North East London NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating was changed to good. This meant the trust had arrangements in place to support people to receive safe care and treatment.

At our last assessment in 2017 we rated the ‘SAFE’ key question as requires improvement. The service was in breach of legal regulation in relation to Regulation 18 (2)(a), as staff were not consistently or regularly provided with clinical supervision or appraisals. Improvements were also needed in how evidence of clinical competence was recorded for agency nurses. During this inspection, we saw improvement. Most staff were receiving regular supervision and appraisal. We also saw that staff competencies had been clearly documented.

Staff knew what incidents to report and how to report them, in line with the trust’s policy. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information about what had happened and suitable support. Learning from incidents was disseminated and staff were able to give examples of learning from incidents.

Staff completed comprehensive risk assessments which were regularly reviewed. Identified risks were managed or mitigated appropriately. Staff identified and acted quickly when a patient’s condition deteriorated. Staff worked collaboratively with other agencies, such as home care, to ensure continuity of care. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

The service had suitable facilities to meet the needs of patients and their families. The service had enough specialist equipment to help them to safely care for patients. Staff carried out regular safety checks on this equipment. Staff adhered to infection control principles and where appropriate used personal protective equipment.

Staff vacancy and turnover rates were much improved. Mandatory training rates were in excess of 85% and staff could access a range of specialist training appropriate to their role.

Staff were suitably trained and competent to administer medicines. Staff had access to support from the pharmacy department if needed. However, improvements were needed in the policies and processes in place for the management of medicines and secure stationary kept in staff’s homes. Improvements were also needed to ensure that peoples drug allergy information was accurately and consistently recorded.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. The trust had a strong, proactive and positive culture of safety, based on openness and honesty. Staff knew what incidents to report and how to report them, in line with the trust’s policy.

Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information about what had happened and suitable support. Learning from incidents was disseminated at handover meetings and in regular team meetings.

Staff we spoke with gave examples of learning from incidents. Recent incidents where learning had occurred included medicine errors in relation to insulin administration, pressure care and safeguarding.

We observed staff’s attitude to patient care during various meetings. These included safety huddles, handover meetings, multi-disciplinary team meetings (MDT) and risk meetings. Staff were respectful, interacted well, spoke openly, were supportive of each other and came together to problem solve. Senior managers were supportive and where appropriate, identified learning needs for individual team members.

The trust worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We reviewed 49 care records in total. Staff completed risk assessments, and identified risks were managed or mitigated appropriately. Staff worked collaboratively with other agencies, such as home care, to ensure continuity.

Staff told us their teams often received poor quality or inappropriate referrals from acute hospital settings. They were working with these hospitals to improve the quality and safety of transfers of care to community settings.

The trust worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The trust shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff had received adult and child safeguarding training at an appropriate level for the service. Staff knew what to do in the event of any safeguarding concerns and could access safeguarding advice from the trust safeguarding lead in all geographies.

We observed interactions between staff and people using the service. Where there was any information of concern staff discussed it appropriately with colleagues in handover meetings. Where required, appropriate safeguarding referrals were made.

Staff were able to discuss safeguarding concerns with designated safeguarding leads. Staff reviewed the outcomes of safeguarding referrals in handover meetings and in team meetings. Staff in Harold Hill district nursing team had raised a recent safeguarding when equipment delivery by an external contractor had been significantly delayed and not installed in a timely manner for a palliative care patient; significantly impacting the person’s comfort, independence, and ability to have their condition managed effectively.

Pressure care concerns graded stage 3 and above were reviewed in weekly risk meetings.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff understood the Mental Capacity Act 2005 (MCA).We saw that staff completed capacity assessments when appropriate and detailed these in patient care and treatment records.

The trust worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed a comprehensive risk assessment for all patients once they were accepted by the service. This was regularly reviewed and updated. Identified risks were appropriately managed or mitigated. Staff identified and acted quickly when a patients condition deteriorated.

Staff used recognised tools to assess the risk to people, such as the surface, skin inspection, keep moving, incontinence/moisture and nutrition bundle (SSKIN) for all patients who were at risk of pressure damage. Where applicable, staff assessed people who were at risk of physical deterioration using a national early warning score tool (NEWS2), to identify deteriorating patients and, where required, escalated them appropriately.

Pain assessments were carried out where people were able to report on the type and severity of pain they experienced. Staff completed other risk assessments that included prevention of falls, mobility, nutrition and hydration, consciousness, moving and handling and continence. The assessments we looked at all had clearly identified review dates and these reviews had been completed in a timely manner.

Staff took photographs of peoples’ wounds and shared the pictures with the team to confirm how healing was progressing. Staff obtained and recorded patients consent to have pictures taken and stored in their records.

District nursing staff ensured that all visits where the person required insulin were completed each day. There had been an increased demand in district nursing insulin visits and in diabetic clinics over recent years. Staff worked to encourage people who had been discharged from hospital to self-administer insulin. Staff were also training carers to administer insulin to reduce the demand for this service upon teams. The trust had identified that diabetes was expected to rise in the next 17 years by 72%. The trust had worked in partnership to identify 8 exemplar sites across North East London to develop and pilot the upskilling of domiciliary and care home staff to administer insulin, in line with Nursing and Midwifery Council (NMC) delegation guidance.

Staff passed on information about patients they had seen at handover. This included all necessary key information to keep people safe. Staff considered patients’ holistic needs during handovers. To ensure handovers were consistent and covered all key information, staff used the situation, background, assessment, recommendation and decision (SBARD) approach. SBARD is a structured form of communication that enables information to be transferred accurately between individuals.

The trust detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had suitable facilities to meet the needs of patients and their families. Buildings which patients needed to access to receive their care and treatment had appropriate adjustments in place, including the provision of ramps and lifts. The service had enough specialist equipment to help them to safely care for patients. Staff carried out safety checks of specialist equipment to ensure it was appropriately maintained and calibrated.

Staff could obtain specialist equipment for persons when they needed to, by ordering this through an external contractor. Hospital transport to support people to attend appointments was also available. Staff raised concerns that external contractors did not always complete orders in accurately or in a timely manner. For example, the ambulance transport did not pick up patients on time, cancelled patient pick-ups or did not return patients home promptly after their appointments. We saw that staff communicated these concerns with their teams in handovers to ensure appropriate follow-up.

Staff followed clear personal safety protocols, including when working alone in the community.

Staff we spoke with gave consistent responses when asked about the lone working procedures in all teams. Staff routinely shared lone working safety and risk issues in team meetings, handovers and/or huddles.

Team bases had fire risk assessments in place and completed fire drills. Regular environmental checks were completed at team bases and staff reported and recorded environmental maintenance issues in a timely manner.

The trust made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers monitored their use of bank and agency staff and requested staff familiar with the service. When necessary, managers deployed bank and agency nursing staff to maintain safe staffing levels or to support team away days. All bank/agency staff had a full induction and access to trust mandatory training. District nursing staffing levels and allocations were reviewed through twice weekly borough wide staffing and allocation meetings.

Vacancy rates were low. The trust had made efforts to recruit and reduce staff vacancies. For example, the Cranbrook and Loxford district nursing service had, through sustained recruitment efforts in the last 12 months, seen vacancy rates decrease from 30% to 3.38%.

Whist staff in the Romford CHS North team had expressed concern in relation to perceived high turnover - particularly for band 5s - data provided by the trust showed a staff turnover rate of 6% with no band 5 leavers in the past few months.

An overall increase in the demand for community health services meant some staff felt overstretched. This included staff at Barking and Dagenham long term conditions and diabetic clinics and the Chadwell Heath district nursing team providing weekend cover. We shared staff concerns with the trust during the inspection. They told us there was an ongoing audit of weekend work to ensure equitable distribution. A senior nurse was on duty to supervise triage and allocation at weekends. A weekend handover had been introduced to support staff.

Staff completed mandatory training. Completion rates for all teams was 85% and above. In addition, staff received Oliver McGowan training in learning disability and autism. Managers made sure staff received any specialist training for their role such as syringe driver training, leg ulcer management; continuous subcutaneous insulin infusion (CSII); wound debridement; the specialist district nursing course, doppler training, peripherally inserted central catheter (PICC) line and wound care.

Some teams had identified additional training needs for their staff, for example the use of the patient health questionnaire PHQ-9 to assess depressive symptoms and generalised anxiety disorder (GAD). Staff working in the leg ulcer clinic delivered training in this area to other teams.

Staff in some teams told us that access to mobile phones and laptops for bank/agency staff nurses was often limited. This meant other staff had to revisit patients at home to take pictures of pressure ulcers which created additional demands on staff time. We shared staff concerns with the trust during the inspection. They told us that the lack of access to mobile phones for agency staff had been raised with the trusts temporary staffing and digital transformation team. A process was underway to reallocate unused smartphones within the directorate to bank staff. In addition, there were 2 extra laptops per health centre that could be allocated to bank staff.

Staff told us that where agile working and compressed hours were available, it made it attractive to work for the trust as it allowed them to balance work and home life commitments.

Managers gave all new staff an induction tailored to their role before they started work. Band 8 senior nurses in the Havering team had devised a new starter park to help students with their induction. This pack had been adopted and was in the process of being rolled out trust wide.

New starters and trainee nurses were invited to give feedback on their experience of induction and placement across the trust.

The trust assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff adhered to infection control principles and where appropriate used personal protective equipment (PPE) such as masks, gloves and aprons. Staff had undertaken infection control training level 1 and 2. Clinical waste was disposed of safely.

Clinical areas were clean and had suitable furnishings which were visibly clean and well-maintained. In clinic rooms for specialist services, there were examination couches and appropriate equipment, all of which were cleaned between appointments. Disposable gloves, aprons, masks and sanitizing liquid gel was available. Staff kept cleaning records for each examination room. Services provided facilities for people to use, for example, the leg ulcer clinic provided a shower available within a private cubicle to enable washing of the leg prior to assessment and treatment.

We observed staff during home visits practice good infection control. Staff used aseptic procedures including hand hygiene measures when providing care and treatment. Staff kept equipment they used during visits to people's homes visibly clean.

Managers completed audits to ensure that staff maintained appropriate standards of cleanliness and infection control. Cleaning records were up to date and demonstrated that the environment was regularly cleaned. Audit systems included unannounced visits to ensure the nursing staff documented anti-septic non-touch techniques (ASNTT). Staff revisited infection control topics during team meeting learning sets, for example, ‘what does “bare below the elbows” mean?’.

We observed staff mostly following best practice when administering medicines to people. They ensured they also followed infection prevention and control measures when administering medicines in the persons home. We observed staff being kind, caring and compassionate when administering medicines. They would monitor for side effects and talk to people about the treatment they were receiving. However, the recording of drug allergies on the electronic system was inconsistent. Some medicines care plans did not contain up to date information.

Staff ensured that people were involved in decisions about their care and treatment, discussing options available to them and the risks and benefits of each treatment choice. We saw clinicians adapting their approach to ensure that people with communication difficulties could also express their preferences. Patient’s and relatives told us how good the care and support given by the teams was. One person told us their relative was ‘really happy with the care they’ve been receiving and the support with medicines. If I ask for help, then it’s there’.

Staff were suitably trained and competent to administer medicines. Staff had access to support from the pharmacy department if needed. Staff told us they worked within their areas of competence when prescribing and had access to appropriate peer support when considering how to manage complex medicine and prescribing decisions.

People were usually supported to receive their medicines in a way which met their individual needs. Copies of all the relevant care records were kept in the person’s home and were reviewed and updated regularly. Staff worked alongside other healthcare professionals to support the holistic care of people. This included working with end-of-life care teams and diabetic care teams to manage people safely and effectively. Visits where medicines needed to be given were prioritised to be completed earlier in the day to ensure people were receiving their medicines at a consistent time. Where possible staff were also trying to help people maintain their independence by supporting them or their family/carers to administer medicines by providing support and training to those individuals. Concerns about deteriorating conditions or lack of response to current treatment were escalated to and discussed at a daily ‘high level risk’ meeting. Errors had sometimes occurred in medicines administration; however, people were reviewed to ensure they were kept safe, they were informed of what had happened and learning was shared both within teams and more widely to limit the chances of similar errors happening again.

There were processes in place to ensure people were receiving their medicines safely and as authorised. Records were kept in the person’s home whilst active and then returned to base to be uploaded onto the electronic record system once completed. Medicines stored onsite at team bases were locked away, monitored and accessible to authorised staff only. Nurse prescribers who worked in the team ensured they only prescribed within their scope of competency. They were able to have peer discussions and took part in learning at regular non-medical prescribers’ meetings. This helped them keep up to date with knowledge and review cases together if needed.

Pharmacy support to the teams was limited; however, staff told us they could contact the pharmacy department if needed.

Improvements were needed in the policies and processes in place for the management of medicines and secure stationary kept in staff’s home, as this was vague. There could be a safety risk if unauthorised persons accessed medicines or stationery, particularly out of hours. Staff were also unclear about how they would manage medicines effectively in vehicles, especially during hot or cold days. Improvements were also needed to ensure that peoples drug allergy information was accurately and consistently recorded. The recording of drug allergies on the electronic system was inconsistent with this sometimes being recorded as ‘unknown’ which suggested staff had not sought this information. Other times it stated ‘unknown’ when other documents in the persons records did have allergies recorded.

Medicines care plans were reviewed routinely but we found that the detailed information included in them which included doses of prescribed medicines was sometimes out of date. For people administered medicines by district nurses via a PEG (percutaneous endoscopic gastrostomy) tube the authorisations and care records did not give clear instructions of the amount of flush to be given between doses of any given medicine. Flushing is important to prevent medicines coming into contact with each other and the feed in the tube as well as to prevent blockages or degradation of the tube itself. We did not see that these recording issues had impacted safety for these individual patients as the most up to date information was recorded on documents nurses were accessing during each visit.