Shropshire Community Health NHS Trust

Updated 1 August 2019

Not used

Updated 1 August 2019

• All six core services were rated as good overall

Our full inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/R1D//reports.

Updated 1 August 2019

• Staff protected patients from avoidable harm and abuse. They ensured that legal requirements were met.
• There was a good multidisciplinary and multi-agency approach to coordinated care and treatment for patients.
• Staff provided effective care and treatment to patients that met their needs and resulted in good patient outcomes.
• Staff treated patients and those close to them with dignity and respect. They supported patients and their loved ones, and involved them as partners in their care.
• Services were delivered and organised in a way that met the needs of the local population.
• The leadership, governance and culture promoted the delivery of high-quality, patient-centred care.

Updated 1 August 2019

• We rated safe, effective, caring, responsive and well-led as good.
• The service had enough staff with the right skills and training with managers who supported and monitored their performance.
• There was a positive working culture where learning from incidents was encouraged.
• There were effective safeguarding procedures in place and multidisciplinary teams worked together to protect vulnerable children.
• Staff provided individualised, child-centred care. Children, young people and their carers were treated with compassion, dignity and respect. Staff provided appropriate information and support to enable them to make decisions about the care they received.
• National programmes of care were followed and evidence-based practice was delivered across all children services.
• There were clear governance structures to monitor the quality of care delivered.

Updated 1 August 2019

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

• Staff were qualified and competent to carry out their roles. They completed mandatory training to support them. There were effective systems in place to safeguard patients from abuse or neglect. Premises and equipment were clean and hygienic and used dental instruments were sterilised according to nationally recognised guidance. As a result of two never events a process had been put in place to reduce the likelihood of these occurring again.
• Staff provided treatment, advice and care in line with nationally recognised guidance. The service used skill mix effectively through the use of dental therapists and dental nurses with extended duties. Staff worked together as a team and with other healthcare professionals in the best interests of patients. Staff had a good awareness of their responsibilities under the Mental Capacity Act 2005.
• Staff cared for patients with compassion and kindness. Patient feedback was positive. They told us staff were kind, polite, pleasant and respectful. We observed positive interaction between staff and patients.
• The service took into account patients’ individual needs. Reasonable adjustments had been made to all clinics which we visited to help wheelchair users or those with limited mobility to access dental treatment. The service had hoisting facilities and a wheelchair tipper. The service provided care and oral hygiene advice to patients at the local orthopaedic hospital. The service dealt with complaints promptly, positively and efficiently.
• There was a clearly defined management structure. Managers had the right skills to support high quality sustainable care. Systems and processes were in place to help manage the risks associated the carrying on of the regulated activities. Staff engaged with patients, external stakeholders and other healthcare professionals to continually improve the service.

However:

• Not all actions identified in the fire risk assessment at Dawley dental centre had been actioned.
• A blind ended pipe which had been identified in the Legionella risk assessment at Shrewsbury dental centre had not been removed.
• Glucagon was not stored in a temperature monitored fridge and the expiry dates had not all been adjusted accordingly.
• The dentists did not obtain signed consent for urgent courses of treatment.

Updated 1 August 2019

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

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staffing levels and skill mix were planned and reviewed so that people receive safe care and treatment.
• The service controlled infection risk well. Staff kept equipment and the premises clean. They used control measures to prevent the spread of infection.
• The service had suitable premises to meet patient’s needs. The environment was secure. Equipment had been regularly tested for safety in accordance with policy.
• Staff kept appropriate records of patients’ care and treatment. Records were mostly clear, up-to-date and available to all staff providing care. Records were audited in order to identify areas for improvement.
• The service stored, prescribed, administered and recorded medicines appropriately. Patients received the right medication at the right dose at the right time.
• Risks to people who used services were assessed, and their safety was generally monitored and maintained.
• The service used safety monitoring results appropriately. Managers collected safety information and shared it with staff, patients and visitors.
• The service generally managed patient safety incidents appropriately. Staff recognised incidents and reported them. Managers investigated incidents and lessons learned were shared with the team and wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service demonstrated that it provided care and treatment based on national guidance and evidence of its effectiveness. Managers had policies and processes in place to ensure that sure staff followed guidance and best practice.
• Staff gave patients enough food and drink to meet their needs and improve their health. The service made adjustments for patients’ religious, cultural and other preferences.
• Staff assessed and managed patients’ pain and pain assessment tool were in the process of being introduced for people who experience difficulty communicating.
• The service monitored the effectiveness of care and treatment and used the findings to improve them. They worked with other services to improve outcomes for patients.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them in order to provide support and monitor the effectiveness of the service.
• Staff worked together as a team to benefit patients. Doctors, nurses, therapists and other healthcare professionals supported each other to provide care.
• The service reviewed patient needs to improve their health. Recognised national screening mechanisms were seen to be used as part of the inpatient admission process.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them with kindness and care.
• Staff provided emotional support to patients and carers to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment. The service took action to address issues of patients not feeling involved in their care and treatment, including addressing issues with ward and medical staff.
• The trust generally planned and provided services in a way that met the needs of local people. There was coordination between the community hospitals, acute services and community services to plan and delivery services which meet people’s needs. The service was reviewing therapy input within the inpatient service to ensure it met people’s needs.
• The service took account of patients’ individual needs. Services were planned, delivered and coordinated to take account of people with complex needs, for example those living with dementia.
• There was a general decrease in the percentage of patients who experienced discharges that were delayed.
• Lessons learned from the results of complaint investigations were shared with staff.
• The service had leaders at all levels who were visible and approachable with the skills and abilities to run the service. Staff spoke positively about the senior management team and ward managers and they felt supported by them.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action. Objectives had been developed which were aligned with the trust objectives.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Most staff reported they felt respected and valued.
• The service used a systematic approach to continually improve the quality of its services and safeguard high standards of care by creating an environment of excellence in clinical care.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
• The service engaged with patients and staff to plan and manage appropriate services.
• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

However:

• The service provided mandatory training in key skills to all staff but did not make sure that everyone completed it. Mandatory training compliance rates were below the trust target, including for safeguarding.
• We found that some improvements could be made to falls prevention as assistive technology was not readily available for use as a method of mitigating the risk of falling.
• There were limited outcome measures in use for therapy interventions and this was recognised by the service as an area for improvement.
• Mental capacity assessments were not undertaken by all nursing staff although managers were in the process of addressing this with additional staff training.
• Patients could not always access aspects of the service when they needed it; patients admitted at evenings and weekends did not have timely access to routine medical assessment. Therapy services were not readily available over the weekends and staffing issues had resulted in a reduction against planned physiotherapy cover.

Updated 1 August 2019

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

• We rated safe, effective, caring, responsive and well-led as good.
• The trust now had an end of life strategy and staff documented and monitored patients’ medical care through the use of care plans.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• Staff were given time to reflect and review their practice and this was recorded in a workbook to demonstrate skills, knowledge and competencies supporting NMC revalidation.
• The service controlled infection risk well.
• Records we looked at showed that assessments of patients’ needs were recorded to minimise their risks and maximise their comfort.
• The service now provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• A staff supervision strategy was now in place to support staff in delivering high quality, safe care.
• The service now monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff provided emotional support to patients to minimise their distress. Families and patients unanimously told us that the staff were all caring and thoughtful.
• Patients’ individual needs were now appropriately planned and risk assessed.
• Concerns and complaints were taken seriously, investigated and lessons learned from the results, which were shared with all staff.
• A wealth of complimentary cards and letters, received from relatives, were displayed in the community wards.
• Managers had the right skills and abilities to run a service providing high-quality sustainable care. Leaders were visible and approachable.
• Staff now felt engaged and valued. The leaders had become fully engaged with regards to promoting the strategy. The drive and commitment was evident to all staff involved with the process.
• Managers promoted a positive culture that supported and valued staff.
• The service had effective systems for identifying risks.
• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

However:

• The service should ensure progress is made in the implementation of electronic prescribing for prescriptions with the necessary security safeguards.

Updated 1 August 2019

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• The MIU and DAART environments posed some challenges to staff. The trust was aware of these challenges and plans to address these challenges were in progress. Suitable equipment was in place and was appropriately maintained.
• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
• An effective early warning system was in place to identify deteriorating patients and appropriate action was taken in response to this.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
• The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Where appropriate, the staff gave patients enough food and drink to meet their needs and improve their health.
• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Patients were supported to live healthier lives and manage their own care and wellbeing needs where appropriate.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They understood how and when to assess whether a patient had the capacity to make decisions about their care and followed the trust policy and procedures when a patient could not give consent.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The trust planned and provided services in a way that met the needs of local people.
• The service took account of patients’ individual needs. This included the needs of people with a mental health need or learning disability.
• People could access urgent care services during their opening hours. Waiting times from initial presentation/referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high quality sustainable care.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
• The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

• The service provided mandatory training in key skills to all staff. However, the trust’s training compliance targets were not always met.
• The service did not always have enough permanent staff available to provide care and support. However, bank and agency staff were used to mitigate the risk of harm and to ensure patients received the right care and treatment at the right time.
• The service should ensure that patients’ right to confidentiality and privacy are protected consistently protected.
• The service should continue to engage with commissioners and other providers to ensure local X-ray services are available to patients when they access urgent care services.

Updated 7 September 2016

We have rated this service overall as requiring improvement. This is because:

• Systems or processes were not sufficiently established and operated to effectively ensure the trust was able to assess, monitor and improve the quality and safety of end of life care.

• There was no risk register specific to end of life care.

• There was no method of categorising end of life care incidents and complaints to monitor themes and share learning.

• On some prescription charts, guidelines stating the limits to frequency of dosages of anticipatory medicines were not always present.

• Plans did not provide sufficient information to identify the personal wishes and preferences of patients and their families.There was a lack of assessments of patient’s cultural, spiritual and emotional needs.

• 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. The trust had implemented the end of life care plan prior to ensuring sufficient numbers of staff had received training on how to use it.

However we also saw that:

• End of life care provision was caring and responsive to patients’ individual needs and requirements. Relatives told us how good the care was and that staff were kind, compassionate, caring and considered the patient's dignity.

Updated 7 September 2016

We rated this service as requires improvement. This is because:

• The service did not have sufficient staff to provide effective care. None of the CAMHS teams could provide the full range of psychological therapies recommended by the National Institute for Health and Care Excellence (NICE).
• Average caseloads within the CAMHS learning disability team exceeded national guidance.
• The tier 2 Telford and Wrekin service was not fully staffed and was unable to triage referrals to CAMHS or offer interventions on a Friday.
• Staff did not feel engaged by senior managers. Staff found out about a major CAMHS transformation plan after its public release and did not broadly believe that senior managers understood CAMHS services or listened to their concerns.
• The trust failed to consistently inform staff about lessons learnt from CAMHS incident investigations.
• The service did not effectively manage waiting lists. Teams organised waiting lists around where patients lived rather than the urgency of patients’ needs. Staff did not actively monitor for changes to waiting list patient risk levels.
• The service made limited use of outcome measures and did not undertake regular audits of performance and quality. The service did not use key performance indicators other than referral-to-treatment waiting times to measure and monitor the quality of services.
• The environment was not suitable for delivering effective care. Soundproofing was ineffective across all CAMHS sites. Conversations and movement were heard between staff offices, consultation rooms and adjacent rooms, disturbing work and compromising confidentiality.

However we also saw that:

• The service worked around patient, family and carer needs.
• The teams had flexible appointment times, and carers told us they could access support quickly if needed.
• Staff were respectful and supportive and adapted their behaviour to match patients’ ages and specific requirements.
• Staff completed detailed and recovery-focused care records. Staff also worked with patients, families and carers to produce written plans that set out how the service would meet the patient’s care and support needs.
• The service encouraged and facilitated patient feedback, and made changes based on this feedback where possible.
• When the service received formal complaints, the trust investigated responded and implemented changes when appropriate.

Updated 7 September 2016

We rated this service as requires improvement. This is because:

• The recording of information about safety within Care planning and Risk Assessment documents was often partial or incomplete. In the paper and clinical notes we reviewed, we found staff had not documented the identified risk and management plans sufficiently well.
• There were no serious incidents recorded in the previous twelve months. Incidents could be reported on Datix.
• Trust substance misuse team staff did not use trust systems or processes to learn from safeguarding incidents, instead relying on the local authority to manage and feedback on all safeguarding incidents.
• The Community Substance Misuse Team (CSMT) had not responded to public health guidance on opiate overdose, shown by the fact it had no programme for delivering Naloxone hydrochloride. Opiates are medicines with effects similar to opium. This includes illicit heroin which is a drug associated with a high risk of overdose. Naloxone is a medication used to block the effects of opiates, especially in overdose. Public health guidance states it is good clinical practice to give this drug to substance misusers and their carers.
• Multidisciplinary teamwork was inadequate and there was no evidence of case discussion in clinical notes.
• There had been no clinical supervision of prescribing medics since June 2015.
• However, we also found the following areas of good practice:
• Patients reported positive experiences of approachable and caring staff at the CSMT.
• There were short waiting times for community detoxification although these had recently increased.
• Community detoxification was carried out in accordance with NICE clinical guidelines.
• Referral to partnership agencies was high as recorded in the clinical notes.
• We saw that the service consulted local community pharmacists about patients it referred to them.
• Electronic prescribing systems and administration were well organised and systems were in place for the timely and accurate production of prescriptions for controlled drugs.
• Mandatory training records for safeguarding were observed by the inspection team to be up-to-date and meeting trust targets.
• We saw that supervision and appraisal records were up-to-date.