Lincolnshire Community Health Services NHS Trust

Our rating of the trust improved. We rated it as outstanding because:

• We rated safe, effective and caring as good and responsive and well-led as outstanding. We rated three core services as good overall and one as outstanding. In rating the trust, we took into account the current ratings of the three core services not inspected this time.
• We rated well led for the trust overall as outstanding. The rating for well led is based on our inspection at trust level, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement.

• The service provided mandatory training in key skills to all staff and made sure everyone completed it. Data from April 2018 showed compliance with mandatory training was 93.2%. Although the trust target was 95%, this was better than other comparable trusts.
• Staff understood their roles and responsibilities regarding safeguarding vulnerable adults and children. Staff had received appropriate levels of safeguarding training and could tell us about examples of where they had identified and raised concerns.
• Staff demonstrated good practice with regards to hand hygiene and infection control. We saw hand gel available in clinical areas and the environment and equipment were visibly clean. Equipment was regularly serviced and cleaned.
• There were effective processes for the reporting and management of incidents, most staff were aware of their responsibilities to report incidents and we saw learning from incidents was shared.
• Patients’ individual care records were written, however, whilst most of the information needed was available to relevant staff in a timely and accessible way, there was inconsistency in the use of printed records in patients’ homes.
• The service provided care and treatment based on latest evidence and national guidance and maintained a quality dashboard to monitor outcomes. There was a clear approach to monitoring, auditing and benchmarking the quality of services and outcomes for people. The service participated in relevant quality improvement initiatives and local and national audits.
• Staff of different kinds worked together as a team to benefit patients. Nurses, therapists and support staff worked with professionals from other services to provide good care. Staff had the right skills and knowledge to safely care for patients.
• Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.
• Staff understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Staff cared for patients with kindness and compassion and respected their privacy and dignity. Feedback from patients confirmed that staff were kind and caring.
• Staff involved patients and those close to them in decisions about their care and treatment.
• Staff worked collaboratively with patients and provided emotional support to patients and their relatives to minimise their distress. Services provided mostly reflected the needs of the fluctuating population served ensuring flexibility, choice and continuity of care.
• Staff took account of patients’ individual needs and made use of technology to improve communication with patients.
• Although the average time taken to close a complaint was longer than trust policy, service leads analysed trends and shared key areas of learning from complaints with staff.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, we did see a degree of silo working and lack of consistency across the teams with respect to assessments, processes and best practice.
• The trust had clear governance structures and effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The risk register was reviewed regularly and staff had an awareness of the risks throughout the service.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. The services’ vision and strategy was in line with national priorities.

However,

• Whilst we saw staff were using a less task-focused, holistic approach to care, we were not assured there was consistent practice across the trust in the approach to assessments and the use of records, tools and care plans to recognise and treat the patients who condition may been deteriorating.
• Although staff in some areas told us the service had enough staff with the right qualifications, skills, training and experience, others raised concerns about the number of daily visits they were expected to undertake and the unpaid hours they had to work to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• Whilst we saw staff were improving and developing services to meet patients’ needs, services were not provided consistently in all areas of the trust. Monitoring of ‘did not attend’ rates was inconsistent, and for some there were long waiting times for ‘referral to initial assessment’ for some specialities.

• Risks to children and young people using the service were assessed and their safety was managed so they were protected from avoidable harm.
• Record and care plans were individualised, clear, accurate and up to date. Records were completed in a timely manner post visit in line with national guidance.
• There was sufficient equipment available to meet the needs of the children and young people.
• Overall, we found that care provided was evidence based and followed recognised and approved national guidance. Staff were clear of their roles in care pathways.
• Staff had access to policies and evidence-based guidance through the trust intranet and staff we spoke with could access policies relevant to their practice.
• Staff treated parents, children and young people with kindness, dignity, respect and compassion.
• We observed good, warm and positive interactions between staff and children. Staff maintained eye contact with children, sat on the floor with them, smiled and nodded in response to each child.
• We found all staff were focused on the needs of the children and young people and actively sought to minimise risks to them. Staff told us how hearing the voice of children and young people was fully reflected in the way care was planned and delivered. Feedback and comments from parents was positive and confirmed their views were sought at all times.
• Leaders had the right skills and abilities to run a service providing high-quality sustainable care.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff.
• Managers across the trust promoted a positive culture that supported and valued staff.
• The service had effective systems for identifying and managing risks.

However;

• The trust policy on record keeping was paperless, therefore all records were stored electronically, however, staff we spoke with were not clear on what actions to undertake to access patient records should the electronic system not be available due to either a cyber-attack or other situation.
• The service did not respond to all complaints in line with the trust policy which stated that complaints should be closed within 35 days.
• Whilst the service collected patient outcomes on an individual basis, the service was unable provide evidence that it monitored the outcomes of the service as a whole.

• Feedback from patients and people who are close to them was consistently positive. Those we spoke with felt that staff often went the extra mile and the care they received exceeded their expectations.
• There was a strong, visible person-centred approach to care. We saw caring and supportive relationships between staff, patients, and those close to them were valued and promoted by staff and leaders.
• Patients’ individual needs were highly respected by staff and embedded in their care and treatment.
• Staff had a good understanding of managing individual patient needs and helping patients living with dementia.
• Governance arrangements were proactively reviewed and reflected best practice.
• Leaders had an inspiring and shared purpose. There were comprehensive leadership strategies in place to develop the desired culture.
• There was a positive culture amongst staff across all wards and departments. Staff and managers appeared receptive of our review of services. Any concerns we identified during our inspection were recorded, shared with relevant staff, and acted upon immediately.
• Staff were patient-focussed, proud of the work that they carried out and shared responsibility to achieve positive outcome for the patients.
• There was clear accountability and reporting from ward to board.
• A hospital based community ward (Digby) was temporarily established over one of the most challenging periods during winter pressures and was staffed by nurses and therapists deployed from Louth County Hospital as well as agency staff.
• There was an improved culture of shared learning across the organisation following incidents and near misses.
• There were effective systems for infection prevention and control and the management of sepsis.
• Staffing levels were planned and reviewed to keep people safe, with any staff shortages responded to quickly. Staff had the skills and competence to carry out their roles effectively and in line with best practice.
• Dementia screening and training improved.
• The implementation of the five steps to safer surgery included all stages including briefing and debriefing.
• Collaborative multi-disciplinary working enabled patients’ independence and supported evidence based care.
• There had been improvements to governance arrangements, with a number of new initiatives introduced to monitor clinical practice and identify and assess risks to patients.
• Staff understood their roles and responsibilities under the Mental Health Act 1983, and the Mental Capacity Act 2005.
• Scarborough Ward at Skegness Hospital had introduced environmental changes known as a ‘Memory Pathway’ to help patients with dementia to find their way around the ward. The pathway was colour coded to direct patients around the ward area and many historical pictures displayed of Lincolnshire landmarks.
• Reminiscence software was used on the wards to provide stimulation for elderly patients and patients living with dementia.
• The trust provided transitional care across services and system providers to ensure that home first principles were proactively viewed as the starting position and not the end point.   The service was significant in the system and provided an essential function in supporting the emerging Neighborhood Team models of care to achieve admission avoidance and reduce acute Delayed Transfer of Care (DToC). 

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

• There were robust systems and processes in place to safeguard people from abuse and harm. All staff were aware of how to respond to a safeguarding concern and felt competent and confident to take appropriate action.
• There was an open and transparent approach to safety and an effective system in place for recording, reporting and learning from significant events. Staff were encouraged to record incidents. Outcomes of investigations were acted upon and learning was shared with staff.
• There were comprehensive arrangements for audit and the service had a strong focus on monitoring and improving the clinical care of patients to ensure that it was in line with best practice guidance.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• The urgent and emergency care services teams were aware of the needs of their local population and understood that the nearest A&E departments to most of the centres was some distance away from where people lived. They had responded to this and adjusted their approach to delivering care to better meet their needs.
• Patients could access services when they needed, overall 99% of patients were seen treated and discharged within four hours. This was against a compliance target of 95%.
• Leaders planned to take account of winter pressures at all centres, and for Skegness centre, there was a summer plan to manage the increased influx of holiday makers during the summer season.
• The service leads had identified a trend for patients presenting at some centres with more serious illness, and had adjusted their workforce to take account of this
• Staff were overwhelmingly positive about the leadership within the service, including the chief executive as a very positive role model.
• Staff had experience in urgent care and had received training to assess and treat adults and children with minor illness/injury.