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Provider: Wye Valley NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 18 March 2020

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

  • We rated safe, effective, responsive and well-led as requires improvement and caring as good.
  • We rated seven of the trust’s 13 services as good and five as requires improvement and one as inadequate. In rating the trust, we took into account the current ratings of the five services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.
  • During this inspection, we did not inspect services for children and young people, acute end of life care and outpatients. We also did not inspect, community health services for children and young people or community dental services. The ratings we published following the previous inspections are part of the overall rating awarded to the trust this time.
Inspection areas

Safe

Requires improvement

Updated 18 March 2020

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

  • Surgery was rated as inadequate.
  • Staff did not always use equipment and control measures to protect patients, themselves and others from infection, the design, maintenance and use of facilities, premises and equipment was not always maintained in a manner that kept people safe. Staff did not complete and update all risk assessments for each patient and did not remove or minimise every risk, staff did not always follow systems and processes to safely prescribe, administer or record medicines. The service did not always have enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • Medicine, critical care and maternity at County Hospital, were rated as requires improvement.
  • Not all risks to patient care had been assessed, staff had not received enough training and experience to provide the right care and treatment, trust staff did not always use equipment and control measures to protect patients, themselves and others from infection. The staff did not always use systems and processes to safety prescribe, administer and store medicines.
  • Urgent and emergency care was rated good.
  • Community health inpatients was rated as requires improvement.
  • Records were not clear and easily available to all staff providing care, staff felt that due to staff shortages, they did not have the time needed to complete a full holistic assessment or visit.
  • Community health end of life care and community health adult services were rated good.

Effective

Requires improvement

Updated 18 March 2020

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

  • Surgical services, medicine and community health inpatient services were rated requires improvement.
  • The surgical service monitored the effectiveness of care and treatment and but did not always use the findings to improve, some care pathways were not completed fully or followed, and audits carried out by the service did not always contain action plans. There was no clinical audit programme to benchmark and monitor the quality and effectiveness of the community inpatient services and there were limited measures to monitor and evaluate patient outcomes. The medical service mostly provided care and treatment based on national guidance and evidence-based practice. However, some guidance had not been updated and did not reflect current best practice.
  • Urgent and emergency care, critical care and maternity were rated as good.
  • Community health adult services and community end of life care was rated as good.

Caring

Good

Updated 18 March 2020

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

  • All services were rated good.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment.

Responsive

Requires improvement

Updated 18 March 2020

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

  • Urgent and emergency care, surgery and critical care were rated as requires improvement.
  • People could not always access the service when they needed it and did not always receive care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards. However, the standards had improved since the last inspection.
  • Medicine and maternity were rated as good.
  • Community health inpatient services community health adult services and community health end of life care services were rated as good.

Well-led

Requires improvement

Updated 18 March 2020

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • Surgery was rated as inadequate.
  • Not all leaders had the integrity, skills and abilities to run the service. While leaders operated governance processes throughout the service and with partner organisations, it did not always have a systematic approach to continually improve the quality of its services, not all staff said they felt respected, supported and valued, although staff were focused on the needs of patients receiving care.
  • Critical care and maternity were rated as requires improvement.
  • Leaders did not always have the knowledge they needed to run the service. Staff were not clear about the leadership structure that their service was a part of, the critical care service did not always collect reliable data. Staff could not always find the data they needed to understand performance, make decisions and improvements. Leaders operated governance processes, throughout the service and with partner organisations but there was not always clear escalation to the trust board.
  • Urgent and emergency care and medicine were rated as good.
  • Community health inpatient services community health adult services and community health end of life care services were rated as good.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 18 March 2020

Our rating of use of resources improved. We rated it as requires improvement because:

  • The trust was not consistently making best use of its resources to enable it to provide high quality, efficient and sustainable care for patients.

Combined rating

Combined rating summary

Requires improvement

Updated 18 March 2020

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

  • We rated safe, effective, responsive, and well-led as requires improvement; and caring as good.
  • We took into account the current ratings of the five core services not inspected at this time. We rated seven of the trust’s 13 services as good and five as requires improvement and one as inadequate.
  • The trust was rated requires improvement for use of resources.

Checks on specific services

Community end of life care

Good

Updated 18 March 2020

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However

  • A syringe driver policy was in place and available to all staff via the intranet. However, at Bromyard Community Hospital and the Hereford District Nursing base staff were not sure where to access an up to date policy and were only able to show us an out of date policy.

Community health services for adults

Good

Updated 18 March 2020

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

  • The service had staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients. They managed medicine prescribing well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

  • Records were not clear and easily available to all staff providing care. It was difficult to find the most recent information, including risk assessments, and not all patient documentation had been completed fully, updated or was missing. Not all staff had full access to the patient notes system and could only see their departments notes.
  • Staff felt that due to staff shortages, they did not have the time needed to complete a full holistic assessment or visit. Capacity also impacted in their ability to fully complete patient documentation.
  • The service had not met its target to have 90% of staff trained in basic life support.

Community health inpatient services

Requires improvement

Updated 18 March 2020

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

  • The service did not have enough staff to care for patients and keep them safe. Staff reported being overstretched and unable to complete the necessary recording of all the care interventions and assessments they completed. Staff assessed risks to patients and acted on them but did not always kept good care records to evidence this. The service did not routinely implement all infection prevention control measures, such as staff remaining “bare below the elbow”. The service provided mandatory training in key skills to all staff but did not make sure everyone completed it.
  • Staff did not always store patient records securely and did not always update individual patient records in a timely manner. Some staff told us this was because there was not enough time for them to do so.
  • There was no clinical audit programme to benchmark and monitor the effectiveness of the service. There were limited measures to monitor and evaluate patient outcomes.

However:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Community dental services

Good

Updated 20 January 2016

Overall rating for this core service Good l

We found dental services provided safe and effective care. 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 found the overall care provided at the service to be good. We observed good examples of effective collaborative working practices 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 the service.

Effective multidisciplinary team working ensured patients were provided with care that met their needs and at the right time. This was achieved by thorough effective management of resources.

At the time of inspection we saw no evidence to indicate that the service collected referral to treatment times for urgent and routine referrals, only for patients requiring general anaesthetic. This meant that the services stablished systems and processes did not operate effectively to monitor all the dental services waiting time data. Waiting times for patients requiring general anaesthetic ranged between six and 14 weeks. This met the national 18 week referral to treatment target.

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 that they generally felt well supported and that they could raise any concerns.

Community health services for children, young people and families

Good

Updated 20 January 2016

Overall rating for this core service Good l

Community children and young people’s safety performance was monitored by dashboards and governance processes. When something went wrong there was a process in place to review or investigate incidents involving all staff, children, young people and their families. Lessons were learned and communicated widely to support improvement in all children’s and young people’s services, as well as services that were directly affected. There were clearly defined and embedded systems and processes to keep children and young people safe and safeguarded from abuse. Staff received up-to-date training in safeguarding to an appropriate level. There was active and appropriate engagement in local safeguarding procedures and effective working with other relevant organisations. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Monitoring and review processes and meetings enabled staff to understand risks and gave a clear and accurate picture of safety.

Staffing levels and skill mix were planned, implemented and reviewed to keep children and young people safe at all times. Any staff shortages were responded to quickly and adequately to ensure staff could manage risks to children and young people who used services.

Risks to children and young people were assessed, monitored and managed on a day-to-day basis. Staff recognised and responded appropriately to changes in risks to children and young people who use services. Risks to safety from service developments, anticipated changes in demand and disruption were assessed, planned for and managed effectively. Plans were in place to respond to emergencies and major situations.

Children and young people had good outcomes because they received effective care and treatment that met their needs. Children and young people’s care and treatment was planned and delivered in line with current evidence-based guidance, best practice and legislation, including the Healthy Child Programme (2009) (HCP). This was monitored to ensure consistency of practice.

There was participation in relevant local audits and other monitoring activities such as service reviews and service accreditation. Accurate and up-to-date information about effectiveness was shared internally and externally and was understood by staff, and used to improve care and treatment and children and young people’s outcomes.

Children were cared for by a multidisciplinary team of dedicated and skilled staff. Staff felt supported and had access to training. Wye Valley NHS Trust was an early implementer site (EIS) for the ‘health visitor implementation plan 2011-2015’.

Children and young people and their parent were supported, treated with dignity and respect, and were involved as partners in their care. Feedback from children, young people and families was positive. Children and young people and families felt supported and said staff cared about them. Children and young people were involved and encouraged in making decisions about their care. They were communicated with and received information in a way they could understand. Staff responded compassionately when children and young people needed help and supported them to meet their basic personal needs. Children and young people’s privacy and confidentiality was respected at all times.

Children and young people’s services were planned and delivered in a way that met the needs of the local population. The importance of flexibility, choice and continuity of care was reflected in the services provided. Building community capacity was a key aspect of the community early implementation service (EIS) plan, this emphasised delivering services in a range of settings to maximise the number of people that had access to a range of services.

The integrated family health services (IFHS) model bridged health and social care. The aim of the service model was to improve children and young people’s outcomes and experience through bringing existing community services from health and social care into a more combined way of working. Children’s and young people’s care and treatment was co-ordinated with other services and other providers.

The trust was working with the clinical commissioning group (CCG) and local authority to ensure children had new offers for respite care, prior to closure of 1 Ledbury Road respite unit in March 2016.

Complaints handling policies and procedures were in place. All complaints to the service were recorded. Information on the trust’s complaints policy and procedures was available on the trust’s internet website.

The leadership, governance and culture of community children and young people’s services promoted the delivery of child-centred care. The trust had a clear statement of vision and values that had been developed through a structured planning process with regular engagement from staff. The IFHS community children and young people’s service was undergoing a significant reorganisation of services. We found that some staff were unclear about the long term strategy for health visiting and school nursing services. The trust board and other levels of governance within community children and families services functioned effectively and interacted with other services appropriately. Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, were clearly set out and understood.