Archived: Gloucestershire Care Services NHS Trust

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

Overall rating for this core service Requires Improvement l

• Gloucester Care Services NHS Trust provides community healthcare services for a population of around 605,000 people living in Gloucestershire. Adult community services cover approximately 1045 square miles in the Gloucestershire area. The care and treatment is provided under the regulated activities; diagnostic and screening procedures and treatment of disease, disorder or injury.

• We spent three days inspecting the adult community services provided, during which time we visited staff and patients in Gloucester, Tewkesbury, Forest of Dean, Stroud, Cheltenham and the Cotswolds. We spoke with a total of 95 members of staff and reviewed the following services: 6 integrated community teams which included community nurses, occupational therapists, and physiotherapists, homeless healthcare, diabetes specialist nursing, respiratory nursing, pulmonary rehabilitation, cardiac rehabilitation, telehealth, heart failure, rapid response, overnight nursing, speech and language therapy, endoscopy, outpatient’s clinics, musculoskeletal physiotherapy, wheelchair services, ambulatory care centre, and the Kingham reablement unit. This was in addition to organised drop in sessions where staff were invited to come and speak with us regarding their role and the services provided. We spoke with13 patients and their relatives to seek their views of the service provided.

• During the inspection we looked at patient care documentation and associated records and observed care in patients’ homes and in clinics and in a reablement centre. We reviewed meeting minutes, operational policies and staff records.

• We judged community health services for adults as requiring improvement in the safety domain. Shortage of experienced nursing and therapy staff left teams overstretched. Record keeping was inconsistent and omitted important risk assessments. This meant nursing staff did not always have a clear understanding of a patient’s health status when giving treatment. Staff did not always complete a personalised care plan.

• Staff were not consistently following best practice in their approach to pressure ulcer wound assessment. This meant that deterioration or improvement in a wound might not be detected. In one location, medical supplies were stored above room temperature which meant that the effectiveness of the ingredients could not be guaranteed.

• Some equipment was shared between teams and staff had no record of when this equipment was last cleaned and serviced. Details regarding which patients had used this equipment were not traceable.

• Several of the staff in the community teams were out of date with their mandatory training; this was particularly noticeable in the overnight nursing team. Staff in the community adult teams were not required by the trust to complete the safeguarding awareness level 2 course. This contradicted guidelines produced by the Royal College of Paediatrics and Child Health. Board assurance of safeguarding could be strengthened.

• There was a clear incident reporting system in place, and learning was shared between teams. Community nursing staff had access to well serviced equipment and were able to access specialised equipment to meet patients’ needs when required. The community service used effective hand hygiene procedures.

• The community health service for adults was effective. Teams worked together in a coordinated way and made appropriate referrals on to specialised services. The service participated in audits and developed action plans to improve. Staff gained consent for treatment and involved patients and relatives in decisions. Patients who were experiencing pain were helped to manage their pain. Staff used evidence based care informed by NICE guidelines. Telehealth services were used effectively to prevent hospital admission. A case management model was being used to address the needs of very complex patients at risk of hospital admission.

• Staff experienced some difficulties accessing information because the electronic record keeping system was not always available due to connectivity problems. Social care staff and health care staff used different patient record systems, which complicated the process of obtaining up to date information about patients.

• Healthcare staff tended to refer to other agencies when mental capacity required assessment. Supervision and appraisals of staff were not consistently completed.

• Patients received a caring service from staff that were kind and respectful towards them. Staff treated patients with dignity, involved patients and their families in their care and supported them during times of crisis. Staff gave clear explanations for treatment and encouraged patients to reach their goals.

• The community health services for adults were not always responsive. There were long waiting lists for occupational therapy and physiotherapy, both within the integrated community teams and in musculoskeletal physiotherapy, musculoskeletal clinical assessment and treatment, 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, the respiratory home oxygen service and the heart failure service.

• Staff considered the needs of people who may have difficulty accessing services and adapted their care approach to show respect for cultural factors. There was evidence of learning from the complaints received from patients and families.

• The community health service for adults was well led. There was a clear vision for the service. There were inspiring examples of innovation. This included the development of a health and social care complexity tool and some collaborative work with an industry provider in tissue viability services. Risk registers reflected the key areas of concern to frontline and management staff.

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.

Overall rating for this core service Good

We rated Gloucestershire Care Services NHS Trust as‘good’ overall for its inpatients service. This trust provided inpatient services at seven community hospitals with 196 beds between them. Care was provided by nurses, healthcare assistants and allied health professionals. Medical cover was provided either by visiting consultants from the local acute trust or by general practitioners.

We rated safety as‘requires improvement’. We found a proactive culture of incident reporting and safety performance within all of the community hospitals. However the threshold of what staff considered a reportable incident varied. We saw medicines were appropriately managed according to local policy. Records were mostly complete and concise and the managementof patient risk was well documented. The wards were well staffed according to safer staffing requirements. There were deviations from this but matrons were able to justify the reasoning behind this. Some elements of the environment at Tewkesbury Hospital were not conducive to safe patient care. Bathroom lights turned off automatically while patients were in the bathroom and nurses were not able to observe patients at all times.

We rated effectiveness to be ‘good’. We found positive examples of evidence-based practice being utilised at all of the hospitals. We saw evidence of how changes to best practice had influenced change in both practice and policy. We found an outstanding culture of multidisciplinary working embedded throughout the organisation. Multidisciplinary team meetings were effective and detailed discussions took place about the needs of patients and carers. We saw a fully integrated approach to the management and recording of care records using an integrated care form, allowing all disciplines to work together effectively. Nutrition, hydration and pain relief were managed effectively. Staff were mostly positive about the quality of their appraisals and support received in relation to gaining competencies. However, in surgery staff felt that opportunity to maintain certain competencies was limited due to limited access to specific types of care.

We rated caring to be ‘outstanding’. Environments were calm and happy places. We saw examples of care where nurses and doctors sat with patients to have casual, friendly conversation and were laughing with them. We found that there was a strong patient-centred culture within all of the community hospitals and that patients, carers and relatives were active partners in their care. Patients said that they were treated excellently and that all grades/disciplines always tried to spend as much time as possibleth them. Care offered by staff was kind and compassionate and promoted people’s privacy and dignity. In some hospitals we found that all staff, including external contractors, treated rooms as if they were patients’ homes and asked for permission to enter. Staff recognised and respected people’s needs and always took this into account when delivering care. Patients said that they were always treated as an individual and that they were always asked for consent when an intervention from a staff member was needed.

We rated responsiveness as ‘good’. We found that the service was planned and delivered to meet people’s needs. The average length of stay was 16.9 days which was slightly above the trusts target. Targets had been set to ensure the correct mix of direct access (admittion through GP’s) and acute access patients. We found elements of outstanding practice in the community hospitals. The range of activities available to patients met their needs. Examples of these included strawberries and cream being available during the Wimbledon tennis tournament, drama therapy, and pampering sessions. We found that medical cover varied between sites. Some cover was provided by general practitioners and others by consultants from the local acute trust. There were some concerns about the responsiveness of this cover out of hours. We found that most complaints were managed well at local level..

We rated the well-led domain as ‘good’. We found that the service vision and strategy were substantive, measurable and realistic and that projects for improvement were making progress. We found a positive culture of risk management and managers had good oversight of risks. Risk assessments and risk registers were comprehensive and information was disseminated appropriately. The leadership and governance around the reduction of falls was outstanding. 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 hospitals. We saw very good local leadership in all of the community hospitals and this was reflected in the culture of the staff. Matrons led by example and were supportive of all their staff. However, we found that there was a disconnection between the community hospitals and the executive team. Staff said that communication from the executive team had little meaning and that the staff were not widely visable in the community hospital although this had been improving.

We found two breaches of regulations. Firstly, we found that resuscitation trollies were not appropriately checked and there was some inconsistency in recording of these checks. We also found that the level of compliance for mandatory training did not provide assurance that staff were appropriately trained to provide safe care and treatment for patients. There was disparity between local records and records held centrally by the trust. A level of compliance was recorded differently at a local level than that held by the trust and there was little trust oversight.

Overall rating for this core service Requires Improvement

We found the end of life service to be safe, caring and responsive to patients’ needs and requirements, particularly in the last days of life. Patients and carers told us how good the care was and that staff were kind, caring and considered the patients’ dignity. However we found the service required improvement in the effective and well led domains which resulted in our judgement of requires improvement overall. 

A commissioned report into the end of life services resulted in the development of an action plan to address points raised, however there was no strategic plan in place for end of life care. There was no plan in place for the end of life service to be accredited to best practice in alignment with the gold standards framework. There was no recognition of this work having been commissioned and undertaken by the medical lead for end of life care. There was very little evidence of audit to support effects of some of the work having been undertaken. This meant there was a lack of systems and processes to help identify people entering the last 12 months of life.

It was unclear as to how patients’ mental capacity had been assessed particularly in relation to documentation of the ‘do not attempt cardio-pulmonary resuscitation’ (DNAR CPR) forms. The only provision for seven day specialist care was in the form of a 24 hour advice line being managed by another organisation. Although this was easily accessible to staff there was no provision for patients or relatives to get advice out of hours.

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.

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.

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.