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Archived provider: Gloucestershire Care Services NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 19 April 2018

Our rating of the trust improved. We rated it as good because:

We inspected four of the trust’s seven core services and rated them as good.during this inspection. We rated safe, effective, caring and well-led as good. In rating the trust, we took into account the current ratings of the three services not inspected this time. Responsive therefore remained as requires improvement.

We rated well-led as good because:”

  • The trust had an experienced executive and non-executive director and senior leadership team with the skills, abilities, and commitment to lead the delivery of high-quality services. The leadership team recognised the training needs of leaders and managers at all levels, including themselves, and worked to provide development opportunities for deputies ensuring leadership succession.
  • The board and senior leadership team had set a clear vision and values that were at the heart of all the work within the organisation. They worked hard to ensure staff at all levels understood them in relation to their daily roles.
  • The trust strategy was directly linked to the vision and values of the trust, local sustainability and transformation plans and the joint work with local mental health foundation trust. The trust involved clinicians, patients and groups from the local community in the development of the strategy and work with the local mental health trust.
  • There was a clear five-year quality strategy for the period 2014-19. There were strategic objectives which described the principle aims that the organisation aspired to achieve in 2016-17 and plans for implementation of the 2017-18 priorities to provide high-quality care with financial stability.
  • Non-executive directors visited all parts of the trust on a three monthly basis and fed back to the board to discuss issues staff faced and challenged directors appropriately.
  • The trust had a clear board assurance framework and structure for overseeing performance reports, quality and risk which enabled oversight of issues facing the service and it responded when issues in service where identified.
  • The performance reports included quantitative and qualitative data about the services, which non-executive and divisional leads challenged appropriately.
  • The trust was committed to improving services by learning from when things go well and when they went wrong, promoting training, research and innovation and it enabled divisions to share learning across the trust.
  • The trust included and communicated effectively with patients, staff, the public, and local organisations. It supported divisions to develop their own communication and engagement strategies and encouraged staff to get involved with projects affecting the future of the trust.
  • The trust recognised the risks created by the introduction of new information technology systems in the services. Staff managed these risks well at service level.
  • We saw improvement to the supervision and leadership arrangements within the minor injury and illness units. There was evidence of high levels of respect between staff and passionate and knowledgeable managers who motivated their staff and made them feel valued. Staff told us how their working lives had improved as a result of changes.
  • Board members recognised there were staff shortages in some community services and innovative measures had been taken to improve recruitment in community adults and other areas of the trust.
  • The trust recognised that patients could not always access all services when they needed it. Some services were not always achieving targets for receiving treatment including musculoskeletal physiotherapy and musculoskeletal assessment and treatment services. The services were reviewing their waiting lists daily and implementing actions to improve performance.

However:

  • Black and minority ethnic staff (BME) we spoke with felt the trusts efforts at enabling opportunities for them to be engaged needed to be better to properly recognise what it meant to individual and groups of BME staff in the service. Board members recognised that work was required to improve staff diversity and equality across the trust and at board level and had plans to engage staff better in 2018.
  • Not all staff were trained in the safety systems, processes and practices to keep patients safe in community adults, community inpatients and urgent care. Strategies had been implemented to improve compliance with mandatory training including online training workshops and the appointment of training and development nurses to facilitate local training at community hospital locations.
  • Not all staff had received an appraisal on time and some were given late.

Inspection areas

Safe

Good

Updated 19 April 2018

Our rating of safe improved. We rated it as good because

  • Since our last inspection the trust had continued to deliver a number of training courses in the care and treatment of adults and children. This gave staff confidence they were providing a high standard of care.
  • Systems and processes were in place to ensure the safeguarding of children and vulnerable adults.
  • The clinical spaces were clean, well-maintained, spacious and well-lit. They ensured patient dignity and privacy was respected. The units made specific provision for children, including toys to distract children while they received treatment and to alleviate distress.
  • Checks were carried out on equipment and it was safe to use.
  • Monitoring tools were in place and pathways for the identification and treatment of sepsis were well understood.
  • The triaging system introduced since our last inspection ensured patients were treated in order of clinical priority and the most unwell patients were treated without delay. Patients were triaged by a suitably trained clinician.
  • Since our last inspection, a system for safe staffing levels and the skill-mix of staff had been introduced. This worked alongside a clear escalation process that helped service leads decide when a safe service could not be provided and the unit should be closed.
  • Medicines were stored and managed in a way that kept people safe with clinical protocols that were clear and accessible. Medicines were checked regularly and stored securely and at the right temperatures.
  • Since our last inspection, the culture had improved around the reporting of incidents. Staff understood why incident reporting was important and understood how it could improve patient care.

However:

  • Mandatory and some essential training attainment were below target. For example fire safety, resuscitation (level two), safeguarding, infection prevention and control, safeguarding and the Mental Capacity Act.
  • Standards of hygiene were not always maintained in line with trust policy. On some days, daily cleaning and equipment checks were not recorded as complete, beds not wiped down and a lack of consistency around the cleaning of toys.
  • Sluices containing hazardous materials were sometimes left unlocked and accessible to patients.
  • Audit of the standard of record keeping within the units required improvement. However, the records we reviewed were well-completed.
  • Patients in Cirencester and Tewkesbury were not in direct line of sight by staff whilst they were waiting for treatment. The trust had mitigated risk to patients through intentional rounding, which involved checks every 30 minutes on patients waiting to be seen.

End of life care

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

  • The service provided mandatory training for all staff. There was a comprehensive mandatory training programme, which included courses around patient safety. End of Life training was not mandatory but was covered on the trusts induction programme.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff received training on how to recognise and report abuse and were able to describe how they would make a safeguarding referral.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. Most staff used control measures to prevent the spread of infection and audited practice across all services to monitor performance.
  • Most premises and equipment were suitable and well maintained. Equipment was readily available and any repairs were dealt with promptly.
  • The systems for monitoring equipment and servicing due dates ensured equipment was safe for use in community hospitals and patient’s own homes.
  • Comprehensive risk assessments were carried out for patients and appropriate plans were developed which ensured staff delivered safe care and treatment.
  • Staff kept appropriate records of patients’ care and treatment. All of the records we reviewed were up-to-date and available to all staff providing care. The Shared Care record was kept with the patient for use wherever the patient was receiving care. We saw contemporaneous records were made of the end of life template on the electronic patient record.
  • Medicine management was safe. Staff ensured medicines were prescribed, administered, recorded and stored appropriately. The use of non-medical prescribing meant patients got their medication without delay
  • Openness and transparency about safety issues was encouraged. Staff understood their responsibilities to raise concerns and report incidents. Patient safety incidents were reported appropriately and investigated.
  • When something went wrong, there was appropriate investigation and any learning was shared across the trust.

However;

  • Some specialised equipment was not readily available to the Palliative Care Occupational Therapists.
  • The trust target for completion of mandatory training had not been met. Data provided before and after our inspection showed services had achieved 83% of staff completing mandatory training which was below the trust target of 92% of all staff completing each training module.
  • The service did audit completion of records specific to end of life care, and so could not be assured that these were being completed effectively.

Effective

Good

Updated 19 April 2018

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

In community adults

Our rating of effective stayed the same. We rated it as good because

  • There were processes to ensure care and treatment was delivered in line with current evidence-based national guidance. Team managers and professional leads audited practice and delivered training to staff to ensure the latest guidance was being followed. We observed staff providing care and treatment to patients which was in line with national guidance.
  • Most staff assessed patients’ nutrition and hydration needs using appropriate assessments, where applicable. The majority of patient records, within services we visited, contained malnutrition universal screening tool (MUST) assessments whenever required.
  • Pain assessments were carried out routinely, reviewed regularly and patient’s pain was managed effectively.
  • The service collected data on the effectiveness of care and treatment provided to patients
  • Staff were competent to carry out their roles. Managers carried out appraisals, monitored work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Nurses, therapists and other healthcare professionals supported each other to provide good care. We saw multiple examples of safe and high quality care provided to patients delivered in a coordinated way, by clinicians working across different services.
  • Patients were given advice on improving their general health and wellbeing. This including staff advising patients on smoking cessation and weight loss. Staff within the homeless healthcare service were also supporting patients to address alcohol and drug dependencies.
  • Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system which they could all update. We reviewed patient records and saw that all relevant information was available and could be accessed quickly but there were some delays due to system connectivity issues.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to obtain consent and support those patients who lacked the capacity to make decisions about their care.

However;

  • An audit of the complex leg wound services, carried out between September 2016 and August 2017, showed malnutrition universal screening tool (MUST) assessments had not been recorded in any patient records.
  • Data was collected on patient outcomes within the speech and language, physiotherapy and occupational therapy services but we did not see how the data was being used to improve patient treatment.
  • Not all staff across all services had received an appraisal. The appraisal rates were below the trust target of 92%.
  • However not all documentation related to the Mental Capacity Act was completed in line with the trust’s policy. Recent audit data from 2016 and 2017 showed some services were not recording all data related to consent or appropriate Mental Capacity Act assessments.

In urgent care

Our rating of effective improved. We rated it as good because

  • Clinical pathways, policies and audits were based on national guidance and evidence from NICE (National Institute of Health and Care Excellence) and RCEM (Royal College of Emergency Medicine).
  • Staff had attended programmes of training to maintain and develop their skills. There was a skills and competencies framework that clearly outlined the skills and training required for staff in each role.
  • Significant improvements had been made since the last inspection around the training of staff and the information provided about the care of children.
  • Service leads promoted best practice to staff through audit feedback, supervision, newsletters and team meetings.
  • Staff at all levels said they were well-supported. Although appraisals were not always up to date, staff received regular one to one meetings with their mentor or line manager and met regularly as a team.
  • Most patients in urgent care were asked about their level of pain and given pain relief if they required it.
  • The trust monitored patient outcomes in urgent care through audit and used the information to drive continuous improvement.
  • The levels of unplanned re-attendance in urgent care were better than the national target (0.9% against a target of less than 5%).
  • Staff of different professions and grades worked well together and made good use of each other’s’ areas of expertise.
  • Effective pathways were in place for the referral of patients to specialist services; this included local mental health services.

However:

  • The patient records for venous thromboembolism, chest pain and scaphoid management did not always confirm that the treatment being delivered was in line with the clinical pathways in place.
  • Not all staff were up to date with their training in the Mental Capacity Act (2005).
  • Pathways did not exist for the direct referral of patients for X-ray at the local emergency department. Patients were required to book in as a new patient and be reassessed by staff at the emergency department, which often took several hours.
  • The recording of conversations around consent sometimes missed information about the anticipated outcome, risks, complications and alternative options available.
  • Some staff had not received an annual appraisal.
  • Agency staff did not always have the information they needed to work safely. The welcome pack containing relevant information for agency staff was not known of, or available, at one location.

In community end of life care

Our rating of effective stayed the same. We rated it as requires improvement because:

  • We saw little evidence of outcome data being used to improve or benchmark services. The service was not yet able to collect data about patients dying in their preferred place of death.
  • Not all staff across all services providing end of life care had received an appraisal.
  • The service could not be assured of the effectiveness of their End of Life Care. There was limited audit information relevant to End of Life Care to show the systems in place were being effective.
  • Some staff working in the service at the time of the inspection had no End of Life Care training but were providing care. However detailed End of Life Care training for all relevant staff had been developed and was due to rolled out in the months following our inspection.

However:

  • Patient care, treatment and support was delivered in line with legislation and national evidence-based guidance. Every staff member we talked to within inpatient wards and community settings talked about the ‘Six Ambitions of Care’. This national guidance formed the basis of the trust’s strategy for providing end of life care, and consequently translated into the actions of its staff.
  • Staff assessed and managed patient’s pain effectively.
  • Staff, including nurses and therapists, from different disciplines and organisations worked together to benefit patients. We heard of numerous examples of care provided to patients delivered in a coordinated way, by clinicians working across different services.
  • There was a holistic approach to planning patient’s discharges/admissions to ensure they were in their preferred place of death where possible. Arrangements reflected individual circumstances and preferences.
  • Staff had access to up-to-date and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system which they could all update.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to obtain consent and support those patients who lacked the capacity to make decisions about their care.

Caring

Good

Updated 19 April 2018

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

In community adults

Our rating of caring stayed the same. We rated it as good because

  • Staff treated patients with kindness and compassion. Staff ensured patient’s dignity and respect was maintained.
  • Friends and family test results were high although they were slightly lower (worse) than the England average.
  • Staff identified and provided emotional support to patients to minimise their distress.
  • Staff directed patients to support services when appropriate to do so.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients’ and their loved ones’ needs and decisions were respected and staff kept them informed of developments and treatment plans. Communication with patients was prompt and in a manner which could be easily understood.

In urgent care

Our rating of caring stayed the same. We rated it as good because

  • We saw staff treating patients with dignity, respect and kindness at all times.
  • Staff were aware of patient comfort and privacy. Doors were kept closed and cubicle curtains were drawn during treatment.
  • Staff were sensitive to patient’s emotional needs. Staff responded with kindness to patients who became distressed and private assessment areas were available where confidential conversations could take place.
  • We saw examples of complex and sometimes non-medical needs of patients being handled with consideration. Staff were non-judgmental and non-discriminatory in their attitudes.
  • We saw staff communicating well with patients and ensuring that they were fully informed about their diagnosis, their treatment options and how to look after themselves after treatment.

In community end of life care

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

  • Feedback from patients, those close to them, and stakeholders was continually positive about the way they were supported and cared for. Patients thought staff went the extra mile and the care they received often exceeded their expectations.
  • Staff were highly motivated and inspired to offer care that was kind. Relationships between patients, those close to them and staff were strong, caring and supportive.
  • Patients’ privacy and dignity needs were understood and respected. Relatives of patients said they felt their loved ones were treated with care and compassion and in an individualised way.
  • Patient’s emotional needs and feelings were identified and treated sensitively. Patient’s social needs were also identified. Staff directed patients to relevant support services when appropriate.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients’ and their loved ones’ needs and decisions were respected and staff kept them informed of developments and treatment plans. Communication with patients was prompt and in a manner which could be easily understood.

Responsive

Requires improvement

Updated 19 April 2018

  • Staff planned and provided services in a way that met the needs of local people. End of life Care was planned to ensure patients had flexibility, choice and continuity of care.
  • Patients had access to community and inpatient based services when they needed them. Services were available 24 hours a day seven days a week.
  • There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that met those needs and promoted equality.
  • The service took account of patients’ individual needs. Staff understood how to manage and support patients living with sensory impairments, dementia and learning disabilities. Translation services, including British Sign Language, were available. Staff described having used the service.
  • The service took concerns and complaints seriously. They were investigated and lessons learned were shared with all relevant staff.

However:

  • The service did not capture information about a patients preferred place of death so was not able to not able to analyse if patient’s choices were being met.

Community dental – Southgate Moorings

We did not inspect sufficient services to re-rate. We found that this service was providing responsive care in accordance with the relevant regulations.

  • The service’s appointment system was efficient and met patients’ needs.

  • The service took patients views seriously. They valued compliments from patients and responded to concerns and complaints quickly and constructively.

Well-led

Good

Updated 19 April 2018

  • The trust had managers at all levels with the skills and abilities to run End of Life services. Professional leads had been recruited to ensure clinical leadership was effective. Service leads and managers were approachable and supportive.
  • The trust had a vision for what it wanted to achieve in terms of End of Life services. A countywide strategy had been developed which included an End of Life training framework and improved ways to measure patient outcomes. Implementation was ongoing. Staff were aware of the values of the trust and the plans for End of Life services.
  • Staff were proud to be working for the organisation and spoke highly of the culture across the trust. They felt valued and respected by service leads, line managers and colleagues. There were high levels of engagement with staff. Staff were actively encouraged to raise concerns.
  • There were effective processes for discussing, reviewing and sharing information across services. Service wide and local team meetings took place regularly and all levels of staff were involved in them.
  • The End of Life service had effective systems for identifying and managing risks. Staff were aware of significant risks within their services and knew what was being done to address them.
  • The trust engaged with patients, staff, the public and local organisations to plan their services. There was a post bereavement survey carried out by the trust to actively seek feedback, ideas and opinions from relatives of patients who had died.
  • The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. Pilots were being run within End of Life services to improve the care patients received.

However:

  • A lack of processes to capture the effectiveness of End of Life Care meant there was not sufficient information to enable leaders to understand performance in this area.

Community dental – Southgate Moorings

We did not inspect sufficient services to re-rate. We found that this service was providing well-led care in accordance with the relevant regulations.

  • The service had arrangements to ensure the smooth running of the service. These included systems for the service team to discuss the quality and safety of the care and treatment provided. There was a clearly defined management structure.
  • The service monitored clinical and non-clinical areas of their work to help them improve and learn. This included asking for and listening to the views of patients and staff.

Checks on specific services

Community dental services

Good

Updated 22 September 2015

Overall we judged the dental services to be good. Patients were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.

Dental services were effective and focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practises within the service. The service was able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of staff.

The patients we spoke with, their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion and of effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

The service was well-led. Organisational, governance and risk management structures were in place. The operational management team of the service were visible and the culture was seen as open and transparent. Staff were aware of the vision and way forward for the organisation and said they felt well supported and that they could raise any concerns.

There was effective multidisciplinary team working and links between the different clinics to refer people onward for care. Individual assessments were carried out and specialist equipment was available to meet the needs of patients who had reduced mobility or for those patients who were obese. However. the service was not always responsive to people’s needs, with some waiting times exceeding six months.

We found inconsistencies in decontamination procedures across the service. These had not all been identified through routine audit.

Community end of life care

Good

Updated 19 April 2018

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

  • Action had been taken to address the concerns raised during the last inspection.
  • There was a strong and improving focus on monitoring and improving care for End of Life patients and those close to them.
  • Openness and transparency were encouraged across the trust in terms of risk management and safety. Staff were encouraged to report incidents.
  • There were safe staffing levels with an appropriate skill mix. Arrangements were in place if demand was unexpectedly high or in the case of adverse weather conditions.
  • Staff were motivated and committed to providing the best care and support they could in collaboration with patients and other specialist services.
  • There was a positive culture among the staff. Staff respected each other, their managers, their patients and those close to them. There was active engagement with the local community.
  • Staff were caring and compassionate providing individualised support to patients and those close to them. They worked collaboratively with specialist services to ensure the best possible care for patients tailored to their needs.
  • Patient information was up to date and available to relevant staff. Patients and those close to them were actively encouraged to be involved in decisions about their care.
  • Feedback from patients was very positive. Feedback had identified areas for improvement and the trust had acted on these.
  • Leaders were accessible, approachable and supportive.
  • Staff were motivated and proud to be providing end of life care and support across the trust.

Community health inpatient services

Requires improvement

Updated 19 April 2018

Community health services for adults

Good

Updated 19 April 2018

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

  • Additional systems had been put in place to protect patients from abuse and there were resources for staff to access for additional support. Safeguarding incidents, issues and themes were escalated appropriately and discussed in a wide range of forums.
  • Processes were in place to prevent patients suffering harm. Risk assessments were carried out and risk management plans were implemented in line with guidance. Staff were aware of their responsibilities in ensuring safe care and treatment was delivered to patients at all times.
  • Medicine management practices were safe. Staff ensured medicines were prescribed, administered, recorded and stored appropriately. Services use of non-medical prescribing promoted prompt and effective treatment as delays in prescribing were limited which in turn ensured patients received the right treatment at the right time.
  • Safety performance was monitored and improved to ensure patients did not suffer avoidable harm. Data on safety was collected safety and shared with staff. Patient safety incidents were reported appropriately and investigated to ensure lessons were learned.
  • Evidence based care and treatment was delivered to patients to ensure they achieved the best outcomes. Practice was audited by professional leads to ensure care and treatment was in line with professional standards.
  • Staff were competent in the roles they performed. Competency frameworks were completed to ensure the care and treatment delivered to patient was safe. Staff underwent regular clinical and managerial supervision.
  • Multidisciplinary working across all services was good. Clinicians within different disciplines worked together to achieve the best outcomes for their patients. Care was delivered in a coordinated way and communication between services, teams and staff was clear and prompt.
  • The information available to staff was up-to-date, accurate and comprehensive. Staff could access patient information with relative ease which meant care and treatment could be delivered without delay.
  • Patients received care from staff which was compassionate, kind and respectful. Patients dignity was protected at all times.
  • Staff were aware of and addressed patient emotional needs and offered support whenever possible.
  • Staff ensured patients and those close to them were involved in their own care and treatment.
  • The services provided to patients were planned and provided to meet the needs of local people. Patients had flexibility and choice in respect of where and when they wanted their care and treatment.
  • Patients’ individual needs were considered and staff took action to manage and support patients living with dementia, learning disabilities and those with visual and hearing impairments.
  • Concerns and complaints were reviewed, managed and actioned appropriately. Lessons from complaints were identified and shared with staff.
  • Leaders had the right skills and abilities to run their services which provided high-quality sustainable care to patients.
  • The vision for services was based around improving the quality and safety for patients. The strategy for achieving the vision was reasonable and was centred on improving services by increasing staffing levels and their competency, improving access to information for staff and reducing the waiting lists.
  • The culture within the service was positive and was shared by all staff. Staff felt supported and valued which created a sense of common purpose, promoted challenge and supported performance improvement.
  • Services had systems to continually improve the quality of the care and treatment provided to patients. Information was discussed, reviewed and disseminated across services and to all levels of staff.
  • Risks within services were identified, rated and reviewed. Systems were in place to ensure significant risks were identified and actions implemented to reduce the impact upon services.
  • Information was collected, analysed, managed and used to support all service activities.
  • Patients and staff were engaged to plan and manage services. Collaboration with partner organisations took place and resulted in improvements to services.

However;

  • Despite a comprehensive mandatory training programme available to staff, mandatory training targets had not been met as staff within the service had not completed all modules. This included some safeguarding training.
  • There were three occasions when staff did not follow trust policy, practices and procedures in relation to infection prevention and control.
  • Equipment and servicing were not monitored effectively across all services and localities.
  • There were staff shortages in some services.
  • Record keeping within the service was not always in line with trust policy.
  • It was unclear as to whether outcome measure data was being used to improve or benchmark services.
  • Appraisal compliance rates were below the trust target.
  • Documentation practices, related to the Mental Capacity Act, were not completed in line with the trust policy.
  • Referral to treatment time targets were not be achieved in some services

Community urgent care services

Good

Updated 19 April 2018

  • Actions had been taken to address most of the concerns raised following the last inspection
  • The arrangements for triage had greatly improved. We found it was conducted by suitably trained staff, in an appropriate area and in such a way that they could ensure the most unwell patients were seen without delay and other patients were seen in order of priority. Self-presenting patients were triaged within the 15 minute target timeframe.
  • There were comprehensive arrangements for audit and the service had a strong focus on monitoring and improving the clinical care of patients to ensure it was in line with best practice guidance.
  • Arrangements for clinical skills training were excellent. Skills analysis had been undertaken and staff were aware of the skills they should develop in each role and timescales were laid down for achieving them. Enhanced training had been provided in some subjects, particularly in relation to the care of children and mental health patients.
  • Safe staffing numbers and skill mix had been determined and escalation arrangements were used for managing risk to patients when staffing was disrupted or demand was unexpectedly high.
  • The arrangements for equipment, devices and medicines had been improved. Equipment had recently been safety checked and was in in good condition. Medicines were well-organised, stored safely and at the right temperature.
  • A healthy reporting culture existed where incidents were reported and learning from them was shared with all staff. Staff understood their responsibilities to raise concerns. Serious incidents were managed appropriately and changes made to pathways and processes to prevent things going wrong again.
  • Consideration was given to the needs of patients with mental health needs. Some staff had received training in suicide prevention, information was available for patients engaged in self-harming behaviours and pathways for referring patients to mental health services had improved.
  • Safeguarding procedures and a proactive safeguarding team existed to ensure staff were supported when protecting patients from harm or abuse.
  • There was a positive and caring working culture. Staff respected the patients, their colleagues and managers. We saw healthy engagement with the local community, service users and stakeholders. The trust had an open and transparent approach to enquiry.
  • We saw that staff were caring and compassionate towards patients. They spoke respectfully at all times and responded kindly if patients were afraid or distressed. Staff understood the need for some patients to have privacy or a quiet space. Staff had also thought of the needs of children receiving treatment, particularly at Cirencester Hospital.
  • Arrangements for leadership had improved and staff felt this had directly impacted on their working environment. Staff said that they worked better, were well-supervised and, overall, they felt safer in their work since the new management structure had been introduced.

However:

  • Mandatory and some essential training had fallen below the trust’s expected standards in some subjects. These included fire safety, resuscitation (level 2), safeguarding, infection prevention and control, safeguarding and the mental capacity act.
  • Not all staff had received an appraisal.
  • Cleaning still needed to be improved. Although we saw good hand hygiene and effective infection control arrangements, we saw occasions when beds were not wiped between patients and cleaning checklists were not completed and there was an inconsistent approach to washing toys in the children’s waiting areas.
  • Patients in some units could not be observed by staff waiting for treatment. This was a concern for patients who may deteriorate whilst waiting for treatment. This issue was on the departmental risk register, however it had not been resolved since the last inspection when it was highlighted.
  • The improved audit arrangements had highlighted some performance concerns where patient records suggested the relevant clinical pathways had not been followed in relation to scaphoid fractures, chest pain and venous thromboembolism. Actions had been agreed and re-audits were already planned.
  • The availability of X-ray facilities did not match the times of highest demand. Also, an effective X-ray referral pathway had not been established or discussed with the local acute hospital X-ray department.

Community health services for children, young people and families

Good

Updated 22 September 2015

Overall community health services for children and young people were found to be good. We found that services were safe, effective, caring, responsive and well-led.

Gloucestershire Care Services NHS Trust provided specialist community services for children, young people and families in Gloucestershire. As part of this inspection we talked to 28 professionals delivering the service. We also met and spoke with five children and young people and nine parents. We visited services at Quedgeley Clinic, Stroud General Hospital, the Springbank Resource Centre and the Independent Living Centre in Cheltenham, the Dilke and Lydney hospitals and trust headquarters. We also spent time on school and home visits with the school nurses, community children’s team, health visitors and therapy staff.

We judged the safety of community health services for children and young people as good. Risk was managed and incidents were reported and acted upon with feedback and learning provided to most staff. This was with the exception of the way medicines were administered by health care assistants in the complex care team.

Care was effective, Care was evidence based and followed recognised guidance. There was excellent multidisciplinary team working within the trust and with other agencies.

Care and treatment of children and support for their families was delivered in a compassionate, responsive and caring manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their families.

We saw that staff understood the different needs of the children and young people and designed and delivered services which met the specialist needs of children.

There were clear lines of local management in place and structures for managing governance and measuring quality.

Reference: Urgent care services not found

Requires improvement

Updated 22 September 2015

Overall rating for this core service Requires Improvement l

Overall, minor injury and illness services required improvement.

We could not be assured that there were always sufficient numbers of appropriately qualified, experienced and skilled staff to ensure that people were protected from avoidable harm. Staffing levels, skill mix and competencies had not been reviewed in response to increased demand and a changing profile of attendance. At times units operated with a skeleton staff and this put people at risk. We were particularly concerned that patients arriving at minor injury and illness units (MIiUS) were not being promptly assessed by a registered nurse to ensure that they were appropriately prioritised and cared for. In some MIiUs, patient assessment was being undertaken by non-registered nurses and we could not be assured of their competence to undertake this role.

Risks associated with staffing had been identified but were not yet fully understood. A lack of reliable information compounded this and meant we could not be assured that steps taken to mitigate risks were adequate. Plans to re-model staffing and assess and address any outstanding areas of staff competence were being developed but were in their infancy. Risks did not appear to have been given sufficient attention or priority by the board.

The service was appreciated by those who used it. Patient feedback was overwhelmingly positive. Patients and their relatives told us that staff were caring and compassionate. They they said that they were treated with courtesy and dignity, were given information about their condition and were supported to make informed decisions about their care and treatment. However, we could not be assured that care was effective. The trust provided little evidence that they audited their practice to show that they followed evidence-based guidance and achieved good outcomes for patients. Where audits did take place, there was little evidence of learning or dissemination of learning. There was little assurance of the competencies of staff because this information was not held centrally. Staff received little formal supervision and no clinical supervision.

Patients did not always receive the right care and treatment in the right place at the right time. The service was consistently meeting or exceeding targets in respect of time spent in MIiU and the time people waited for treatment. However, waiting times had increased as demand for the service had increased and, particularly at weekends, staffing levels did not always match demand or the pattern of attendances. Care pathways for people presenting with minor illness were confusing and cumbersome for patients and often entailed patients having to wait, return at a later time or travel to another hospital. Premises were not all fit for purpose. Some waiting areas were cramped and the triage area at Stroud General Hospital did not allow for private consultations.

The management and governance arrangements in urgent care MIiU services did not assure the delivery of high quality care. We were concerned about the lack of information which was available to demonstrate that the service was fit for purpose and able to respond to changing demands.

The service was going through a period of change, brought about by increased activity and a changing profile of attendance. Support provided by out-of-hours services had decreased, following a change of provider. The impact of this change had been significant and had exposed deficiencies in the governance and leadership of the service. It had also exposed vulnerability in terms of staffing levels, skill mix, staff confidence and competence. Some steps had been taken to mitigate identified risks but improvements plans were in their infancy and there were no timescales or accountability agreed for making necessary improvements. Risks did not appear to have been given sufficient attention or priority by the trust board. Board members were not visible or influential in urgent care.

Reference: Community health (sexual health services) not found

Good

Updated 22 September 2015

Overall rating for this core service Good

Gloucester Care Services provided sexual health services across the county of Gloucester. The service was registered to provide the following registered activities: diagnostic and screening procedures, treatment of disease, disorder and injury, termination of pregnancy and family planning. The registered locations were at Hope House on the site of the Gloucester Royal Hospital and Milsom Centre in Cheltenham. Other clinics and services were provided throughout the county which enabled people to access services in their local area.

During the inspection we spoke with 14 patients who were attending the service for care and treatment. Patients were very satisfied with the service they received and made positive comments about the staff who provided their care and treatment. We also received 35 completed comment cards which patients had completed in the week prior to our inspection. These contained positive comments regarding the care and treatment provided, but also reflected that the booking system was problematic and at walk in clinics there was often a substantial wait for treatment.

Services provided by the sexual health services were safe and were delivered by trained and competent staff. Staff were aware of how to report incidents and were encouraged to do so by their managers. Staff generally received feedback following the reporting of an incident.

Lockable storage was provided for all medication within clinics, although we observed two occasions where staff had not followed the system in place to secure the medication.

Infection control procedures were in place in all areas and the environment appeared clean, tidy and free from clutter and odours.

Concerns were reported around staffing levels in some areas therefore services were arranged to ensure a safe service was provided to patients when staffing levels or the skill mix of staff was compromised.

Care and treatment provided to patients from the sexual health service was in line with regional and national guidance. The service provided was an integrated service and staff worked well as a multi disciplinary team to provide a seamless service for patients. Staff were supported by their managers and met for one to one supervision sessions and received annual appraisals.

The sexual health service provided a caring service to patients who attended the clinics. Patient’s privacy, dignity and confidentiality were respected at all times. Patients provided us with positive comments about their experience at the clinic and described staff as friendly, warm, welcoming and professional. Patients were supported by staff to understand their care and treatment options.

Clinics had been provided to improve the access for patients. For example over different evenings and on a Saturday morning. However, the service had a single point of contact booking line which was managed at the clinic at Hope House. Staff and patients considered this service did not meet demand and consequently patients had experienced problems getting through to make an appointment and often ended up attending a walk in clinic. This had resulted in patients not being able to access the treatment they required immediately as some procedures required staff to have additional competencies.

Governance arrangements were in place to monitor audit outcomes, risks and incidents. Risk management systems were in operation and escalated outside of the service where necessary. The service had a clear vision and strategy and staff were proud and positive about their work and working for the trust and the sexual health service.

Staff worked as part of a cohesive and effective multi disciplinary team which provided positive outcomes for patients.