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Provider: Great Western Hospitals NHS Foundation Trust Requires improvement

Community health services for children and young people are no longer provided by this trust. Urgent care services: the urgent care centre, previously inspected as part of community services, is now reported under urgent and emergency care.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 June 2020

We did not change ratings at trust level at this inspection. Please see summary of services at Great Western Hospital.

Inspection areas

Safe

Requires improvement

Updated 30 June 2020

Please see summary of services at Great Western Hospital.

Effective

Good

Updated 30 June 2020

Please see summary of services at Great Western Hospital.

Caring

Good

Updated 30 June 2020

Please see summary of services at Great Western Hospital.

Responsive

Requires improvement

Updated 30 June 2020

Please see summary of services at Great Western Hospital.

Well-led

Good

Updated 30 June 2020

Please see summary of services at Great Western Hospital.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 30 June 2020

We rated Use of Resources as requires improvement. Since our last visit, the trust had made some progress particularly with addressing its diagnostic 6-week wait performance but much still needed to be addressed. The latest data available (2017/18) benchmarked the trust’s cost per weighted activity unit (WAU) in the best quartile nationally, however we also found that the trust’s financial position had materially deteriorated since our last assessment driven by operational pressures and the difficulty in delivering sufficient cash releasing efficiencies. The trust had a low staff retention rate and its spend on agency staff continued to be high. The trust also did not meet three of the four constitutional standards at the time of the assessment. However, we noted some innovative practices at the trust which helped manage its clinical services productively. These included ‘reverse streaming’ in its emergency department. The trust also had strong programmes in place to continue to develop clinical support services networking.

Please see the separate use of resources report for details of the assessment. The report is published on our website at: .

Checks on specific services

Community health inpatient services

Good

Updated 21 December 2018

We rated this service as good overall, with all key questions rated good. The service had not been inspected before under our current methodology, so we were unable to provide a comparison of ratings. We rated it as good because:

  • Staff were trained in, and followed safe systems and processes to protect people from avoidable harm.
  • Patients’ holistic needs were assessed and care and treatment provided by multidisciplinary teams, using evidence-based care pathways.
  • Staff acted as patients advocates and promoted choice. Staff provided emotional support to patients and their relatives to help them come to terms with their situation.
  • There was coordinated care, with close links with acute and community-based services.
  • The service was well led; leaders had appropriate skills and experience and supported staff well. There were effective governance arrangements.

However:

  • Nurse vacancies, resulted in reliance on temporary staff.
  • Documentation of best interest decisions needed to improve.
  • There was limited therapy provision at weekends.
  • Complaints were not always responded to within target timescales.
  • Some staff felt they had not been engaged early enough in the service’s improvement journey.

Community health services for adults

Good

Updated 21 December 2018

We rated safe, effective, caring, responsive and well-led as good, because:

  • We were assured the service was consistently meeting the requirements to provide safe care in all areas. Staff protected patients from abuse and maintained infection prevention and control standards. Staff were reporting incidents and lessons were learned from these. Safety information was collected and actions taken to improve services.
  • The service was providing effective care, with patients receiving evidence-based care and treatment. Staff from different services, both internal and external, worked well together. Staff were competent in meeting the assessed needs of patients.
  • Staff took the time to interact with patients and those close to them in a respectful, compassionate and considerate way. Patients and their relatives/carers were actively involved in their treatment and care.
  • Services provided reflected the needs of the population served and ensured flexibility, choice and continuity of care. Services were reviewed and improved when they were identified as not meeting the needs of patients. Complaints feedback was used to improve services provided and learning was shared amongst staff.
  • Leaders had the right skills and commitment to improve the quality of the service. The culture was centred around the needs and experience of patients. There were structures, processes and systems of accountability to support the delivery of the strategy and good quality services.

However:

  • Not all staff within community health services for adults were compliant with the trust’s mandatory training programme. There were shortfalls in some areas, including manual handling and adult basic life support.
  • The safety electrical checks on some equipment, including some medical devices, were out of date. However, the trust was aware of this and was taking action to address this risk.
  • Whilst there were systems for monitoring performance, waiting times were not being formally scrutinised until after our inspection.
  • Complaints were not always responded to within the target time frames set by the trust.

Community urgent care services

Requires improvement

Updated 4 August 2017

We rated the urgent care centre to be requires improvement overall. This was because:

  • We were concerned that following a serious incident the service did not explore all possible areas of improvement.
  • Not all staff had received the appropriate level of safeguarding training which put patients at risk.
  • Some medicines were not stored securely and some were not labelled correctly which meant it could not be identified when they were opened.
  • The quality of records required improvement and the records audit process was not robust
  • Compliance with mandatory training was variable so we could not be assured that staff were familiar with safe systems and processes.
  • The business continuity plan was not robust to account for different situations such as adverse weather.
  • There were incidents of inappropriate referral from the emergency department of patients who were too ill to be in the urgent care centre. Patients were sometime inappropriately streamed to the urgent care centre by the emergency department, NHS 111 and the ambulance service.
  • Due to the computer systems in the emergency department and the urgent care centre being different, patients may be waiting up to eight hours without being outside of target times.
  • Some patients did not have the waiting times explained to them which left them uncertain as to why they were waiting.
  • Staff were uncertain about the future of the urgent care centre and required more reassurance from managers during the transition period.

However:

  • Managers had recognised where services could be improved and various work streams were in place to mitigate and improve them.
  • Staff understood their responsibilities to raise concerns and report incidents. Learning from incidents was shared with them.
  • Staff held the appropriate qualifications and training to perform their role. Staff were given opportunities to develop and improve their skills and to progress within the service.
  • Staff worked well with other services, such as NHS 111, the ambulance service, GP’s and, particularly ambulatory care, to ensure that treatment was effective.
  • Feedback from patients was positive about the way staff treated them. Patients were treated with dignity, respect and kindness during all interactions.
  • Staff encouraged patients to be partners in their care and supported them to make decisions. Staff responded compassionately when people needed help.
  • Confidentiality was respected at all times.
  • The department consistently met or exceeded the national standard which requires that 95% of patients are discharged, admitted or transferred within four hours of arrival at the urgent care centre.
  • There was suitable support provided to patients with complex needs such as patients living with dementia or a learning disability. Staff understood the reasonable adjustments needed to ensure vulnerable people were cared for appropriately.
  • The urgent care centre was accessible by patients with a disability and chaperone and translation services were available.
  • Governance and performance management systems were being proactively assessed and established. The centre had set up a dashboard and governance processes in line with processes in the wider trust and were using them to monitor performance
  • The urgent care centre used risk registers to identify where the biggest risks were and they were taking steps to mitigate known risks.
  • Leadership the urgent care centre were proactive and well respected. The leadership within the unscheduled care division had the skills needed to integrate the urgent care centre with the division.
  • Despite the amount of change going on within the urgent care centre, staff morale was positive; staff felt respected, valued, and supported by their leadership team.

Community health services for children, young people and families

Outstanding

Updated 19 January 2016

Overall rating for this core service

Outstanding

We found that services were safe, effective, caring, responsive and well led. The staff were competent, compassionate, enthusiastic and well supervised in their role. During the inspection, we met with managers, staff, children, young people and parents in a variety of community settings. We observed staff delivering care being in schools, outpatient clinics and in the child’s own home. There was an open reporting culture for any incidents that took place. Staff were encouraged to raise incidents and managers gave them feedback when appropriate. Staff were aware of their responsibilities to safeguard children and young people from abuse and worked closely with different agencies where appropriate. Recruitment had been a concern within the health visiting service, but we did not see any evidence that this had a negative effect on the care provided.

Care provided to children and young people was evidence based, using NICE guidance, Department of Health research and from advice from specialist centres. Local, regional and national audits were undertaken. Managers shared the outcomes with staff and, where services needed to improve, we saw action plans in place and plans to re-audit. Multidisciplinary and multi-agency working was embedded across the teams. We saw evidence that staff received regular supervision and appraisals.

We received excellent feedback from children, young people and their parents/carers about the care and treatment they received and the staff who provided it. Staff were skilled at communicating with children and young people and treated them with respect and dignity. Staff were friendly, warm, caring and professional. Staff always put the children and young people at the heart of everything they did and always involved them in their care and treatment. Specially trained health visitors and school nurses took part in a rapid response team to support parents in Wiltshire who had experienced the unexpected death of their child. We saw staff were responsive to the needs of children, young people and their families. Interpreting services were used for families where their first language was not English. Robust clinical governance structures were in place. Staff felt supported by their team leaders and managers within the community services.

Community end of life care

Good

Updated 19 January 2016

Overall rating for this core service GOOD 

We judged the overall service provision of end of life care as good. We found the service to be safe, effective, caring, responsive and well-led.

There were systems in place to keep patients safe. There was a good provision of equipment, including syringe drivers and mattresses for patient use in the community. We saw pre-emptive prescribing of anticipatory medications and availability of the ‘just in case’ medications.

End of life care was delivered through evidence based research and guidance. Education programmes had been developed and delivered, new documentation had been successfully introduced to the trust improving the pathway for patients

Patients and relatives spoke highly of the teams of nurses in the community; they were seen as very responsive to their needs. Out of hours there were good resources for staff to access including a 24 hour advice line managed by specialist palliative care nurses at a local hospice.

End of life care was seen as a priority for the trust. There was a clear overarching strategy for the service and plans to improve the delivery of care had already begun to take place with good results. The staff were able to collate evidence and influence change to improve services for patients.