and end of life care. The community nurse teams were led by district nurses (specialist practitioners in this area of work).

Community matrons provided expert care for patients with one or more long term conditions, such as diabetes, coronary heart disease, Parkinson’s disease, and multiple sclerosis.

The rapid response team provided advanced clinical assessment and intervention for patients presenting with acute illness/deterioration. They provided an urgent two hours response and could access a range of nursing and therapy support.

The tissue viability service supported community staff, in the prevention, early identification and treatment of pressure ulcers and complex wound management.

Our rating of services stayed the same. We rated them as good because:

  • We rated the service as outstanding for caring and good for safe, effective, response and well-led.
  • Feedback from patients, relatives and carers was overwhelmingly positive about the competence and compassion of the community nursing staff. They said staff respected and valued them as individuals, and worked with them as partners in their care, both practically and emotionally. They described dedicated staff who went the extra mile to support them. Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them to understand their conditions. They provided sensitive emotional support to patients, families and carers.
  • Staff provided a high standard of care and treatment, checked that patients ate and drank enough, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent.
  • Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, and supported them to make decisions about their care.
  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.
  • The service controlled infection risk appropriately, including appropriate precautions to address the Covid-19 pandemic.
  • Staff assessed risks to patients, acted on them and kept good clear care records. They managed medicines well. The service managed safety incidents well and learned lessons from them to improve the service.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff were clear about their roles and accountabilities.
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued.
  • Your Healthcare CIC had planned, carried out and published a wide range of research. Recent research projects included improving the timeliness of referrals for end of life care from care homes; using National Institute for Health and Care Excellence guidelines to empower patients to self-administer intravenous therapy at home; and remote working with people with learning disabilities.

However:

  • Although staff were keeping patients safe, vacancies and staff absence (largely relating to the Covid-19 pandemic) had led to staff working extra hours and some exhaustion within the teams. An increase in patient referrals and complexity of patients was also putting pressure on the service. The provider was actively working to recruit to staff vacancies and develop staff to progress within the organisation.
  • Sixty-three per cent of eligible community nursing staff, and 64% of rapid response staff were up to date with clinical risk assessment training. Remaining staff may not have been up to date with risk management priorities for patient care.
  • Staff did not label equipment used in people’s homes to show when it has been cleaned.
  • The service did not have a sufficiently robust process in place to monitor NHS prescription stationery issued and used by staff.
  • Sample sizes of internal audits carried out within the service were not always sufficient to provide meaningful learning, and audit action plans could have been more robust with clear measurable actions.
  • Although staff reported having regular and helpful supervision sessions with their line managers, the provider did not have a robust system for monitoring the frequency and quality of staff supervision provided.
  • Although patients we spoke with said that the service responded quickly to informal feedback or complaints, the service did not have a robust system for keeping an overarching record of this information, in order to identify themes and potential areas of improvement and learning. We recommended this be considered in the 2016 inspection.

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

15 - 17 November 2016

During an inspection of Community health services for children, young people and families

Overall rating for this core service

Requires improvement


Overall, the children and young people and families service requires improvement because;

  • The timeliness of some of the five standard development checks within the universal offer in the Healthy Child programme fell below national targets for the new born and one year old checks, although the service performed better than the national average for 6-8 week checks.
  • The sexual health clinics were performing below target in several areas.
  • There were some staff vacancies in all service areas although a recruitment campaign was in progress.
  • The budget for speech and language therapy only allowed the service to support children with higher levels of need. There was a paper process for prioritising provision but not all children were seen for a face to face assessment within 18 weeks of referral.
  • The child continence service had not been provided for some months because of staff shortage and had only recently re-started; waiting lists were long.
  • Mandatory training was reported by numbers attending without a percentage target, and the provider did not consider their central training record to be accurate, which made it difficult to determine the number of staff who had attended.
  • There was an appropriate mission statement but no documented strategic vision for the children and families service as a whole.

However;

  • Parents we spoke with had confidence in the staff that provided their children’s care.

  • Staff knew how to report incidents although very few incidents were reported.

  • Staff working with children were trained in safeguarding and had access to regular safeguarding supervision with expert colleagues.

  • There was evidence of good Multi-Disciplinary Team (MDT) working between school nurses and health visitors.

  • Health visitors held clinics in a number of different locations across the borough so that families could access them without travelling long distances.

  • Care and treatment was evidence based, and children, young people and families were protected from inappropriate care or treatment for which they had not given proper consent.

  • Staff working for Your Healthcare were caring. They worked hard to ensure that children received good support. Families were involved in decisions about their children and understood the services available.​

15 – 17 November 2016

During an inspection of Community health services for adults

Overall, we rated adult community health services as good for safe, effective, responsive, caring and well led.

  • Your Healthcare Community Interest Company provided adult community services to support people in staying healthy in their homes and after discharge from hospital and sought to prevent unnecessary hospital admissions.
  • We rated safe as good because their safety performance data was better than the national average for most of the time. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
  • Staff followed processes to report safety incidents and manage risks. There was a pro-active approach to following patient safeguarding procedures.
  • Staff understood their responsibilities to raise concerns and report incidents and staff told us they received feedback from reported incidents. Safeguarding was embedded in the service and medicines were stored, managed and administered appropriately and safely.
  • We rated effective as good because people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
  • There was well-established multidisciplinary team (MDT) working across all the teams we visited. Staff had mandatory training and most had had appraisals and access to personal development.
  • Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005. We saw evidence that patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.
  • We rated caring as good because feedback we received from patients was consistently positive about the way nursing and therapy staff treated them. Patients told us that staff go the extra mile and we witnessed this during our inspection.
  • Patient and their families received compassionate, focused care, which respected their privacy and dignity.
  • Patients and relatives expressed satisfaction with the service and we found a caring and compassionate approach from staff in the areas we visited.
  • We rated responsive as good because services were planned and delivered in a way that met the needs of the local population. The needs of different people were taken into account when planning and delivering services. Staff respected the equality and diversity of patients and their families.
  • The service had many examples of responsive teams working collaboratively to meet their patients’ needs. They provided care close to or within the patients’ home environment, thus reducing hospital admissions.
  • We saw examples of very responsive and accessible services such as rapid referral and quick assessment of patients.
  • We rated well led as good because the provider had a clear statement of vision and values which was integrated within the teams. Staff we spoke with were aware of and based their care around the provider’s values.
  • Staff in adult community services told us they were well supported by local team leaders and managers and felt empowered to develop local solutions based on good practice.

However;

  • Staff did not always manage to update patient records with all the assessments required.
  • IT connectivity problems and pressures on staff time meant there were risks of delayed recording and sometimes incomplete records.
  • Risk management and public engagement needed to be improved.

15 -17 & 30 November 2016

During an inspection of Community health inpatient services

We rated this service as good because:

  • The admissions policy and procedure ensured that patients were suitable for the nurse-led care provided.
  • Medicines were stored securely and medicine audits had been used to good effect to improve practice.
  • The provision of four nurse prescribers on the unit meant that patients’ pain could be relieved in a timely manner.
  • Multi-disciplinary team working was embedded within the unit.
  • GPs on the Unit had access to a consultant community geriatrician. This was in line with national guidance and is an example of good practice.
  • People were treated with dignity and respect and relationships with staff were positive.
  • There was consideration for the needs of patients living with dementia and reasonable adjustments had been made on the unit that were suitable for these individuals.
  • There had been a low number of complaints and the responses provided to those received had been appropriate.
  • Average waits for patients to access the unit were low.
  • Staff on the unit were positive about their local leadership and the support that was provided to them.
  • The risk register reflected the issues that the unit faced.

However:

  • The unit had not reported deaths that had occurred on the wards as part of their statutory requirements.
  • There were high nursing vacancies and a high staff sickness level. In addition there was no acuity tool used for assessing staffing levels and this meant that staffing could be stretched, resulting in delays to patient care, particularly when patients had a higher dependency.
  • Although the unit collected safety information, it was not openly displayed in the ward environment and was not used as part of regular safety discussions on the wards. Levels of harm free care reported in July 2016 were extremely low at 68%.
  • Although patient outcomes were collated and looked at as part of individual care, this was not used to assess the overall outcomes on the unit or look for themes or improvements.
  • Walking frames were removed from some patient’s beds at night, meaning that they were not being encouraged to be independent.

15 – 17 November 2016

During an inspection of Community end of life care

We have rated this service overall as requires improvement because;

  • Some staff were not confident about what process they should follow if patients did not have capacity.
  • There were gaps in MUST nutritional assessments, either not available in patient records or not completed thoroughly.  
  • There were no personalised care plans on nutrition and hydration 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.
  • Staff we spoke with were not aware of the vision and values for the end of life care services.
  • 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 structured end of life care training plan or register of training to ascertain the skills of staff in different roles and teams.
  • There was no care plan and pathway widely in use that was specific to patients who were dying during the inspection.
  • Patient’s records were not holistic and not all reflected emotional and spiritual needs, and in some records, relevant assessments had not been completed and recorded.

However;

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses; they said they had been fully supported when they did so. Staff monitored and reviewed safety incidents to enable them understood the risk associated with their services.
  • The service worked closely with the local hospices to provide a collaborative multi-disciplinary approach to care and treatment.
  • Nursing staff received timely appraisals and were supported with professional development and NMC revalidation.
  • Patients and their families were very positive about staff and the service they received. The service demonstrated a high level of compassionate care to patients and their families.
  • Community nursing staff providing end of life care services told us they were well supported by local team leaders and managers. Staff across the service had opportunities to review the quality of care and the way that teams worked. They told us they felt empowered to develop local solutions based on good practice.