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Archived provider: Liverpool Community Health NHS Trust Requires improvement

Reports


Inspection carried out on 2, 3, 4 and 11 February 2016

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of Hospitals

We last inspected this trust in May 2014 and we rated the provider as ‘requires improvement’ overall. In reaching our judgement, we told the trust that they must make improvements to:

  • ensure there are sufficient numbers of staff to provide safe, effective and responsive services;

  • ensure all clinical staff have access to regular protected time for facilitated, in-depth reflection on clinical practice.

We carried out an announced follow-up inspection of this trust between 2 – 4 February 2016 and an unannounced inspection on 11 February 2016 to make sure improvements had been made. As part of the inspection, we assessed the leadership and governance arrangements at the trust and inspected the core services that required improvement at the last inspection:

  • Community health services for adults;

  • Community services for children, young people and families;

  • Community inpatient services.

Before carrying out the inspection, we reviewed a range of information we held and asked other organisations to share what they knew about the trust and its services. These included local clinical commissioning groups (CCGs), NHS Trust Development Authority (TDA), NHS England, Health Education England (HEE), the General Medical Council (GMC), the Nursing and Midwifery Council (NMC) and the Royal colleges. Patients also shared information about their experiences of community services via comment cards that we left in various community locations across Liverpool and Sefton.

Since the last inspection, there had been a number of changes to senior staff at the organisation and there had been a concerted effort to improve the culture and support for staff, which was evident at the time of the inspection. The trust had developed a transformation programme that had led to services being delivered within a framework of localities across the trust’s geographical footprint and staff reported that they felt engaged and included as part of this process.

It was evident that the trust had sought to address the findings of our last inspection and improvements had been made in the areas we identified. However, progress in making the necessary changes was often slow and some services required further improvement at the time of the inspection.

Our key findings were as follows:

  • At both of our previous inspections we found that the culture in some services was very negative and on occasion intimidating. At this inspection we saw significant improvements in culture across the organisation.

  • Staffing had improved in the community since the last inspection but there were still concerns in some areas of the community adults service. There were also concerns in the community children, young people and families service about the number of staff health visiting team leaders were responsible for as well as high levels of sickness in some teams.

  • Performance against key metrics in the Healthy Child Programme had improved but progress had been very slow and performance was still below key national targets. The Trust told us that this would improve following the transfer of pre-school vaccination programmes from health visitors to Primary Care, in-line with practice elsewhere else in England, from April 2016.

  • Waiting times in the community adults and the children, young people and families’ service had improved in some areas but in others, they had regressed and on some occasions, performance was worse than at the last inspection.

  • The governance systems need to be improved in some key areas to ensure that the trust are using all available information to measure quality and drive improvement in services.

We saw several areas of outstanding practice including:

  • The school nursing service had responded at short notice to a requirement to carry out a flu vaccination programme, which involved immunising 18,000 children in 200 schools over a 4 week period.

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

Importantly, the provider must:

  • Ensure where duty of candour is required, evidence is available to show that the trust has discharged their responsibility;

  • Ensure that robust governance systems are embedded in all services to assess, monitor and improve the quality of the services provided.

In community services for children, young people and families

  • The number of health visitors reporting to one team leader was excessive and could lead to a lack of adequate support for the team leaders. The trust must address this to ensure that caseloads are manageable and staff have the appropriate support from their team leaders.

  • There is a risk present as long as hybrid paper and electronic recording systems are being used. The provider must ensure that all record keeping risks are mitigated.

  • The trust must ensure that policies and procedures relating to safeguarding take account of the latest statutory guidance.

In community services for adults

  • The provider must ensure where duty of candour is required, evidence is available to show that the trust has discharged their responsibility.

  • The provider must ensure that robust systems are embedded in all services to assess, monitor and improve the quality of the services provided.

Professor Sir Mike Richards

Chief Inspector of Hospitals


CQC inspections of services

Service reports published 8 July 2016
Inspection carried out on 2, 3, 4 and 11 February 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 2, 3, 4 and 11 February 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 2, 3, 4 and 11 February 2016 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
See more service reports published 8 July 2016
Inspection carried out on 12-15 May 2014

During a routine inspection

We found that the provider was performing at a level which led to a judgement of requires improvement.

We judged the majority of services to be safe; however there was a risk to patient safety from reduced community staffing levels, most notably in children’s and family services, and from the acuity of patients being admitted to the intermediate care wards. Staff reported incidents and the majority felt confident to do so; however learning tended to take place within local teams. Staff levels and caseloads varied in risk across the organisation; community services carried the greatest risk, though action had been taken to improve staffing levels in district nursing services. The acuity of patients on inpatient wards had resulted in a lack of rehabilitation.

Staff were able to describe how to use pathways of care and treatment that are based on nationally agreed best practice. There was multidisciplinary team work taking place. Training had improved recently and staff welcomed the block training approach that offered them better opportunities to attend. The trust took part in national audits; local audits were also carried out. Learning tended to remain local within teams.

Most patients commented on the caring and compassionate approach of staff across the organisation. We saw staff treating patients with respect. Patient surveys carried out by the trust showed good levels of patient satisfaction. Patients were involved in care decisions in the majority of services. However some patients were concerned about shared waiting areas in the walk in centres. There were some concerns regarding care within intermediate care wards which didn’t demonstrate patient involvement in their care and assessment.

The majority of services we reviewed were responsive to the needs of the patients. There was good triage in the walk-in centres. Multidisciplinary teams were working to make sure patients were discharged smoothly and the children’s care services were centred on the needs of families. Concerns were identified with access to some services; although staff had taken a range of action to improve the service, there remained long waiting times for access to wheel chair assessments for adults. Some elements of the healthy child programme were not being met due to staffing arrangements and a prioritisation of vaccination and immunisation clinics. Response times at the single point of contact were adversely impacting on access to some services.

The trust had a vision and values in place, but these were not well known by all staff, and staff had not been engaged with effectively in some service reconfigurations. Governance structures had developed since a warning notice was issued in January 2014 but trend analysis required further development and systems to share and develop learning needed to be embedded across the trust. There had been recent changes amongst executive staff at the trust and staff we interviewed welcomed the changes. Staff told us they felt there had been improvements in the culture of the organisation and some more punitive processes had been changed. Patient engagement was good with evidence of service development as a result of patient stories shared with the trusts board.

The trust had been served with two warning notices in January 2014. The provider was served with a warning notice for outcome 16 (regulation 10, assessing and monitoring the quality of service provision) and ward 35 intermediate care unit was served with a warning notice for outcome 14 (regulation 23 supporting workers). The trust was told to ensure they were compliant with these regulations by 1 April 2014.

During our inspection in May 2014 we judged that the provider had met the requirements of regulation 10 and had demonstrated suitable improvements to its systems for assessing and monitoring the quality of service provision. With regard to the warning notice served on ward 35 intermediate care unit, we judged that the provider had met the requirements of regulation 23 supporting workers.

In addition to this compliance actions were served on both the provider, ward 35 intermediate care unit and Alexandra Wing, Broadgreen Hospital. At the provider level, these were outcome 4 (regulation 9 care and welfare of service users), outcome 11 (regulation 16 safety, availability and suitability of equipment), outcome 13 (regulation 22 staffing) and outcome 14 (regulation 23 supporting workers).

At ward 35 intermediate care unit these were outcome 4 (regulation 9 care and welfare of service users), outcome 9 (regulation 13 management of medicines), outcome 13 (regulation 22 staffing), and outcome 14 (regulation 23 supporting workers).

At Alexandra Wing, Broadgreen Hospital these were outcome 9 (regulation 13 management of medicines) and outcome 14 (regulation 23 supporting workers).

Whilst trusts are told the date by which they are to be complaint when served with a warning notice; trusts inform CQC when they expect to be compliant when served with a compliance action. At the time of this inspection (12 May 2014), the dates for compliance (against the compliance actions served above) were;

  • Outcome 4 (regulation 9) – June 2014
  • Outcome 9 (regulation 13) – March 2014
  • Outcome 11 (regulation 16) – July 2014
  • Outcome 13 (regulation 22) – June 2014
  • Outcome 14 (regulation 23) – June 2014

As a result of this, whilst we reviewed evidence against these outcomes, with the exception of outcome 9 (regulation 13) further inspection will be required to judge compliance against these outcomes during the coming months. During the inspection in May 2014 we assessed and judged the trust compliant with outcome 9 (regulation 13).

Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.