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Provider: Birmingham Community Healthcare NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 October 2018

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated effective, caring and responsive as good. We rated safe and well led as requires improvement.
  • We rated well led for the trust overall as requires improvement. The rating for well led is based on our inspection at trust level. Taking in to account what we found in individual services. Ratings for other key questions are from combining ratings for services and using our professional judgement.
  • At core service level we rated effective, caring and responsive as good overall. We rated safe and well led as requires improvement. This meant we rated community inpatient services as good overall and community services for children and young people as inadequate overall. In rating the trust, we took in to account the current ratings of the core services not inspected on this occasion.
  • Community health services for children and young people went down from good to inadequate overall. The question of safety went down from good to inadequate. Effective went down from good to requires improvement. Caring stayed the same as good. Responsive stayed the same as requires improvement, and well led went down from good to inadequate. Mandatory training and safeguarding training were below target. The safeguarding children policy did not support staff effectively. Staffing levels and performance were not aligned to national standards. Staff did not adhere to infection prevention and control standards. Systems to secure investigation, audit and learning were inefficient. Care planning was inconsistent and referral to treatment waits were beyond the 18-week target for therapy and child development services.
  • Community inpatient services remained good overall. The question of safety went down from good to requires improvement. Effective, caring, responsive and well led remained good. Patient risks were assessed and managed appropriately and incidents were managed and lessons learned. Staffing levels were planned and managed well. Staff used evidence based interventions and best practice guidelines, auditing their practice. Teams were made up of staff from a wide range of disciplines to meet the needs of the patient groups they worked with. Staff were supported in ensuring they were reflective in their practice and identified learning and skills areas for improvement. Staff understood the principles relating to mental capacity and restrictions placed on the patient’s liberty. Staff worked compassionately and displayed a caring and patient centred approach. Patients found services accessible and stakeholders were involved to ensure needs were met. Leaders were efficient at managing resources and a supportive environment. Governance arrangements were in place and staff understood their responsibilities. We found areas for improvement relating to staff training and appraisals along with patient access to services.
Inspection areas

Safe

Requires improvement

Updated 15 October 2018

Our rating of safe went down. We rated it as requires improvement because:

  • Services for children and young people went down in safe from good to inadequate. The service did not meet mandatory training or safeguarding requirements for medical staff and systems and processes to safeguard children and young people were inconsistent. Staff did not comply with infection prevention and control requirements. Systems to respond to and manage risk were ineffective. Staffing levels were below requirements and some caseloads were unmanageable. Audit results demonstrated deterioration and were not always accurate. Learning from incidents was inconsistent and may have resulted in harm. Service leaders did not consistently understand, act on or support staff to raise concerns. However, the systems to prevent and protect children and young people from a healthcare-associated infection were effective. Mandatory and safeguarding levels for nurses were achieved and staff were knowledgeable about safeguarding responsibilities and processes.
  • Community adult inpatient services went down in safe from good to requires improvement. There were risks associated with gaps in mandatory and safeguarding training across the service. The trust had not provided staff with level 2 training as recommended in the safeguarding children intercollegiate document. However, the service managed patient safety incidents well, sharing lessons learned with the whole team and the wider service. The service controlled infection risk well. Staff assessed and responded to risk using a comprehensive range of methods and tools. The service had enough staff with the right qualifications, skills, training and experience. Staff kept appropriate records of patients’ care and treatment and the service prescribed, gave, recorded and stored medicines well.

Effective

Good

Updated 15 October 2018

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

  • Services for children and young people went down from good to requires improvement. Health visiting teams did not undertake all aspects of the healthy child programme or consistently record the advice given to families. Healthcare passports were not embedded within the service for children in care and children with complex health needs were not supported effectively to plan transition. There was not always a clear approach to monitoring, auditing and benchmarking the quality of services. Targets for training were often not met. However, there was a comprehensive competency assessment and renewal process for those staff caring for children and young people with complex healthcare needs.
  • Community inpatient services improved to good. The service provided care and treatment based on national guidance. The effectiveness of care and treatment was monitored well with regular cycles of audit activity. Staff were competent and received regular appraisals to deliver their roles. Systems of multi-disciplinary working were efficient and staff understood their roles and responsibilities under the Mental Health Act (1983) and the Mental Capacity Act (2005). However, the service had not complied with its appraisal target.

Caring

Good

Updated 15 October 2018

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

  • Services for children and young people stayed the same as good for caring. We observed that staff were kind and children and families told us staff were kind and compassionate. Staff gave young people, parents and carers the time and opportunity to ask questions and be involved in care decisions. Care and emotional support was individualised and children and young people were involved in their care. However, we found variability in approaches to joint working between children, young people and families across the service.
  • Community inpatient services stayed the same as good for caring. Staff cared for patients with compassion and the feedback from patients confirmed that staff treated them well and with kindness. Staff ensured personal preferences were included in care and afforded people privacy, dignity and respect. Staff provided emotional support to patients and facilitated religious support. Staff involved patients and those close to them in decisions about their care and treatment.

Responsive

Good

Updated 15 October 2018

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

  • Services for children and young people stayed the same as requires improvement for responsive. Some waiting times were worse than national targets and some services did not monitor performance against demand. We found an inconsistent approach to supporting people under the Equality Act (2010) and some services did not have the resources required to meet the needs of the service. Mechanisms to ensure lessons learned from concerns and complaints were inconsistent and unclear. However, staff could access telephone and face-to-face translation services and the PSAS (paediatric sexual assault service) offered 24-hour service provision. The service supported children and young people with additional needs and those with complex health care needs to remain in school. School nurses delivered important public health education to children and young people.
  • Community inpatient services stayed the same as good for responsive. Services were tailored to meet the needs of the local population, offering flexibility and choice. Reasonable adjustments were accommodated including disabled access, hearing loops for those with hearing impairments, translation services, dementia friendly environments, equipment and tools to aid accessibility. Waiting times were in line with good practice and the service worked well with social care colleagues.

Well-led

Requires improvement

Updated 15 October 2018

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • Services for children and young people went down for well led from good to inadequate. Risks were not consistently or effectively managed and investigations were not prioritised. Staff were unaware of who was part of the trust’s senior leadership team and some experienced negative responses from local managers when they spoke up about concerns. Service strategies were outdated and staff were unclear as to the current strategy which was being refreshed at the time of the inspection. There was no systematic programme of clinical or internal audit and leaders were not sighted on team performance. Leaders did not have full oversight of the performance and outcomes within the division because the children, young people and families’ division did not participate in the trust wide essential care indicators. Managers did not always adhere to trust policies and procedures regarding staff performance and record keeping was not always effective. There were gaps in communication and information sharing. Lone working practices were mixed across the service and not in line with trust’s lone working policy. However local managers were visible and accessible and most staff described a positive culture. The children in care team enabled the young person’s voice to be heard and children and young people were included in interview processes. Children and young people with a learning disability were supported to draw their feedback to ensure their voices were heard.
  • Community inpatient services stayed the same as good for well led. Managers had the right skills and abilities to run a service providing high-quality sustainable care and promoted a positive culture. The service identified risk effectively and engaged well with patients, carers and families. The service encouraged learning and promoted training, research and innovation. However, service strategies were outdated and staff were unclear as to the current strategy which was being refreshed at the time of the inspection.

Checks on specific services

Community health inpatient services

Good

Updated 15 October 2018

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

  • Patient risks were assessed and managed appropriately and incidents were managed and lessons learned as a result. Staffing levels were planned and managed to ensure patients and staff needs were managed safely.
  • Staff used evidence based interventions and best practice guidelines to ensure positive outcomes for those using the services. They regularly audited their practice and made changes when appropriate. Teams were made up of staff from a wide range of disciplines to meet the needs of the patient groups they worked with. Staff were supported in ensuring they were reflective in their practice and identified learning and skills areas for improvement. Staff understood that patients should have their needs met based on their consent. They understood the principles relating to mental capacity and restrictions placed on the patient’s liberty. As such they ensured they practiced in their patient’s best interests.
  • Staff worked compassionately and displayed a caring attitude to those they worked with and those who were involved in patient care. Staff demonstrated a patient centred approach and were emotionally supportive which was relayed to us by those who used the services.
  • All services were delivered with the rehabilitation, wellbeing and comfort of patients at its heart. Patients found services accessible, adjustments were made and resources provided if required. All key stakeholders were involved to ensure everyone’s needs were met. Peoples’ views were encouraged and used to make changes to improve on accessibility and outcomes.
  • Leaders were efficient at managing resources and providing a supportive environment for staff. Staff were supported in their learning and development and there were opportunities to reflect and be supported in professional growth as well as staff wellbeing. Information was shared, staff engaged in service development and research. Governance arrangements were in place and staff understood their responsibilities. There was a culture of putting patients first and staff feeling they played a valuable role in contributing to positive outcomes.

However:

  • The service provided mandatory training in key skills to all staff but did not make sure everyone completed it. This meant the service could not assure itself that staff working in the inpatient units had the skills essential and necessary for the safe and efficient delivery of services.
  • Staff we spoke with understood how to protect patients from abuse, however, not all eligible staff had completed training on how to recognise and report abuse. The trust had not provided staff with child protection level 2 training as mandated in the safeguarding intercollegiate document. When we raised our concerns with the trust appropriate and timely action plans were put in place immediately.
  • There was work to be done on building the strategy, vision and values of the service. This was because of change in the direction of the organisation and new leadership.

Community health services for children, young people and families

Inadequate

Updated 15 October 2018

Our rating of this service went down. We rated it as inadequate because:

  • There was a lack of a learning culture. Learning from lessons was not always shared to ensure action was taken to improve safety. Following a serious incident within the health visiting service, which occurred in April 2017, learning appeared to have been identified but there was no evidence it had been shared with staff within the trust.
  • There was a lack of understanding of the risks within the service. The trust’s serious incident investigations did not consider broader, systemic issues that may have contributed to an incident, so learning was limited.
  • We found risk management was limited across children, young people’s and family services. Risk assessment was not consistently undertaken to ensure those most vulnerable received timely and effective care and support.
  • Leaders did not always understand the importance of staff being able to raise concerns and appropriate learning and action was not always taken as a result. Concerns raised by staff about their colleagues were not always investigated or acted on which impacted on the care delivered to children. Some staff told us they felt fearful of raising concerns with their managers.
  • We found staffing levels inadequate to provide the level of service required across health visiting, children in care teams and therapy services. The trust was unable to respond effectively to ensure the risk of harm was being assessed and managed.
  • Health visiting teams did not meet the requirements of the healthy child programme or consistently undertake antenatal visits.
  • There was not always a clear approach to monitoring, auditing and benchmarking the quality of all services or the outcomes for people receiving care and treatment within the children, young people and families’ division.

  • Mandatory training compliance did not consistently meet the trust average target of 85%. Safeguarding training did not consistently meet the trust targets and was not in line with intercollegiate guidance.
  • The safeguarding children’s policy did not effectively support staff in the trust’s endorsement of the Birmingham Safeguarding Board (BSB) or the West Midlands protocols.
  • Staff did not adhere to Infection prevention and control best practice, national guidance and the trust’s policies across all children’s services.
  • Care planning was not consistently done and care plans not consistently updated across the service.
  • The service did not consistently achieve the trust target of 90% compliance with yearly appraisals for staff.
  • Staff compliance with Mental Capacity Act 2005 training was below the trust target of 85% for medical and dental staff.
  • The trust was not meeting the referral to treatment (RTT) target of 92% of patients being seen within 18 weeks of the referral within therapy and children’s development centres. Nor were assured that deterioration of the child was not occurring as a result.
  • Compliance with the Equality Act (2010) was ineffective: we found a lack of specialist training for staff to support transgender young people within the paediatric sexual assault service and a lack of information in languages other than spoken English, including medical advice and treatment plans.
  • There was no systematic programme of clinical and internal audit to monitor quality, operational and financial processes or systems to identify where action should be taken.
  • Although leaders understood the challenges to quality and sustainability, and could identify the actions needed to address them, they were not always aware of the performance of their teams.

However:

  • Medicine management was good across the service.
  • Staff across the service had good knowledge of how to safeguard people and what their responsibilities were.
  • Staff supervision was happening, including safeguarding supervision however this was not always consistently provided and undertaken.
  • Staff met the nutritional needs of children and young people, including specialist and non-oral feeds.
  • Competency assessments were undertaken yearly to ensure effective and safe care delivery by staff.
  • Staff were kind and compassionate when delivering care to patients and their families.
  • Staff provided support to patients and families in difficult and emotional situations.
  • Children and young people with additional needs and those with very complex needs were supported by school nurses and the complex care team to attend school.
  • Local team leaders were visible and approachable. Most staff felt supported by their line manager and local leaders.
  • The children in care team and complex care team engaged service users in the development of the services.