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Archived provider: Gloucestershire Care Services NHS Trust Good

Reports


Inspection carried out on 16 January 2018

During a routine inspection

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.


CQC inspections of services

Service reports published 19 April 2018
Inspection carried out on 16 January 2018 During an inspection of Community end of life care Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 16 January 2018 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 16 January 2018 During an inspection of Community health services for adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 16 January 2018 During an inspection of Community urgent care services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 19 April 2018
Service reports published 22 September 2015
Inspection carried out on 23 - 26 June 2015 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 23 - 26 June 2015 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 23 - 26 June 2015, 4 and 6 July 2015 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 23 - 26 June 2015 During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on 23 - 26 June 2015, 4 and 6 July 2015 During an inspection of Reference: Urgent care services not found Download report PDF (opens in a new tab)
Inspection carried out on 23 - 26 June 2015 During an inspection of Reference: Community health (sexual health services) not found Download report PDF (opens in a new tab)
Inspection carried out on 18 - 21 August 2015 During an inspection of Community dental services Download report PDF (opens in a new tab)
See more service reports published 22 September 2015
Inspection carried out on 23 – 26 June 2015, 4 and 6 July 2015 and 18 – 21 August 2015

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence. There has not been any variation to the ratings principles on this inspection.

Letter from the Chief Inspector of Hospitals

We inspected Gloucestershire Care Services NHS Trust as part of our programme of comprehensive inspections of all community healthproviders. We carried out an announced visit on 23 – 26 June and 18 - 21 August 2015. We carried out an unannounced visit on 4 and 6 July 2015.

Gloucestershire Care Services NHS Trust has a total of 19 registered locations, including seven hospital sites with a total of 196 beds, nine dental locations and community teams registered at the trust headquarters.

During the inspection we visited the following locations

  • Hope House
  • Cirencester Hospital
  • Dilke Memorial Hospital
  • Lydney and District Hospital
  • North Cotswolds Hospital
  • Stroud General Hospital
  • Tewkesbury community Hospital
  • The Vale Hospital
  • Southgate Morrings
  • The Dental Clinic – Redwood House
  • The Dental Clinic – St Pauls Medical Centre
  • The Dental Clinic – Springbank
  • The Dental Clinic - Bourton on the Water
  • The Dental Clinic - Lydney

We inspected the following core services:

  • Community adults
  • Community inpatients
  • End of life care
  • Urgent care services
  • Children and young people’s services
  • Sexual Health
  • Dentistry

We rated the trust as requires improvement overall. The trust was rated as requires improvement for safety, effectiveness, responsiveness and the well-led key questions. We rated caring across the trust to be good, and found it to be outstanding within the community inpatient service.

Our key findings were as follows:

Safe

  • We judged safety in the urgent care service to be inadequate. This is because we were not assured that people were adequately protected from the risk of avoidable harm. We were concerned that some patients waited too long to be assessed by a registered nurse on arrival at Minor Injuries and Illness unites and that unregistered practitioners were undertaking this task without adequate training or supervision.
  • There was a positive safety culture including a proactive approach to reporting incidents, particularly within the community hospitals, however within urgent care services the threshold for reporting an incident was too high.
  • Resuscitation trollies and other equipment were not always appropriately checked.
  • The trust could not be assured about the levels of mandatory training being completed by staff. There was a disparity between locally held and centrally held training data and there was little oversight or understanding of the scale of the problem by the trust. From the information available it appeared that targets for completion of mandatory training were not being met. Not all staff who were required to have undertaken safeguarding training at level 2 had achieved that.
  • All wards within community hospitals were well staffed according to safer staffing requirements (requirements for the minimum levels of staff on an adult inpatient ward). However some services within the trust had insufficient staff to meet needs. Shortage of experienced nursing and therapy staff within the community adults service left teams overstretched.
  • We could not be assured that Minor Injuries Units were consistently staffed by sufficient numbers of appropriately qualified, experienced and skilled staff. Staffing levels and skill mix had not been adjusted in response to increased and activity and a changing profile of presentations.
  • We were concerned that some patients waited too long to be assessed by a registered nurse on arrival at Minor Injuries Units and that unregistered practitioners were undertaking this task without adequate training or supervision.
  • Within the adult community service staff were not consistently following best practice in their approach to pressure ulcer wound assessment.
  • In one community clinic, medical supplies were inappropriately stored above room temperature which meant that the effectiveness of the ingredients could not be guaranteed.
  • Staff adhered to infection prevention and control practices. Staff were ‘bare below the elbows’ and observed good hand hygiene.
  • There were processes in place to ensure the safeguarding of vulnerable adults and children, however processes were not subject to audit within Minor Injuries Units to ensure all concerns were captured and acted upon, and board oversight and assurance was limited.
  • The layout of some Minor Injuries Units meant that waiting patients, including children, were not adequately observed.

Effective

  • Staff in all areas provided care that was based on the best available evidence. However within the Urgent Care Service there was little audit to demonstrate best practice was followed.
  • Multidisciplinary team working featured highly in all areas, with teams working in a coordinated way.
  • In places within the community settings there were difficulties accessing information about patients on the electronic record keeping system because internet connectivity was not always available, particularly in rural areas.
  • Social care staff and health care staff used different patient record systems which complicated the process of obtaining up to date information and important alerts at the point of referral.
  • ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms did not contain clear explanations for the reason for the decision to withhold resuscitation and records of discussions with patients and their relatives, or of reasons why decisions to withhold resuscitation were not always documented.
  • Patients with long-term conditions who might have been in the last year of life were not consistently recognised by staff throughout the trust.
  • The trust was not able to fully assure us that people’s needs were assessed and care and treatment delivered in accordance with current legislation because not all staff had received training in the Mental Capacity Act 2005.

Caring

  • We found that there was a strong, visable patient-centred culture within all of the community hospitals and that patients, carers and relatives were active partners in care and worked in partnership with staff. It was clear that the anxieties of patients and their relatives were alleviated with the caring nature of all of the staff. Staff spoke with passion about their work and were proud of what they did.

  • Throughout the trust care offered by staff was kind and compassionate and promoted people’s privacy and dignity. Staff gave clear explanations for treatment and encouraged patients to reach their goals.

Responsive

  • The community health services for adults were not always planned and delivered in a way that met people’s needs, particularly with regard to people being able to access the right care at the right time for non-urgent needs. There were very long waiting lists for occupational therapy and physiotherapy services both within the integrated community teams and in musculoskeletal physiotherapy, musculoskeletal clinical assessment and treatment (MSKCAT), and pulmonary rehabilitation.
  • Waiting list data held by the Trust was unreliable for the integrated community teams and for certain specialist services such as podiatry, respiratory home oxygen service and heart failure service which meant that senior managerial oversight was unclear. Occupational therapists and physiotherapists did not work on the weekends and there was no plan to implement this.
  • In some areas patients were found to be waiting over six months for dental treatment.
  • Guidance regarding the use of interpreting services was not consistently followed across all areas.
  • There was a fast track discharge to enable patients to return home if they wished to die there
  • Within community hospitals, patients had a very high range of activities, supported by volunteers, available to them which had a positive impact on the wellbeing of patients
  • We found medical cover varied between community hospitals. During the day the level of cover was adequate. However, there were some concerns about the responsiveness of medical staff out of hours.
  • Complaints were managed well and there was a robust method for investigating them. Most complaints were investigated and resolved at a local level. However the trust received very low numbers of complaints given its size and in a number of places it was difficult to find information about how to make a complaint.
  • Staff understood the different needs of the children and young people and attempted to ensure that services were as flexible and accessible as possible to the widespread community.
  • Within urgent care, waiting times had increased as demand for the service had increased. Staffing levels did not always match the activity and pattern of attendances. Referral processes to out of hours services were cumbersome and often entailed lengthy waits or travel to another hospital.
  • Whilst premises were mostly fit for purpose waiting areas at the Dilke Memorial Hospital and at the Vale Community Hospital out of hours were cramped. The triage area at Stroud General Hospital was not enclosed and was not conducive to a confidential consultation and therefore did not protect people’s privacy and dignity.
  • Within the sexual health service, booking practices did not meet demand and consequently patients experienced problems getting through to make an appointment and often ended up attending a walk in clinic. This had resulted in patients being unable to access the treatment they required immediately as some procedures required staff to have additional competencies .

Well led

  • Staff at all levels in the trust described how the culture had changed since the arrival of the current chief executive. Staff talked about a very open and very patient focused organisation. Many staff felt that they were highly valued and that openness and honesty was encouraged and rewarded.
  • The listening into action programme, launched in March 2014 was having a significant impact. There was work going on across the trust to deliver the actions and improvements. The staff that the team met were universally positive about this initiative, even those who said that they had been sceptical at the start. Staff talked in terms of having ownership, feeling responsible and feeling that things were possible.
  • At trust level the governance processes and the management of risk and quality were improving but were not yet sufficiently robust.
  • The leadership of the community health service for adults supported learning and innovation. There were inspiring examples of innovation including the development of a health and social care complexity tool and some collaborative work with an industry provider in tissue viability services.
  • There was some disconnection between frontline staff and the board in terms of awareness of core values and strategy.
  • There was no strategy for end of life care. The trust-board lead for end of life care was unaware of the action plan devised from the 2014 report commissioned into end of life care services. There was no one person in a position to take end of life care forward and maintain responsibility for provision of the service.
  • The leadership and governance around the reduction of falls was extremely good. We found that the multidisciplinary team working with various organisations, risk analysis and the development of innovative mitigating actions had a positive effect on outcomes in the community hospitals.
  • Staff took pride in their work and being at the centre of the community. They wanted to come to work.
  • The impact of change to the urgent care service had exposed deficiencies in governance and leadership of the service. It had exposed vulnerability in terms of staffing levels, skill mix, staff confidence and competence. Some steps had been taken to address this area of risk but this was not being managed in a structured way. There was no timeframe attached to this piece of work and 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.

We saw several areas of outstanding practice including:

  • The seven day service provided by the children’s community team.

  • The volunteer groups were an integral part of the care team within community hospitals. It was clear that they were having a positive impact on patients’ wellbeing by supporting patients, providing activities, and by representing ‘patient’s perspective at governance meetings’.

  • There was a strong caring culture that was embedded throughout the community hospitals. Staff provided compassionate care which was respectful to people’s needs and wishes. Wards were calm and happy places and feedback given to inspectors by patients, carers and relatives was continually positive. Patients said that staff went the extra mile and it was clear that the care they received went beyond their expectations.

  • People’s individual needs were met in all of the community hospitals . A range of social activities were arranged which were imaginative ways of enhancing patients’ inpatient stay and improving their wellbeing.

  • There was systematic approach to falls prevention. Data was collected, analysed and innovative mitigating actions were put in place. This was having a significant impact on patient care within the community hospitals.

  • Innovation and creativity were encouraged and this was impacting positively on patient experience in community hospitals. Examples included the Vintage Room on Jubilee Ward at Stroud Community Hospital and the use of “twiddlemuffs”. Patients and in particular patients living with dementia were using these muffs to occupy restless hands and there was evidence that their use had a soothing and comforting effect on patients.

  • The community hospitals also had an embedded multidisciplinary approach to the care of patients.

  • The sexual health service was an integrated service, with patients being able to access the necessary care and treatment in one place. The multidisciplinary approach enabled all staff to provide the right care, treatment and support to patients.
  • The dental service had responded to the complex needs of their patients and had invested in a number of items of specialist equipment, such as a wheel chair tipper, a number of bariatric chairs and specialist x-ray equipment. This enabled staff to provide treatment in a safe effective and comfortable way for patients.
  • As part of the dementia link work the dental service had produced a training video which consisted of two parts, one demonstrating a poor approach to oral care and the other showing best practice and how this would ensure a good outcome for the patient. The video was used to initiate discussion at training sessions for community and care home staff.

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

Importantly, the provider must:

  • Ensure medicines administered to children within the complex care team are administered safely.

  • Ensure there is a process in place to audit the prescription of medicines by health visitor prescribers.

  • Ensure that staff trust wide have the necessary mandatory training and essential training to ensure safe care and treatment of patients and that the accuracy of data held by the trust in relation to mandatory training is improved.

  • Ensure resuscitation trollies and equipment on them are checked in line with national guidance and that records of these checks are suitable for the purpose they are intended.

  • Ensure that all documentation relating to the ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) include the completion of a Mental Capacity Assessment, to ensure that the patient’s consent and decisions around best interests are served.

  • Ensure DNA CPR forms include reference to discussions with patients and relatives and must be stored in such a way as to ensure all staff providing care are alerted to them.

  • Review and take prompt action to ensure that MIiUs are consistently staffed by sufficient numbers of suitably qualified, experienced and skilled staff.

  • Ensure that patients arriving at MIiUs receive prompt assessment (triage) by an appropriately trained and experienced registered nurse.

  • Develop and improve systems, processes and governance arrangements across all MIiUs to assure high quality, effective and safe care and treatment.

Professor Sir Mike Richards

Chief Inspector of Hospitals