Archived: Liverpool Community Health NHS Trust

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).

The Walk-in centres were managed through the ambulatory care directorate. The centres had both clinical and service manager leadership.

There were effective systems and processes to provide safe care and support for patients. Patient safety was monitored and incidents were investigated to help learning and improvement. There was not always enough staff to make sure that patients referred to the services could be seen promptly. This may impact on the quality of care delivered by the service.

Systems were in place to support vulnerable patients. Patients and their relatives spoke positively about their care and treatment.

Staff followed national guidelines and had clinical procedures in place based on national and regional guidance. The trust took part in local clinical audits but did not have a clear audit calendar. Changes to the service information system did not facilitate the services ability to communicate with external partners such as GPs in a timely fashion. The clinical managers told us that previously they had been able to carry out systematic peer reviews to ensure that practitioners were clinically effective and adhering to best practice guidance. The changes to the information system in 2010 meant that this was not possible. We were told that the service was about to start procurement for a new Information system.

Staff told us and records showed that they had been appropriately supported with training and supervision, and encouraged to learn from mistakes. We found that the staff were hard working and caring. The team felt supported locally but did not have regular staff meetings due to pressure on staffing and staff were not aware of the trust visions and strategies.

Most services were safe at the time of our inspection. There were arrangements in place to minimise risks to patients including measures to prevent pressure ulcers. Staffing levels were safe in the majority of services and there was on-going recruitment to fill staff vacancies.

There were arrangements in place to manage and monitor the prevention and control of infection, management of medicines and safeguarding people from abuse with dedicated teams to support staff and ensure policies and procedures were implemented.

Staff were familiar with the process for reporting incidents, near misses and accidents and were encouraged to do so. There were some inconsistencies in practice with regards to learning from incidents and sharing of that learning within individual teams and across the organisation.

Most services were effective, evidence based and focussed on the needs of patients. We saw some examples of good collaborative work and innovative practice.

The majority of staff were up-to-date with mandatory training however staff experience of clinical or reflective supervision was variable across community nursing teams and some staff were not accessing regular protected time for reflection of clinical practice.

Waiting times for wheelchair assessments were significantly higher than the expected target although a recovery plan was in place the service remained under pressure and waiting times were not expected to improve in the short term.

Services were caring. Patients and relatives or carers told us they were well supported by staff in multidisciplinary teams. We observed a compassionate and caring approach of staff in clinics and in people’s homes. Staff in the multidisciplinary teams were aware of the emotional aspects of care for people living with long term health problems and ensured specialist support for people where needed.

Services were responsive to people’s needs across the majority of services. Staff worked well in multidisciplinary teams across organisations to provide support to patients in the community. Patients were on the whole able to access the right care at the right time.

Services encouraged patients to provide feedback about their care. Complaints procedures were in place and there were examples where the service had acted on information about the quality of care that it received from patients.

The organisations vision and values were not fully embedded across all teams. The roles and responsibilities for governance and quality performance were understood at a local level however not all staff were aware of the quality issues affecting their service.

There was good leadership and support from local managers and most staff felt engaged with senior management. There was a positive shift in the culture of the organisation and staff felt leadership models encouraged supportive relationships amongst staff and compassion towards people who used the service. Staff were encouraged to raise problems and concerns about patient care without fear of being penalised.

A range of people’s views were encouraged, heard and acted upon. Information on patient experience was reported and reviewed alongside other performance data. Where issues were identified, action plans were put in place to ensure improvements to patient care were made.

There were a number of measures in place to monitor patient safety and reduce the risk of harm to patients. There was evidence of dissemination of learning from incidents and complaints. In the patient records reviewed there was no evidence of risk assessments being completed, which related to issues around staff safety or the patients general living environment. The team relied on risk assessments being completed by community nursing.

The team had procedures based on other national and regional guidelines. The staff within the team followed guidelines from other organisations, such as the Macmillan Cancer Support and Marie Curie Cancer Care. There was effective communication and multidisciplinary team working. The staff within the team were highly trained and had a good understanding of existing end of life care guidelines and implemented these effectively.

Services were delivered by a hardworking, caring and compassionate staff. We observed that staff treated patients with dignity and respect and planned and delivered care in a way that took into account the wishes of the patients.

Staff had a good understanding of the needs of the local population and worked as part of multi-disciplinary teams and routinely engaged with local hospices, GP’s, adult social care providers and other professionals involved in the care of patients. The team delivered comprehensive training to community nursing staff to ensure that care was responsive to people’s needs.

There was an awareness about the trusts visions and strategies, but there was a disconnect between the team and wider trust. There was no audit schedule of key processes in place. Information relating to core objectives and performance targets was not readily available. There was confusion regarding line management within the team.

Services were safe and there were suitable processes in place in terms of identifying and reporting incidents. In addition, systems enabled learning to take place from incidents including serious untoward incidents (SUIs). The risk data for inpatients highlighted falls as an area of concern and this has been highlighted and actions taken; the number of falls had been decreasing.

Staffing levels were suitable; in fact, numbers of nursing staff were in excess of requirements in certain areas. There was a commitment to ensure nurse staffing levels, and staffing in general, remained safe and a nationally recognised tool was being used to monitor this.

Medicines management and related processes had improved, particularly on ward 35, and administration of medicines was done safely. Appropriate training was in place for nursing staff including record keeping and use of controlled drugs.

We found the acuity of some patients on the wards to be greater than expected, to the extent that, on occasion, patients were admitted from nearby acute trusts only to be promptly re-admitted back to the acute trust.

The effectiveness of the service was variable. In terms of rehabilitating patients and preparing patients for discharge home or to a less acute healthcare setting, the service struggled to meet these objectives with many patients because of increased levels of acuity. Rehabilitation and related activities, such as encouraging patients to eat at a table or walking independently was less than expected. In addition, activities to support patients to remain engaged and relieve boredom were limited. The acuity of some patients was a key reason for reduced rehabilitation therapy but there also seemed to be a lack of direction and discharge planning with many patients.    

We recognised the progress made in terms of staff training and support, particularly on ward 35, and staff we spoke with acknowledged the improvements made in ensuring staff had up-to-date skills and knowledge. Some progress had been made with clinical supervision, particularly for nursing staff, but further development was required.

We observed, in the main, positive interactions between staff and patients and the majority of staff were caring, respectful and supportive. However, there were some staff who were not as approachable and were unnecessarily abrupt.

The majority of patients spoke highly of the care they received and felt that staff worked hard to meet their needs. There were some themes from patient feedback and some patients felt there was a lack of stimulation / activities on the ward and patients were not always aware of their care plan / goals.

We observed staff providing emotional support to patients during the inspection but there was limited evidence within nursing documentation about how best to support some patients with their emotional needs. Some patients we spoke with felt that support in relation to their emotional needs could have been better.  

Staff worked hard to meet the needs of people who used the service but the plans of care did not always accurately reflect the overall needs of people. For example, some patients had emotional and / or dementia related needs and these were not always fully addressed.

The rehabilitation needs of some patients, particularly for those wanting to walk more independently, were not always adequately being met because of a conflict between the need to prevent falls versus needing to actively encourage mobility. Physiotherapy staff felt that the increased focus on reducing falls was having a negative impact on rehabilitation which was lengthening people’s stay unnecessarily.

The trust was making steps to review the service, its design and purpose, but at the time of the inspection many patients did not meet the correct criteria for rehabilitation.

Staff spoke positively about the new leadership team and increased visibility of senior staff. Staff were also positive about the changes in culture and it was described as more open and transparent.

Many staff were unclear of the vision and future strategy for the service which made some feel anxious. However, there was open consultation happening to discuss the future model of the service.

There was a sense at ward level that clinical leadership could have been stronger, particularly in terms of patient discharge and patient admissions. This had been recognised by the trust and changes were being made to support senior nurses on the ward in making such decisions.           

We found that children’s and families services were caring but required improvement to be safe, effective and responsive to the needs of the local population.

There were systems in place for reporting and investigating incidents and there was evidence that learning from incidents occurred at a local level within teams. However, there was an inconsistent approach to reporting incidents and varied understanding of what constituted a reportable incident and near miss across the division. Safeguarding arrangements were embedded in practice and staff were well supported with regular safeguarding supervision. Risk assessments were carried out at a local level in order to provide safe care. However, recent restructuring of teams and records management systems had led to a potential increased risk in the safe management of caseloads.

The division provided a range of services both in the community and in schools, and teams aimed to provide a flexible service where possible. Teams worked well locally and had developed processes and effective ways of working. There was some evidence of shared learning across teams in pockets throughout the division. However the approach to shared learning across the division was not consistent.

The clinics we visited were clean and well maintained and staff followed infection control procedures. Staff were passionate about providing person centred care and understood the importance of engaging with families in order to understand their situation and the support they required. Patient experience surveys showed a high level of satisfaction with the services provided. Staff understood the needs of the local communities and there were several examples of local initiatives and joint working to promote care that would meet the needs of children and young people. The trust had tried to plan services to meet the needs of different children and young people through a redesign of the health visiting service and proposed restructuring of the speech and language service. However, staff did not feel engaged in the redesign process and as a result the trust did not fully appreciate the impact the changes would have. There was little evidence that children, young people and their families who used the service had been involved in decisions about the service redesigns. In some cases, staff reported this had led to a loss of engagement.

Outcomes for children, young people and their families using the service varied when compared with other services and national targets; though there was evidence that performance was reviewed and actions were in place to improve outcomes across the different teams. There was good evidence of multidisciplinary team working and inter-agency working within the service but this was not consistent across all teams.

Staff aimed to assess and deliver treatment in line with current legislation, standards and recognised evidence-based guidance. However increased capacity, staffing issues, changes in commissioning contracts and service redesign had led to challenges in delivering the Healthy Child Programme and ability to meet waiting time targets for speech and language, occupational therapy and physiotherapy. We found there were insufficient numbers of staff to ensure the health, safety and welfare of people who used services.

Staff awareness of the trust’s visions and values varied throughout the service. The managers and staff we spoke with were clear on the management structures within the division and staff reported they received good support from their direct line managers and team leaders. However, staff were not clear how the information was escalated to senior managers and taken into consideration.

We found mixed evidence of staff engagement with the trust board. There were some good examples of local engagement initiatives but very few of the staff we spoke with had attended one of the ‘Big Conversation’ meetings. The main reason given for non-attendance was not having the time due to work pressures. Throughout the division we found staff who were involved in initiatives and projects to develop and improve care for children, young people and their families. Staff showed they had a good understanding of the challenges faced by the local community and used a variety of methods to support learning, engagement and involvement.