Hounslow and Richmond Community Healthcare NHS Trust

Updated 19 October 2018

Hounslow and Richmond Community Healthcare NHS Trust (HRCH) was created in 2011 from the community services arms of the former Primary Care Trusts for Hounslow and Richmond. HRCH provides community health services for approximately 515,000 people living in the London boroughs of Hounslow and Richmond-upon-Thames. Each month, the trust provides services to about 32,000 different service users.

The population of Richmond-upon-Thames has better health than the England average, with lower than average hospital stays for alcohol-related harm and self-harm, lower than average smoking deaths, excess weight in adults, tuberculosis infections and early deaths from cardiovascular disease or cancer and higher than average physical activity. The population of the neighbouring borough Hounslow is younger and more diverse (with over 50% of the population from an ethnic minority background compared to 11% in Richmond). The health picture is mixed, with lower than average hospital stays for self-harm or alcohol-related harm, but higher than expected levels of diabetes, tuberculosis and sexually transmitted infections.

The trust provides services from three registered locations:

• Hounslow Urgent Care Centre, located at West Middlesex Hospital, where the trust provides urgent treatment for minor injuries and illnesses.
• Teddington Memorial Hospital, where the trust has 29 inpatient rehabilitation beds and an urgent treatment centre (developed from the former walk-in centre) that is open 8am-10pm every day. The trust also hosts outpatient services and provides diagnostic services the Teddington Memorial Hospital.
• Thames House, the CQC-registered location for a range of community services delivered across Hounslow and Richmond.

The trust does not provide dental services or sexual health services. End of life care for adults is integrated into the trust’s district nursing and inpatient services, with no specialist palliative care staff, but supported by local hospices which undertake joint patient reviews and provide specialist support. Children’s end of life care is provided by children’s continuing healthcare teams.

Of all community trusts, HRCH has the smallest staff establishment (933 FTEs as of 31 January 2018) and the second-smallest turnover at £70.5m in 2016/17. The trust runs a surplus, which was £2.9m in 2016/17 and an estimated £2.2m in 2017/18.

Updated 19 October 2018

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

• We rated safe, effective, caring, responsive and well-led as good. We rated all of the trust’s five services as good. In rating the trust, we took into account the current ratings of the two services not inspected this time.
• We rated well-led for the trust overall as good.
• Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses and to report them internally and externally.
• Staffing levels, skill mix and caseloads were planned and reviewed so that people received safe care and treatment.
• The trust was meeting its mandatory training target of at least 85% of staff completing the relevant training.
• Staff had access to necessary equipment and medicines; and had a range of policies and procedures based on national standards to support their practice.
• People’s physical, mental health and social needs were holistically assessed and their care and treatment delivered in line with legislation, standards and evidence-based guidance.
• Multidisciplinary working was strong across the services. Staff worked well together and with other organisations to deliver effective care and treatment.
• The services had clear arrangements for supporting and managing staff to deliver effective care and treatment. Staff had annual appraisals and managers encouraged staff and supported opportunities for development.
• Staff were kind caring and treated patients with dignity and respect. Patients spoke of the positive care they received from staff.
• Staff communicated with people so they understood their care, treatment and condition; and advice was given when required. Staff involved carers and families in the patient’s care, where appropriate.
• Services delivered were accessible and responsive to people with complex needs or in vulnerable circumstances. People with the most urgent needs had their care and treatment prioritised. Waiting times were within the trust target.
• Leadership teams were visible and supportive to frontline staff and demonstrated good knowledge and understanding of the services they provided.
• Managers made a concerted effort to involve staff in changes to services.
• There was a positive organisational culture, which supported openness and transparency.
• In the Hounslow urgent treatment centre, the patient champion service worked well to support homeless patients regarding access to services. The service produced an information leaflet designed to inform homeless patients of their rights, advising them on how to access care and what community services and support was available.
• The trust was the first trust to use a wound care app, which was an online electronic reference guide for appropriate treatment and care option for wounds. This was innovative practice and enabled staff to obtain advice from senior and specialist staff, which helped them assess and identify the correct grading and possible deterioration.
• The wheelchair hub in Hounslow offered comprehensive wheelchair, seating and sleep system for people with long-term mobility problems. The service offered a single streamlined service for wheelchair and posture assessment, equipment and review, repairs and maintenance.
• Intravenous therapy nurses at the trust developed the cellulitis pathway where a small portable antibiotic infusion pump that patients could either wear around their necks or place in their pockets. This was innovative practice and its purpose was to prevent patients being admitted to hospital.
• The trust collaborated with several external providers (Marie Curie, Hospice Staff, Out of Hours Providers) and these relationships were positive and promoted best practice.
• The children’s continuing care team delivered high quality care to children receiving end of life care. Relatives we spoke with told us they were their lifeline during periods of distress.

However:

• Patients’ pain scores and whether analgesia was offered were inconsistently recorded.
• The vacancy rate for qualified nursing staff was high at 22%, which the trust recognised. Nursing staff in Hounslow said the shortage of staff resulted in a heavy caseload, which sometimes made for a stressful working environment.
• In the urgent treatment centre at Teddington Memorial Hospital, the waiting area was small and patients attending at reception could be overheard by others, impacting on their privacy.
• Several staff members were unaware of the trust’s vision for their respective services.
• The trust had insufficient data to determine the quality of the end of life service being provided.
• There were inconsistences in the completion of some aspects of patient notes.

Updated 19 October 2018

Our rating of this service improved. We rated it as good because:

• Staffing levels, skill mix and caseloads were planned and reviewed so that people received safe care and treatment. Staffing remained a risk on the risk register, but there were robust arrangements to address staff recruitment and retention.
• Safety thermometer results showed good performance, with the majority of patients receiving harm-free care.
• Staff understood their responsibilities to raise concerns, record and report safety incidents, concerns and near misses, and to report them internally and externally. This was an improvement from our last inspection.
• People’s physical, mental health and social needs were holistically assessed, and their care, treatment and support delivered in line with legislation, standards and evidence-based guidance.
• All necessary staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment. We saw strong multidisciplinary working across the service.
• Staff were kind caring and treated patients with dignity and respect. Patients spoke of the positive care they had received from staff.
• Staff communicated with people so that they understood their care, treatment and condition, and advice was given when required. We saw all disciplines of staff involving the patient’s carers and families in the patient’s care, where appropriate.
• Services delivered were accessible and responsive to people with complex needs or in vulnerable circumstances. People with the most urgent needs had their care and treatment prioritised.
• On our last inspection, we raised concerns regarding the waiting times for podiatry, continence, diabetes and musculoskeletal services, which were constantly breaching trust targets. During this inspection, we found these waiting times had been improved. At the time of our inspection, none of the clinic waiting times had breached trust targets.
• The trust demonstrated several areas of outstanding and innovative practice. The trust was the first trust to use a wound care app, which was an online electronic reference guide for appropriate treatment and care option for wounds. The wheelchair hub in Hounslow offered comprehensive wheelchair, seating and sleep system for people with long-term mobility problems. Intravenous therapy nurses at the trust had developed a cellulitis pathway, including the use of small portable antibiotic infusion pumps, that patients could either wear around their necks or place in their pockets. The aim of the pathway was to prevent patients being admitted to hospital.

However:

• The vacancy rate for qualified nursing staff was high at 22%, which the trust recognised. However, it should be noted that this figure was combined with the vacancy rate for qualified health visiting staff, and was in line with the national context for community trusts. Nursing staff in Hounslow said the shortage of staff resulted in a heavy caseload, which sometimes made for a stressful working environment. Staff told us the workload felt relentless.
• Most staff we spoke to in Hounslow were not aware of arrangements to keep staff safe when working alone, despite there being a lone working policy across both boroughs.
• Staff did not routinely use a formal pain assessment tool.

Updated 6 September 2016

We found that services for children and young people at Hounslow and Richmond Community Healthcare NHS Trust were effective, caring, responsive and well-led. 

We rated the children and young people (CYP) service as good for safety. This was because:

• There were comprehensive processes and training for child safeguarding.
• Incidents were reported and investigated appropriately. Learning from incidents was disseminated.
• All of the locations we visited were clean and tidy and staff complied with infection prevention and control processes.
• There were effective risk management systems in place, including a robust lone working process for staff.

However,

• There were significant staffing shortages, high turnover of staff, and heavy and unsustainable caseloads for practitioners. This was across all universal and specialist services.
• Staff could not immediately access service user records outside of their specific location and service line which presented risks in ensuring all information was immediately available to practitioners.

We rated the CYP service as ‘good’ for effectiveness. This was because:

• Universal and specialist services were based on evidence and good practice and delivered in line with national guidance. There was good provision of evidence-based advice and guidance to service users.
• There was a comprehensive local audit programme. The trust engaged with local and regional panels, peer review and was involved in regional research projects.
• There was effective internal and external multidisciplinary working. This was facilitated by co-location of services and partnership working with other service providers.
• There was good inter-agency partnership working with local authorities and other safeguarding partners.
• Consent processes and documentation were robust and applied consistently.
• The trust assessed they effectiveness of different services using nationally recognised outcome measures.
• There were good learning and development opportunities for staff including well-structured preceptorships and support for professional development and revalidation.
• The trust applied robust competency frameworks and comprehensive supervision structures for staff.

We rated the CYP service as ‘good’ for caring. This was because:

• Staff across the CYP service were courteous and professional. We saw staff communicating with service users in a polite and caring way.
• Service users told us health visitors and therapists had a caring approach. Parents of children using services were universally positive and highlighted the encouragement and support of health visitors in clinics and home visits.
• Service users were treated with dignity and in an age appropriate way.
• Friends and Family Test results and other evaluations were consistently very good across universal and specialist CYP services with a good response rate.
• Some universal services were delivered in noisy and busy children’s centres. This did not always allow for adequate privacy or dignity, particularly when needing to communicate with service users confidentially.

We rated the CYP service as ‘good’ for its responsiveness to service users’ needs. This was because:

• Services were planned and delivered in line with local needs. The trust worked with commissioning bodies to target local provision of services.
• There was good access to multiple CYP services, facilitated by the co-location of services in one location.
• Service users had good access to provision across different locations.
• There were varied appointment times to suit different service users.
• Clinics and therapy sessions were held in child friendly environments.
• Staff communicated with children and young people in an age appropriate way and involved them as decision makers in their care.
• There was good understanding of the different cultural needs and backgrounds of service users. The diverse local community was reflected in the diversity of trust staff. Many staff members spoke community languages and were allocated caseloads accordingly.
• There was good access to translation services, with good provision of patient literature in community languages.
• Service users were able to self-refer for some services, such as speech and language therapy.
• There were some reported challenges with wait times for referrals to therapy services, such as SALT and social communication pathways. Service leaders were aware of these delays and had put in place resources to reduce wait times.
• Some CYP services were only delivered to service users in one borough, for example, Family Nurse Partnership was provided to Hounslow residents only and not those in Richmond. There were some problems with continued access to services if a service user relocated between boroughs.

We rated the service as ‘good’ for well-led. This was because:

• Staff told us that service leaders were very supportive, accessible and approachable.
• The staff we met reflected the trust values and vision. Staff felt autonomous, empowered and trusted to make decisions.
• There was effective representation of children and young people matters such as safeguarding at the trust board.

• There were effective processes for involving service users and the public in the development of services and resources.

• There was effective dissemination of governance and performance information.

• There was no clear, documented vision for the CYP service as a whole and operational staff were not clear about the strategic direction of the CYP service. Although there was a five year plan, local challenges within the health economy were impacting on the trust’s ability to maintain and develop the CYP service.
• Although Hounslow Primary Care Trust (PCT) and Richmond PCT merged to become HRCH in April 2011, the CYP service still presented as two very separate entities: as Hounslow and Richmond. There were limited opportunities for staff interaction and sharing resources across the two boroughs.
• Some staff felt that change management was not handled very well within the trust, with limited opportunities for dialogue or involvement in decision making, for example: relocation of services and redeployment of staff.

Updated 27 April 2017

Letter from the Chief Inspector of Hospitals

We undertook a follow up inspection of the inpatient unit run by Hounslow and Richmond Community Healthcare NHS Trust at Teddington Memorial Hospital on 25 January and 6 February 2017. It was a focussed inspection to follow up on concerns, particularly looking at the safe and caring domains which CQC had judged inadequate in its inspection of March 2016 (published 6 September 2016.) The unannounced inspection reviewed the action taken in response to the requirement notices issued under The Health and Social Care Act (Regulated Activity) Regulations 2014. These had related to dignity and respect, governance processes in relation to monitoring the quality of the service and numbers and training of staff.

Following the March 2016 inspection the provider sent us an action plan detailing how they would improve the areas of concern in the inpatient unit. The unit is now focused on rehabilitation, rather than being a general elderly care step down ward, so the service now provided is quite different from that we inspected in March 2016. We therefore also reviewed the inpatient unit’s performance in the domains of effective, responsive and safe as well. These had formerly been judged as requiring improvement.

We inspected the inpatient unit because we were aware that the provider had made significant changes since the last inspection in March 2016. The inpatient unit was now meeting the regulations that had previously been breached and was providing a good service in all areas. We rated inpatient unit is as good overall.

Our key findings were as follows:

• There was a cohesive strategy for the inpatient unit which the trust had restored to its intended function as a bedded rehabilitation unit. The key elements of the transformation had been in place since September 2016. Work was continuing with staff and external partners on further changes over time.
• There was regular oversight of the inpatient unit by members of the executive team. New managers were in place on the unit and a small transformation team had been working with staff to ensure they owned and understood the benefits of the changes in practice.
• All day shifts were filled 100% by permanent staff and night shifts by 95% permanent staff. Nursing staff were delivering care in line with current national guidelines.
• The inpatient unit environment was visibly clean and was quiet and calm. Our visits were unannounced and we found patients were up and dressed early in the day, most of them ate their midday meal in the day room and on our evening visit we found the inpatient unit was quiet by 10pm so patients could sleep.
• Staff had received additional training in areas that had been identified as weak at the previous inspection: consent, the mental capacity act, infection control. All health care assistants had obtained the care certificate.
• Patient admissions and discharges were appropriately planned and managed.
• We found no issues associated with privacy and dignity in the accommodation, and we observed staff seeking patients’ consent for treatment, including for daily activities such as washing and dressing.
• Rehabilitation patients achieved good outcomes, 97% improving their functional scores by the time of discharge.
• There was a good culture of incident reporting.
• Processes for safe administration of medication were in place.
• We spoke with patients and visitors and all the feedback we received was positive. All patients we spoke with were complimentary about their care and treatment and of the kindness of staff.
• There was resuscitation equipment on the inpatient unit which had not been readily available on the previous inspection, and staff were confident in how to use it.
• The average referral to admission time was 1.8 days which was less than the NHS average of 2.6 days.

An area of outstanding practice was:

• The rapid response and rehabilitation team acted as a single point of access for admissions and was also involved in discharge ensuring that patients were supported to continue their rehabilitation after discharge home.

However, the provider should ensure that:

• All members of staff understand where to locate the originals of DNAR forms and know the process for managing active DNAR orders
• Hand hygiene audits improve to meet the trust target of 95%.

The new ratings impact on some of the trust ratings, although the overall rating remains requires improvement.

Professor Sir Mike Richards Chief Inspector of Hospitals

Updated 19 October 2018

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

• Staff were provided with safety related training and risk assessment tools which ensured patients were kept safe and protected from avoidable harm. The use of risk assessments had improved since our previous inspection. Incidents were reported, investigated and learning was cascaded trust wide.
• During our last inspection we noted nursing staff had no specialist palliative care training. The trust had now made it mandatory for patient-facing staff to complete e-learning modules designed around palliative and end of life care.
• Although there was a reliance on bank nursing staff, there were sufficient staff with the right skills and experiences to provide individualised care. The introduction of the role of end of life care champions meant a nominated individual in each team took responsibility for updating colleagues on matters relating to end of life care.
• Staff had access to necessary equipment, medicines and had a range of policies and procedures based on national standards to support their practices.
• Patients and relatives were satisfied with the standards of treatment and care provided. Staff involved patients and people close to them in decisions regarding their own care and treatment.
• There was a positive culture which supported openness and transparency trust wide.

However:

• Staff were unaware of the trusts vision and aims in relation to end of life care (EoLC), and had limited knowledge of its content.
• The trust had not increased the monitoring of patient outcomes. The trust had insufficient data to determine the quality of the service being provided.
• There were inconsistences in the completion of some aspects of patient notes.

Updated 19 October 2018

Our rating of this service improved. We rated it as good because:

• Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them. Staff at both sites described a positive incident reporting culture and felt encouraged to report incidents and share learning.
• Since our last inspection, the UCC had undergone considerable refurbishment. The service had addressed specific concerns and the waiting area was spacious, accessible and had a separate waiting area for children.
• The services had clear arrangements for supporting and managing staff to deliver effective care and treatment. Staff had annual appraisals and managers encouraged staff and supported opportunities for development.
• Staff worked together, and worked well with other organisations to deliver effective care and treatment. Both services had good links with partner organisations and patient information was shared appropriately to facilitate coordinated care pathways.
• At both services, we saw clinical and administrative staff taking the time to interact with people who use the service and those close to them in a respectful and considerate way.
• Both services were responsive to the needs of people in vulnerable circumstances. For example, vulnerable patients were helped to access support services such as homeless organisations and alcohol and drug support services. The patient champion service at the UCC had produced information leaflets specifically designed to inform homeless patients of their rights and how to access care and support.
• Leadership at both sites was visible and demonstrated good knowledge and understanding of the services they provided. Staff we spoke with at both sites described leaders as very visible and approachable and described feeling well supported by managers.
• Staff were actively engaged so that their views were reflected in the planning and delivery of services and in shaping the culture. Managers had made a concerted effort to involve staff in changes to the service and staff described feeling involved in planning and design. They described feeling reassured by managers around concerns that they had raised.

However:

• Both services used templates to input information into the patient record, which meant that key information could be recorded. However, pain scores and whether analgesia was offered were inconsistently recorded at both sites. This meant that there was no clear assurance in the patient record of whether their pain had been checked and suitably managed.
• At the WiC, the waiting area was small and patients attending at reception could be overheard by people already waiting, impacting on the patient’s privacy.
• The services had inconsistent understanding of the overall trust vision and strategy and while staff and leadership could describe the values of the service, the UCC did not have a clear vision and strategy.
• Although the UCC and WiC provided different models of care, we saw limited crossover between the UCC and WiC. Service managers had organised some joint learning days but contact and sharing of initiatives or improvements between sites was limited.
• There were high nursing and medical vacancy rates at the UCC, although the service used bank and agency staff to cover shifts and had ongoing recruitment to fill the posts.

Updated 6 September 2016

Overall, we rated community end of life care as good because;

• Patients were protected from abuse and avoidable harm. When something went wrong, people received a sincere and timely apology and were told about any actions taken to improve hospital processes to prevent the same event reoccurring. Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses; they said they had been fully supported when they did so. Monitoring and reviewing activities enabled staff to understand risks and gave a clear, accurate and current picture of safety.

• The senior nurses regularly reviewed incidents and shared the findings with individual staff and at team meetings. We were, however, unable to find evidence of this learning being shared trust wide other than at team meetings at the clinics where the incident occurred.

• Nursing staff completed risks assessments and we noted that the shared care record was being used appropriately by the EOLC clinical nurse specialist (CNS) and the district nursing teams. The shared care record (Palliative Care Plan) was a document used when patients were identified as being in the last few days of their life. There was good access to out of hours support and advice for nursing staff from the local hospices.

• The feedback from people who used the service and their families were positive about the care received by patients nearing the end of life. Staff always took patients personal, cultural, social and religious needs into consideration when delivering care. Patients’ emotional and social needs were valued by staff and were an important part of their care and treatment. Families were very positive about staff and the service they received. The service demonstrated a high level of compassionate care to patients and their families.

• Patients’ needs were assessed appropriately and care and treatment planned and delivered accordingly, however this was not in line with current legislation. There was a multi-disciplinary collaborative approach to care and treatment within community services as they worked closely with Princess Alice and Meadow House Hospices.

However;

• Some of the DNACPR forms we reviewed did not contain discussions held around Mental Capacity Act (MCA) and best interest decisions. It was unclear how patients’ mental capacity had been assessed particularly in relation to documenting best interest decisions.
• There was no plan in place for the end of life service to be accredited to best practice in alignment with the gold standards framework (The National Gold Standards Framework Centre (GSF) help doctors, nurses and care assistants provide the highest possible standard of care for all patients who may be in the last years of life. It’s a model that enables good practice to be available to all people nearing the end of their lives, irrespective of diagnosis. It is a way of raising the level of care to the standard of the best). There was no recognition of this work having been commissioned and undertaken by the lead director for end of life care. There was very little evidence of audit to support some of the work been undertaken. This meant there was a lack of systems and processes to help identify people entering the last 12 months of life.