Buckinghamshire Healthcare NHS Trust

We had previously carried out a comprehensive inspection in March 2014 because Buckinghamshire Healthcare NHS Trust was in special measures and had been flagged as a potential risk on the Care Quality Commission’s (CQC) intelligent monitoring system. In March 2014, we inspected Stoke Mandeville Hospital, Wycombe Hospital and Amersham Hospital. We did not inspect the Minor illness and Injury Unit at Wycombe Hospital as this is run by Buckinghamshire Urgent Care Service. The trust came out of special measures in 2014. However, there were still concerns about staffing levels (particularly of senior medical staff at night and weekends), the emergency care pathway and patients’ experiences of care . The responsiveness of emergency care services and the effectiveness of end of life care services were rated ‘inadequate’ at this time. These reports are available on our website.

For this inspection, we carried out a comprehensive inspection of the trusts community health services in Buckinghamshire on 24 – 27 March 2015 and unannounced inspections on the 10 - 11 April 2015. We also undertook an unannounced focused inspection of urgent and emergency care and end of life care services at Stoke Mandeville Hospital and end of life care services at Wycombe Hospital on 24 - 27 March 2015. This is because these core services had at least one inadequate rating based on the previous inspection findings in March 2014.

Overall, this trust was rated as ‘require improvement’. The trust required improvement to provide safe, effective, responsive, and well led services, we rated it ‘good’ in terms of providing caring services.

Our Key findings relate to the inspections findings in March 2015.

Key findings from our focused inspections

• During our inspection in March 2015 we identified that the trust had made significant improvements to the urgent and emergency care services. The pace of change over the last 12 months was rapid and there was clinically led service developments. Services were being planned based on the needs of the local population and action was being taken, in conjunction with health and social care partners across Buckinghamshire, to respond to demands. There were new services to speed the assessment and treatment of patients and avoid patient admission to hospital. The trust had identified peak attendance times in the emergency department (ED) and planned staffing to respond. The new services included an initial assessment and treatment centre in the ED, assessment and observation centre (AOU), short stay acute medical unit, and ambulatory care service. These areas still needed to function appropriately across the hospital as patients were still delayed in the ED.

• Patients in the ED were assessed and treated within standard times and the modified early warning score was used effectively to identify deterioration in a patient’s clinical condition. The service needed to improve its assessment and documentation of patient risks, for example, for falls and pressure ulcer damage. The service had improved its performance against the national emergency access target (that is for 95% of patients to be admitted, transferred or discharge within four hours). However, the target was not being met consistently. The hospital response to the flow of patients still needed to improve. We observed the ED to be busy but calm. Many patients were still waiting for excessively long periods in the ED although they did not have long waiting times on trolleys or in corridors.

• We found improvements in end of life care. Nursing and medical care had improved and patients received better symptom control and anticipatory drugs for pain relief. Patient’s nutrition and hydration needs were being assessed. Patients and relatives gave examples of compassionate nursing care. They felt involved and informed regarding their care and treatment.

Key findings from our community health services inspection

• Community services varied in their service developments. The trust clinical strategy was around the integration of acute, community and primary care service. This was developing in adult community services and under strategic development and consultation in end of life care and community inpatient services. The strategy was undeveloped in children, young people and families services. Governance arrangements and risks needed to be better managed across all community services. The leadership of the children, young people and families services was ‘inadequate’ with some managers at team and operational level demonstrating inappropriate behaviours to manage risks and ensure and open and transparent culture. Patients were complimentary about services although some concerns were indicated in community hospitals

Children, young people and families

• The majority of parents told us they were treated with dignity and respect by community staff. The staff displayed an encouraging, sensitive and supportive attitude and children and young people’s personal, social and cultural needs were recognised. Staff understood and respected confidentiality.
• Patients, and those close to them, were involved in their care and treatment. The staff took the time to tell children in an age appropriate manner what was going to happen and encouraged them to ask any questions about the treatment. Parents were supported to manage their own health, care and wellbeing. Parents told us they felt confident in managing their children’s needs. Parents and children were supported emotionally.
• The parents we spoke with told us that the services were accessible and that staff were knowledgeable, informative and caring.
• The trust’s incident report system was not being used appropriately. Some staff were not reporting incidents and some had been discouraged to report. Where incidents were reported, there was evidence of action but there was not consistent learning or improvement for when things went wrong. There was no assurance that all incidents and risks were being adequately identified and managed.
• Staff we spoke with were able to recognise safeguarding concerns for children and young people and showed a good knowledge and awareness of the safeguarding processes. However, some staff within school nursing teams told us that they had been asked to participate in child protection work beyond their competencies. Information was unclear on the level of safeguarding children training staff had undertaken.
• Staff identified that budgetary constraints meant that some equipment was not available, such as clinical needles for immunisation and toys to distract children when receiving treatment.
• The trust used a mixture of electronic and paper records. Some electronic systems were not compatible and so information was not being shared effectively across services about children’s care. Records did not appropriately include salient information that summarised children’s health needs and family history.
• Staff were following infection control procedures but toys were not being appropriately cleaned. Trust targets for staff mandatory training were not met.
• The service was assessing risks to patients but were not responding effectively due to workload pressures. Some children with identified risks were not being seen in a timely manner or could be missed because processes were not robust.
• Staffing levels were assessed and vacancies were identified as low. However, a matrix for weighting health visiting caseloads had identified a shortfall in health visitor hours. The ratio of qualified school nurses to number of secondary schools was below that recommended by national guidance. Staff within health visiting and school nursing teams told us that they were unable to perform certain aspects of their role due to workload pressures. The family nurse partnership could only fulfil 40% of its programme because of staffing capacity
• Medicines were appropriately managed.
• National and evidence based practice guidelines were used to define services. However, the guidance was not always followed for example, there were only targeted, not universal antenatal contacts by health visitors; this meant there was limited early identification of need and risk. The trust was not meeting its own performance targets in key areas and there was not effective audit and monitoring to demonstrate patient outcomes or compliance with quality standards.
• There were a limited number policies that covered care and treatment to children and young people and practice was inconsistent. Staff did not have support to develop professional practice around national guidance and there was inconsistent care and support provided across teams.
• Staff supervision and appraisal varied and staff identify difficulties in accessing training. There were no specialist trained nurses working with children with a learning disability. Staff working with children with a learning disability told us they did not fully understand the Mental Capacity Act 2005 and the deprivation of liberty safeguards (DoLS) to ensure decisions were being taken in a child’s best interest.
• There was effective multi-disciplinary working in therapy teams but coordination of care pathways and IT arrangements to share information or liaise with other agencies, such as GP surgeries, midwives and across acute hospital care, were inconsistent . There were good arrangements for multi-disciplinary team working for looked after children.
• Community children and young people’s services were commissioned with indicators to monitor operational service delivery. The services were not informed by the needs of the population and not addressing the needs of different people.
• The initial assessment within 28 days for looked after children target were not met. The waiting list for the learning disability service was not meeting the 18 week waiting time target.
• Staff had had training in equality and diversity and individually took account of patient needs but services were not offered to support the needs and preferences of different people that might be based on age, gender, race or religion. There was no evidence of reasonable adjustments for people with a physical disability. Interpreter services were available but information leaflets were only printed in English.
• There was not a consistent way of logging, investigating, responding to and learning from complaints. Most staff did now the process for handling complaints. People we spoke with did not know how to make a complaint or raise concerns. Where concerns had been raised, these were not always addressed.
• Staff told us that they prioritised work with people in vulnerable circumstances and would see people at times and places convenient for the young people and parents or carers. We saw evidence of person-centred care that showed community staff were responsive to individual needs and worked flexibly with people towards improved health and wellbeing.
• Children had good access to services, and parents could attend appointments with health visitors and at child health clinics at convenient time

• The trust did not have a strategy for children and young people’s services. Staff did not know and understand what the vision, values and strategy were for the trust. The majority of staff told us that the services they delivered were not high on the trust agenda.
• Staff within school nursing team told us that they were discouraged or not heard when they raised concerns about being able to deliver services safely. There had been a lack of management support and staff were dissuaded and bullied if they raised concerns. The concerns included being told to take on responsibilities beyond their competencies and workload pressures leading to staff being unable to perform some of their role. A new database tool had identified risks in children but staff were unable to address these. Staff reported their concerns but these had not been acted on and these had not been escalated to the board .
• The was a process of governance and performance was monitored but many staff told us the culture was focused was on achieving performance indicators and their skills and many aspects of the preventative work were not valued.
• Some policies and pathways in community children and young people’s services had been developed within teams of staff at a local level. They had not gone through a governance process and had not been ratified by the trust.
• Risks were not being identified, monitored and assessed appropriately. This was being impeded by individuals rather than processes. There were not robust lone working arrangements or an escalation process. The trust board had only recently started to engage with the service to understand what services were delivered and identify areas of concern.
• The service supported innovative practice but staff were not well resourced or given time to contribute or deliver this effectively. The service did not have plans for future improvement or sustainability, in terms of staffing, succession planning and managing finances. Most staff told us the focus of the trust was on the acute sector and that children and young people were not high on the trust agenda.
• Patient feedback was developed in therapy services and in the Family Nurse Partnership team but there were limited opportunities for people who used the service to give feedback elsewhere. .
• The Family Nurse Partnership (FNP) service had the right structures and processes and assessed as performing well.

Adult community services

• We found staff were caring and compassionate. Without exception, patients we spoke with praised staff for their empathy, kindness and caring. Some patients described what they felt were examples of staff going above and beyond the requirements of their job in order to ensure their wellbeing. There were programmes aimed at meeting the needs of specific communities, for example, a drop-in programme run by the diabetes team for patients over Ramadan to help them make adjustments to their medication while fasting.
• Incidents and near misses were not always reported. There was a lack of clarity about who would report an incident which occurred during a home visit or in a community based clinic. Many staff were not aware of the requirements of the Duty of Candour in handling incidents.

• There were significant staffing shortages in many of the community services we visited, with particular shortages of nurses, physiotherapists and occupational therapists. Staff told us that as a result of staff shortages there were waiting lists for some services and that other services were scaled back. There were many examples of this. Staff told us there was a 14–16 week wait for patients to access services at the Thame Day Hospital because there were insufficient staff to provide the service. The pulmonary rehabilitation clinic we visited was short of a physiotherapist and staff told us this had contributed to a delay in providing one of the service’s scheduled rehabilitation programmes. Staff at the Drake Day Hospital told us they prioritised the most complex patients, for example those patients requiring neuro-rehabilitation, and that other patients could not be treated because there were not enough occupational therapists.

• Facilities we visited were clean and hygienic. Trust premises and community locations were generally well maintained although facilities for the head injury service in Cambourne required review. Equipment was available for patients in their homes and was usually delivered promptly, although there were some problems in delivering non-urgent equipment, which were being discussed with the equipment provider. Electronic patient record keeping systems were not often linked together, which meant that some services could not access information about patients which was held by other services.

• Staff across all services described anticipated risks and how these were dealt with. Lone working policies were in place but community staff did not feel these addressed their specific working conditions. Safeguarding protocols were in place and staff were familiar with these. Staff were able to describe the types of major incidents in which they could potentially be involved and the system for responding to major incidents.

• Community services took into account guidance from the National Institute for Health and Care Excellence (NICE). There was well established multidisciplinary team working across almost all the community services we visited, although further work was required to clarify referral criteria between services. Staff had statutory and mandatory training, and described good access to professional development opportunities. However, training in and understanding of the Mental Capacity Act 2005 was variable.

• Patient outcomes were monitored but were aggregated with divisional level data which included data from acute and community services. There were limited systems in place to monitor the performance of community services specifically. Data provided by the trust covering the period January 2014 to January 2015 suggested improving outcomes for patients. Incidents of pressure ulcers varied throughout the period and a plan was in progress to address this.

• Patient feedback was collected and used in planning many of the services we visited, most frequently through surveys or focus groups. Feedback from patient surveys shown to us by trust staff was, almost without exception, positive. Lessons from incidents and complaints were usually shared within the services in which they occurred, but lessons learned from other services within the trust were not routinely communicated.

• Most staff we spoke with felt they could discuss concerns with their line manager but many felt the trust’s senior management could do more to involve them in discussions which affected community services. Community staff felt that trust-wide governance and leadership arrangements lacked sufficient consideration and understanding of community services. Staff identified the availability of community services and referral criteria as being key areas for improvement, as well as training, and policies and procedures that needed to better reflect the context in which community staff worked.
• Performance indicators were used by management to monitor the quality of community services, but performance outcome data for community services only were limited. For example, the community services quality dashboard combined data from all seven community localities and it was not possible to review results by individual adult community healthcare team. Where outcome data was available for community services, they were usually aggregated with patient outcome data from the trust’s acute services.

• Elements of the trust’s vision and strategic forward plan had been or were being implemented in relation to adult community services. Staff were focused on achieving key outcomes and these were linked to the trust’s vision and strategy. Trust management recognised concerns about the sustainability of current staffing levels and described initiatives to address this.

• There was a clearly embedded ethos of improvement and innovation in some services. This was particularly the case in cardiac rehabilitation and respiratory services, the chronic fatigue and pain management services, and the community diabetes service.

Community inpatient services

• Community in-patient services required improvement in aspects of safety, effectiveness, caring, responsiveness and leadership of services.
• We found caring staff across the three hospitals, with a commitment to helping patients on their road to recovery. However there were some instances where caring and attention to privacy and dignity needed to improve.
• There was inconsistent reporting and learning from safety incidents. Improvements were needed in management of medicines; the access, checking and storage of equipment; and the accuracy and secure storage of records. Nursing and therapy staffing vacancies, led to staff shortages and high use of agency staff, particularly at Buckingham hospital.
• Improvements were needed to ensure consistent use of current evidence based guidance, and person centred assessments to include the full range of individual needs. Goal setting and monitoring of outcomes for individuals was inconsistent, and participation in audits was limited. There was evidence of multi-disciplinary working but discharge planning was inconsistent at some hospitals and needed greater involvement of patients and relatives.
• There was little evidence of training or clinical supervision to support professional development. Not all staff had the experience or skills to support the more acute needs of patients being admitted. Specialist and medical support was available but was not always timely.
• The vision and strategy for community inpatient beds was not well developed, and staff in the service had not been involved in the process. There was monitoring of performance and quality using a trust wide dashboard but limited evidence of local auditing of the service. The arrangements for identifying and managing risks did not always operate effectively.
• Inappropriate admissions created longer waits for a bed patients needing rehabilitation, or resulted in some patients needing urgent transfer back to acute services. There was little evidence of monitoring of appropriateness of admissions or the current model of medical and nursing staffing, and the skill base to meet the needs of patients. There were delays in access to specialist support for patients in vulnerable circumstances, for example patients with a learning disability or mental health needs.
• The quality of leadership varied across the hospitals and staff satisfaction was mixed. There was a positive culture and high morale at Marlow and Thame hospitals. But there were concerns about the skills and capabilities of leaders at Buckingham hospital. Staff reported a negative culture of lack of team cohesion and respect and staff not feeling listened to.
• Across the hospitals there was some evidence of the service seeking the views of patients and relatives through ‘You said, we did’ initiatives. Also examples of innovative initiatives by clinical staff to improve the quality of patient care.
• Wards were clean and infection prevention and control procedures were followed, resulting in low incidence of hospital acquired infections. Most staff were up to date with mandatory training , including safeguarding training and they knew how to report safeguarding concerns. Staff were aware of the need for openness and transparency when mistakes were made, although there had been no formal training on Duty of Candour.
• Reasonable adjustments had been made so the premises were accessible and staff demonstrated understanding of equality and diversity.

Community end of life care services

• Staff demonstrated a caring and compassionate approach. Patients and their families were positive about the care and support they received and the way they were treated. Staff were courteous and treated patients and their families with dignity and respect. Patients and their families were involved and encouraged to be partners in their care and in making decisions.
• People and staff work together to plan care and there is shared decision-making about care The CNSs provided emotional support and would refer patients to other professionals if additional support was required. The trust had developed an action plan to improve its end of life service and a project lead had been employed to move this forward. The trust had engaged with staff, patients and their relatives as part of this project.
• The CNSs took a holistic approach to their role and the service was available to all. The children’s hospice at-home team offered individually tailored care, adapted to the child and family’s needs.
• Incidents were reported and there was evidence of learning and improvement as a result. Safeguarding procedures were understood.
• Patients were supported to understand the medication they were taking and how this could be best used to control their symptoms. Medicines to support patients at the end of life were available in the community. Patients had the equipment they required to support their care safely in their own home.
• Staff followed good infection control procedures.
• There were sufficient specialist staff to support patient.
• Staff used records appropriately and were well informed about the potential risks for patients and how these were to be managed. Do not attempt cardio-pulmonary resuscitation (DNA CPR) forms were being used and this was monitored through audit.
• In line with national recommendation the Liverpool Care Pathway was no longer being used and the trust had developed a new pathway that was about to be trialled. Consideration was being given to the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People.
• New treatment escalation plans had also been developed in line with national guidance. Patient’s pain was well managed and the clinical nurse specialist (CNSs) worked in partnership with patients to ensure that this was achieved. Patients nutrition needs were discussed and reviewed by the CNS as part of their holistic approach.
• The trust had participated in the 2013/14 National Care of the Dying Audit – Hospitals (NCDAH) and did not achieve five of their seven key performance indicators (KPI’s) but was similar to the England average for most of the clinical indicators. Local audit to monitor the effectiveness of services was not well developed. The trust had acknowledged this gap and audit needed to be introduced.
• Training in end of life care was available to all staff and specialist staff was further supported to develop their skills. A
• There was a single point of access for all referrals for specialist palliative care and anyone, including parents, could refer a child to the children’s palliative care team. Staff worked together to provide a multidisciplinary service and GP services to provide holistic care and prevent emergency admissions.
• Staff had the information they required to care for patients and were conscious and informed about the requirement to seek consent.
• An interpreting service was available although family members often acted as interpreter.
• The CNS managed their own diaries to ensure that patients were visited at time suitable for them. The children’s palliative care team worked in a similar way liaising with families and scheduling support at a time that would best meet their needs.
• Support and advice was available 24 hours a day and staff were clear on how to access this support. The community teams worked together to support patients and their families and to ensure that they had the support and equipment they required.
• There was a clear vision for the service and the end of life care strategy was being reviewed to ensure that it reflected the service as a whole. The trust was actively making changes to the service to ensure it better reflected current guidance, although while there was some monitoring of the quality of the service, this required further development to include audit and the monitoring of outcomes for patients.
• The director of nursing was the lead for the service at board level and had clear insight into the challenges they were facing and the changes being made. At a local level there was respect for the lead consultant in palliative care. The matron’s role had been expanded and their responsibilities increased, and they were receiving support with their development to assist them in their role.
• There was an open culture that placed the patient and their family at the centre. There was a team approach to caring for patients in the community, with joint working between specialist staff, the adult community healthcare team and the community hospitals.

We saw several areas of outstanding practice including:

• Community adult health services were available to patients 24 hours a day, seven days a week. This included nurses caring for patients in their homes at night.
• In the integrated cardiac rehabilitation service, new technology was used to improve pathway tracking of patients and provide outcome data. Staff told us the information generated as a result of this project helped them to improve the services they offered to patients. The new systems and technology, they said, had improved uptake of treatment from 52% to 82%.
• The trust provided a community diabetic service which offered two hour clinics twice a week for non-English speaking patients, and provided interpreters. Clinics could be accessed by appointment or drop in. There was also a three week education session provided over Ramadan for healthcare professionals and a drop-in programme for patients who had diabetes to help patients make adjustments to their medication while fasting.
• Staff from the respiratory team told us there was a single point of access seven days a week for specialist nursing services provided by their team. Patients, GPs, community nurses and staff from the hospital’s inpatient wards could ring the team on a dedicated phone number for advice and support.
• Patients were given an individualised, multidisciplinary risk assessment regardless of the service they used. For example, patients had assessments as required for mobility, nutrition, pressure ulcers, mental and emotional wellness, occupational therapy, and home environment. We saw evidence of this in almost all the patient records we looked at.
• The trust contributed to the development, launch and use the Bucks Coordinated Care Record. This is a county-wide electronic end of life register that GP practises, NHS Trusts and hospices have signed up to use to coordinate care and services.
• The specialist palliative care nurses provided a daytime service with telephone advice and support out of hours. Face to face support was available out of hours from the district nurse team. The children’s team worked flexibly and provided a 24 hour service when a child was approaching the end of their life.
• The ‘coppers for cupcake’s idea showed care and compassion towards patients and their visitors at Buckingham Community Hospital. This provided the patients with a pleasant tea and cake experience with visitors, which de-hospitalised the environment they were in. Patients were in a social environment and this had improved communication with their visitors and was a therapeutic distraction for some patients.
• The school nurses were the first in the country to use a new online resource tool. This gave local schools access to an online portal to identify their top three health priorities so school nurses could tailor support, providing early intervention and prevention

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

Importantly, the trust must ensure:

• Patient risk assessments and the documentation that supports them are routinely completed in the Emergency Department.
• There is effective clinical engagement for a hospital wide focus to patient flow and escalation processes and this is monitored.
• There are timely GP discharge summaries following a patient admission to the Emergency Department.
• There is a timely replacement for the Liverpool Care Pathway and all staff follow the current interim policies.
• Staff complete the end of life care plans (Hearts and Minds – end of natural life) appropriately to NICE guidelines for holistic care and they are followed.
• All staff consistently and appropriately complete the DNACPR forms and discussions between patients and relatives are recorded in patient records.
• The overhead lighting lamps in the hospice are replaced to reduce the risk to patients of contact with hot surfaces.
• Staffing levels in the mortuary are reviewed give staff adequate rest time between shifts and to reduce the levels of lone working.
• Mortuary staff have appropriate equipment for bariatric (obese)patients to reduce the risk of harm to staff from inappropriate manual handling.
• Deceased patients are clearly and appropriately identified when being transferred from wards to the mortuary.
• All staff involved in end of life care can identify a patient at the end of life (12 months) to ensure that referrals to the specialist palliative care team are made in a timely manner.

Community adult services

• There are effective operation of systems designed to enable it to identify, assess and manage risks relating to patients which arise from incidents and near misses.
• There are sufficient numbers of suitably qualified staff in all community teams and ensure safe caseload levels.
• The suitability of premises and facilities for the head injuries unit in Cambourne.
• There are suitable arrangements for the privacy and dignity of patients using the multidisciplinary day assessment service (MuDAS).
• Patients are protected against the risks of unsafe or inappropriate care and treatment arising from inaccurate patient records or records which cannot be located promptly when required.
• Staff receive appropriate training on the Duty of Candour and the Mental Capacity Act 2005.
• Community staff and managers have clinical supervision and support to undertake their role.

Community children and young people services

• Staff are able to freely raise any concerns about being unable to deliver services safely and that this is heard and acted on by management.
• Staff use the incident reporting system to report concerns
• Staff have appropriate safeguarding and mandatory training
• Ensure there are mechanisms in place to obtain feedback from people who use services.
• Staffing levels are assessed and reviewed using an evidenced based tool and meet recommended guidelines.
• Staff can appropriate identify and respond to patient risks
• All pregnant women receive a universal antenatal contact with a health visitor.
• Multi-disciplinary team working is effective and pathways of care are coordinated and, where necessary, children receive early support.
• There is an audit programme to monitor the quality and safety of services.
• Children on the learning disability waiting list are appropriately managed
• Consistently log, investigate, respond and learn from complaints in the community children and young people’s services.
• Staff fully understand the Mental Capacity Act 2005 and the deprivation of liberty safeguards.
• There is a service strategy and services are planned effectively around prevention and local need.
• The leadership concerns are fully investigated and action is taken to ensure and open, transparent and supportive culture exists in the service.
• Governance arrangements are improved.
• Patient engagement and feedback is improved across the service
• Staff engagement is improved across the service.
• Budgetary constraints do not adversely affect the care and treatment of children, young people, and parents and carers.

Community inpatient services

• Staff have the skills and knowledge required to care for all patients admitted to the community hospitals.
• Staffing levels and recruitment processes are effective to ensure that there are the right number of staff with the right skill mix on duty at all times.
• There are robust governance processes in place that include effective and informative audits to monitor the quality of the service provision and to use the information to improve the service provided.
• Admission criteria are adhered to for community inpatients and this is monitored.
• Admission is prioritised in accordance with clinical need and waiting times are reduced.
• All staff feel confident to report accident and incidents and they receive feedback and share lessons learnt
• Comprehensive and contemporaneous notes are maintained at all times for all patients.
• Records and confidential information are securely stored at all times when not being used.
• Patients’ privacy, dignity and confidentiality are considered at all times.
• There is effective and supportive leadership throughout the service.
• Systems and procedures for the recording of patients’ and/or their relatives’ consent to information sharing and care and treatment are reviewed.
• There is appropriate access to equipment at weekends.
• The National Early Warning Score (NEWS) system is used correctly and that there is early escalation of concerns if a patient’s condition deteriorates

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall this core service was rated as ‘requires improvement’. We found that community health services for adults were ‘good’ for effective and caring services but ‘required improvement’ to be a safe, responsive and well led service.

Our key findings are:

• Incidents and near misses were not always reported. There was a lack of clarity about who would report an incident which occurred during a home visit or in a community based clinic. Many staff were not aware of the requirements of the Duty of Candour in handling incidents.

• There were significant staffing shortages in many of the community services we visited, with particular shortages of nurses, physiotherapists and occupational therapists. Staff told us that as a result of staff shortages there were waiting lists for some services and that other services were scaled back. There were many examples of this. Staff told us there was a 14–16 week wait for patients to access services at the Thame Day Hospital because there were insufficient staff to provide the service. The pulmonary rehabilitation clinic we visited was short of a physiotherapist and staff told us this had contributed to a delay in providing one of the service’s scheduled rehabilitation programmes. Staff at the Drake Day Hospital told us they prioritised the most complex patients, for example those patients requiring neuro-rehabilitation, and that other patients could not be treated because there were not enough occupational therapists.

• Facilities we visited were clean and hygienic. Trust premises and community locations were generally well maintained although facilities for the head injury service in Cambourne required review. Equipment was available for patients in their homes and was usually delivered promptly, although there were some problems in delivering non-urgent equipment, which were being discussed with the equipment provider. Electronic patient record keeping systems were not often linked together, which meant that some services could not access information about patients which was held by other services.

• Staff across all services described anticipated risks and how these were dealt with. Lone working policies were in place but community staff did not feel these addressed their specific working conditions. Safeguarding protocols were in place and staff were familiar with these. Staff were able to describe the types of major incidents in which they could potentially be involved and the system for responding to major incidents.

• Community services took into account guidance from the National Institute for Health and Care Excellence (NICE). There was well established multidisciplinary team working across almost all the community services we visited, although further work was required to clarify referral criteria between services. Staff had statutory and mandatory training, and described good access to professional development opportunities. However, training in and understanding of the Mental Capacity Act 2005 was variable.

• Patient outcomes were monitored but were aggregated with divisional level data which included data from acute and community services. There were limited systems in place to monitor the performance of community services specifically. Data provided by the trust covering the period January 2014 to January 2015 suggested improving outcomes for patients. Incidents of pressure ulcers varied throughout the period and a plan was in progress to address this.

• Patient feedback was collected and used in planning many of the services we visited, most frequently through surveys or focus groups. Feedback from patient surveys shown to us by trust staff was, almost without exception, positive. Lessons from incidents and complaints were usually shared within the services in which they occurred, but lessons learned from other services within the trust were not routinely communicated.

• We found staff were caring and compassionate. Without exception, patients we spoke with praised staff for their empathy, kindness and caring. Some patients described what they felt were examples of staff going above and beyond the requirements of their job in order to ensure their wellbeing. There were programmes aimed at meeting the needs of specific communities, for example, a drop-in programme run by the diabetes team for patients over Ramadan to help them make adjustments to their medication while fasting.

• Most staff we spoke with felt they could discuss concerns with their line manager but many felt the trust’s senior management could do more to involve them in discussions which affected community services. Community staff felt that trust-wide governance and leadership arrangements lacked sufficient consideration and understanding of community services. Staff identified the availability of community services and referral criteria as being key areas for improvement, as well as training, and policies and procedures that needed to better reflect the context in which community staff worked.
• Performance indicators were used by management to monitor the quality of community services, but performance outcome data for community services only were limited. For example, the community services quality dashboard combined data from all seven community localities and it was not possible to review results by individual adult community healthcare team. Where outcome data was available for community services, they were usually aggregated with patient outcome data from the trust’s acute services.

• Elements of the trust’s vision and strategic forward plan had been or were being implemented in relation to adult community services. Staff were focused on achieving key outcomes and these were linked to the trust’s vision and strategy. Trust management recognised concerns about the sustainability of current staffing levels and described initiatives to address this.
• There was a clearly embedded ethos of improvement and innovation in some services. This was particularly the case in cardiac rehabilitation and respiratory services, the chronic fatigue and pain management services, and the community diabetes service.

Overall rating for this core service - Requires Improvement

Overall this core service was rated as ‘requires improvement’. We found that community health services for children, young people and families was caring but required improvement to be safe, responsive and effective. We rated leadership as inadequate.

Our key findings

Are services safe?

• The trust’s incident report system was not being used appropriately. Some staff reported to us that they were discouraged from reporting incidents. Where incidents were reported, there was evidence of action but there was not consistent learning or improvement for when things went wrong. There was no assurance that all incidents and risks were being adequately identified and managed.
• Staff we spoke with were able to recognise safeguarding concerns for children and young people and showed a good knowledge and awareness of the safeguarding processes. However, some staff within school nursing teams told us that they had been asked to participate in child protection work beyond their competencies. Information was unclear on the level of safeguarding children training staff had undertaken.
• Staff identified that budgetary constraints meant that some equipment was not available, such as clinical needles for immunisation and toys to distract children when receiving treatment.
• The trust used a mixture of electronic and paper records. Some electronic systems were not compatible and so information was not being shared effectively across services about children’s care. Records did not appropriately include salient information that summarised children’s health needs and family history.
• Staff were following infection control procedures but toys were not being appropriately cleaned. Trust targets for staff mandatory training were not met.
• The service was assessing risks to patients but was not responding effectively due to workload pressures. Some children with identified risks were not being seen in a timely manner or could be missed because processes were not robust.
• Staffing levels were assessed and vacancies were identified as low. However, a matrix for weighting health visiting caseloads had identified a shortfall in health visitor hours. The ratio of qualified school nurses to number of secondary schools was below that recommended by national guidance. Staff within health visiting and school nursing teams told us that they were unable to perform certain aspects of their role due to workload pressures. The family nurse partnership could only fulfil 40% of its programme because of staffing capacity
• Medicines were appropriately managed.

Are services effective?

• National and evidence based practice guidelines were used to define services. However, the guidance was not always followed for example, there were only targeted, not universal antenatal contacts by health visitors; this meant there was limited early identification of need and risk. There was not effective audit and monitoring to demonstrate patient outcomes or compliance with quality standards.
• There were a limited number policies that covered care and treatment to children and young people and practice was inconsistent. Staff did not have support to develop professional practice around national guidance and there was inconsistent care and support provided across teams.
• Staff supervision and appraisal varied and staff identify difficulties in accessing training. There were no specialist trained nurses working with children with a learning disability. Staff working with young people up to the age of 21 years with a learning disability told us they did not fully understand the Mental Capacity Act 2005.
• The trust was meeting its performance targets for postnatal care, breastfeeding and the school child measurements, but not for immunisation rates, and one year developmental reviews.
• There was effective multi-disciplinary working in therapy teams but coordination of care pathways and IT arrangements to share information or liaise with other agencies, such as GP surgeries, midwives and across acute hospital care, were inconsistent. There were good arrangements for multi-disciplinary team working for looked after children.

Are services caring?

• The majority of parents told us they were treated with dignity and respect by community staff. The staff displayed an encouraging, sensitive and supportive attitude and children and young people’s personal, social and cultural needs were recognised. Staff understood and respected confidentiality.
• Patients, and those close to them, were involved in their care and treatment. The staff took the time to tell children in an age appropriate manner what was going to happen and encouraged them to ask any questions about the treatment. Parents were supported to manage their own health, care and wellbeing. Parents told us they felt confident in managing their children’s needs. Parents and children were supported emotionally.
• The parents we spoke with told us that the services were accessible and that staff were knowledgeable, informative and caring.

Are services responsive?

• Community children and young people’s services were commissioned with indicators to monitor operational service delivery. The services were not informed by the needs of the population and not addressing the needs of different people.
• The initial assessment within 28 days for looked after children target were not met. The waiting list for the learning disability service was not meeting the 18 week waiting time target.
• Staff had had training in equality and diversity and individually took account of patient needs but services were not offered to support the needs and preferences of different people that might be based on age, gender, race or religion. There was no evidence of reasonable adjustments for people with a physical disability. Interpreter services were available but information leaflets were only printed in English.
• There was not a consistent way of logging, investigating, responding to and learning from complaints. Most staff did now the process for handling complaints. People we spoke with did not know how to make a complaint or raise concerns. Where concerns had been raised, these were not always addressed.
• Staff told us that they prioritised work with people in vulnerable circumstances and would see people at times and places convenient for the young people and parents or carers. We saw evidence of person-centred care that showed community staff were responsive to individual needs and worked flexibly with people towards improved health and wellbeing.
• Children had good access to services, and parents could attend appointments with health visitors and at child health clinics at convenient time

Are services well led?

• The trust did not have a strategy for children and young people’s services. Staff did not know and understand what the vision, values and strategy were for the trust. The majority of staff told us that the services they delivered were not high on the trust agenda.
• Staff within school nursing team told us that they were discouraged or not heard when they raised concerns about being able to deliver services safely. There had been a lack of management support and staff were dissuaded and bullied if they raised concerns. The concerns included being told to take on responsibilities beyond their competencies and workload pressures leading to staff being unable to perform some of their role. A new database tool had identified risks in children but staff were unable to address these. Staff reported their concerns but these had not been acted on and these had not been escalated to the board.
• There was a process of governance and performance was monitored but many staff told us the culture was focused was on achieving performance indicators and their skills and many aspects of the preventative work were not valued.
• Some policies and pathways in community children and young people’s services had been developed within teams of staff at a local level. They had not gone through a governance process and had not been ratified by the trust.
• Risks were not being identified, monitored and assessed appropriately. This was being impeded by individuals rather than processes. There were not robust lone working arrangements or an escalation process. The trust board had only recently started to engage with the service to understand what services were delivered and identify areas of concern.
• The service supported innovative practice but staff were not well resourced or given time to contribute or deliver this effectively. The service did not have plans for future improvement or sustainability, in terms of staffing, succession planning and managing finances. Most staff told us the focus of the trust was on the acute sector and that children and young people were not high on the trust agenda.
• Patient feedback was developed in therapy services and in the Family Nurse Partnership team but there were limited opportunities for people who used the service to give feedback elsewhere. .
• The Family Nurse Partnership (FNP) service had the right structures and processes and had been assessed as performing well.

We rated this core service as ‘requires improvement’. We rated as ‘requires improvement for providing safe, effective, caring, responsive and well led adult inpatient services.

Our key findings:

• Community in-patient services required improvement in aspects of safety, effectiveness, caring, responsiveness and leadership of services.
• We found caring staff across the three hospitals, with a commitment to helping patients on their road to recovery. However, there were some instances where caring and attention to privacy and dignity needed to improve.
• There was inconsistent reporting and learning from safety incidents. Improvements were needed in management of medicines; the access to, checking and storage of equipment; and the accuracy and secure storage of records. Nursing and therapy staffing vacancies, led to staff shortages and high use of agency staff, particularly at Buckingham hospital.
• Improvements were needed to ensure consistent use of current evidence based guidance, and person centred assessments to include the full range of individual needs. Goal setting and monitoring of outcomes for individuals was inconsistent, and participation in audits was limited. There was evidence of multi-disciplinary working but discharge planning was inconsistent at some hospitals and needed greater involvement of patients and relatives.
• There was little evidence of training or clinical supervision to support professional development. Not all staff had the experience or skills to support the more acute needs of patients being admitted. Specialist and medical support was available but was not always timely.
• The vision and strategy for community inpatient beds was not well developed, and staff in the service had not been involved in the process. There was monitoring of performance and quality using a trust wide dashboard but limited evidence of local auditing of the service. The arrangements for identifying and managing risks did not always operate effectively.
• Inappropriate admissions created longer waits for a bed for patients needing rehabilitation, or resulted in some patients needing urgent transfer back to acute services. There was little evidence of monitoring of appropriateness of admissions or the current model of medical and nursing staffing, and the skill base to meet the needs of patients. There were delays in access to specialist support for patients in vulnerable circumstances, for example, patients with a learning disability or mental health needs.
• The quality of leadership varied across the hospitals and staff satisfaction was mixed. There was a positive culture and high morale at Marlow and Thame hospitals. But there were concerns about the skills and capabilities of leaders at Buckingham hospital. Staff reported a negative culture of lack of team cohesion and respect and staff not feeling listened to.
• Across the hospitals there was some evidence of the service seeking the views of patients and relatives through ‘You said, we did’ initiatives. There were also examples of innovative initiatives by clinical staff to improve the quality of patient care.
• Wards were clean and infection prevention and control procedures were followed, resulting in low incidence of hospital acquired infections. Most staff were up to date with mandatory training , including safeguarding training and they knew how to report safeguarding concerns. Staff were aware of the need for openness and transparency when mistakes were made, although there had been no formal training on Duty of Candour.
• Reasonable adjustments had been made so the premises were accessible and staff demonstrated understanding of equality and diversity.

Overall this core service was rated as ‘good’. We rated community end of life care as ‘good’ for providing a safe, effective, caring, responsive and well led services.

Our key findings

Are services safe?

• Incidents were reported and there was evidence of learning and improvement as a result. Safeguarding procedures were understood.
• Patients were supported to understand the medication they were taking and how this could be best used to control their symptoms.
• Medicines to support patients at the end of life were available in the community. Patients had the equipment they required to support their care safely in their own home.
• Staff followed good infection control procedures.
• There were sufficient specialist staff to support patient.
• Staff used records appropriately and were well informed about the potential risks for patients and how these were to be managed.
• Do not attempt cardio-pulmonary resuscitation (DNA CPR) forms were being used and this was monitored through audit.

Are services effective?

• In line with national recommendation the Liverpool Care Pathway was no longer being used and the trust had developed a new pathway that was about to be trialled. Consideration was being given to the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People.
• New treatment escalation plans had also been developed in line with national guidance. Patient’s pain was well managed and the clinical nurse specialist (CNSs) worked in partnership with patients to ensure that this was achieved.
• Patients nutrition needs were discussed and reviewed by the CNS as part of their holistic approach.
• The trust had participated in the 2013/14 National Care of the Dying Audit – Hospitals (NCDAH) and did not achieve five of their seven key performance indicators (KPI’s) but was similar to the England average for most of the clinical indicators. Local audit to monitor the effectiveness of services was not well developed. The trust had acknowledged this gap and audit needed to be introduced.
• Training in end of life care was available to all staff and specialist staff was further supported to develop their skills. A
• There was a single point of access for all referrals for specialist palliative care and anyone, including parents, could refer a child to the children’s palliative care team.
• Staff worked together to provide a multidisciplinary service and GP services to provide holistic care and prevent emergency admissions.
• Staff had the information they required to care for patients and were conscious and informed about the requirement to seek consent.

Are services caring?

• Staff demonstrated a caring and compassionate approach.
• Patients and their families were positive about the care and support they received and the way they were treated.
• Staff were courteous and treated patients and their families with dignity and respect. Patients and their families were involved and encouraged to be partners in their care and in making decisions.
• People and staff work together to plan care and there is shared decision-making about care The CNSs provided emotional support and would refer patients to other professionals if additional support was required.

Are services responsive?

• The trust had developed an action plan to improve its end of life service and a project lead had been employed to move this forward. The trust had engaged with staff, patients and their relatives as part of this project.
• The CNSs took a holistic approach to their role and the service was available to all.
• The children’s hospice at-home team offered individually tailored care, adapted to the child and family’s needs.
• An interpreting service was available although family members often acted as interpreter.
• The CNS managed their own diaries to ensure that patients were visited at time suitable for them. The children’s palliative care team worked in a similar way liaising with families and scheduling support at a time that would best meet their needs.
• Support and advice was available 24 hours a day and staff were clear on how to access this support.
• The community teams worked together to support patients and their families and to ensure that they had the support and equipment they required.

Is the service well led?

• There was a clear vision for the service and the end of life care strategy was being reviewed to ensure that it reflected the service as a whole.
• The trust was actively making changes to the service to ensure it better reflected current guidance, although while there was some monitoring of the quality of the service, this required further development to include audit and the monitoring of outcomes for patients.
• The director of nursing was the lead for the service at board level and had clear insight into the challenges they were facing and the changes being made.
• At a local level there was respect for the lead consultant in palliative care.
• The matron’s role had been expanded and their responsibilities increased, and they were receiving support with their development to assist them in their role.
• There was an open culture that placed the patient and their family at the centre.
• There was a team approach to caring for patients in the community, with joint working between specialist staff, the adult community healthcare team and the community hospitals.

Professor Sir Mike Richards

Chief Inspector of Hospitals