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Provider: Birmingham Community Healthcare NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 May 2020

Our rating of the trust stayed the same. We rated it as requires improvement because:

  • We rated the trust as requires improvement overall. We rated caring as outstanding, effective as good, and safe, responsive and well-led as requirement improvement.
  • We rated five of the six trust’s services as good and one as requires improvement. In rating the trust, we took into account the current ratings of the two services not inspected this time.
  • Although we recognised that the trust had made significant improvements and the board had improved many of its systems, including the vision, values and strategy, there was further work to be improved and completed. However, we were assured that the board and the trust was on a trajectory of positive change that would improve the experience of patients, families, the local population and staff.
  • Staffing levels of health visitors remained low and staff in these teams were carrying high caseloads. Morale remained low in these teams and staff did not feel that leaders effectively engaged with them. This continued to be a problem that was seen at the previous inspections in 2018 and 2019. However, the trust had improved governance arrangements to address these problems and were working with external stakeholders to recruit into these posts and had a clear trajectory of improving staffing levels up to and including 2021.
  • People could not always access the service when they needed it and did not always receive the right care in a timely way. Children and families were waiting too long for a neurodevelopmental assessment, including 147 weeks for the paediatric Attention Deficit Hyperactivity Disorder (ADHD) service, and 127 weeks for the paediatric physiotherapy service.
  • There was further work to embed IT systems across the trust to ensure staff were using them effectively to monitor and plan care to patients. Not all clinical information was kept in the same place and staff required further support to ensure care plans were used effectively and were up to date.
  • There was further work to engage with all staff groups to fully embed the vision and values of the trust. The staff survey in 2019 showed that less staff engaged with the process than in 2018, and although there were improvements in some areas of staff feedback there were areas that required immediate attention, such as equality, diversity and inclusion, and providing a safe environment for staff. Overall, the trust performed worse in the staff survey compared to comparable trusts nationally.
  • Although the experience of staff from a black, Asian and minority ethnic background had improved since 2018, there was further work to undertake to recruit into senior leaders roles, including band 8A and above.
  • Not all staff were following infection control practice in accordance with infection control standards.
  • There was a need to strengthen learning across the organisation to ensure it was shared across all front-line services.
  • We were not assured that opportunities were in place for the five divisions to learn from each other to drive development and opportunities of front-line services.
  • The trust did not have a defined quality improvement methodology however, we recognised that the trust had plans in place for improvement.
  • The trust did not always respond in a timely way to freedom of information requests.

However;

  • The service had enough staff in most services to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well in most services. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and in most services, did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Most staff understood the service’s vision and values, and how to apply them in their work. The majority of staff felt respected, supported and valued. Leaders had improved staff access to clinical supervision. Staff were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
Inspection areas

Safe

Requires improvement

Updated 27 May 2020

Our rating of safe stayed the same. We rated it as requires improvement because:

  • Systems and processes were not always reliable or appropriate to always keep people safe. There was not a consistent way of protecting staff from discrimination. Information about safety in some teams was not always comprehensive however safety to patients over time had improved. Lessons learned were not widely shared across divisions as there was further work to be completed to improve cross division working.
  • There were periods of understaffing which had still not been addressed in health visiting teams. Caseloads remained high and there had not been progress since the previous inspection in 2018.
  • Systems to manage and share care records and information were cumbersome, and not all staff knew how to use electronic patient care records well.

However:

  • Although we found concerns in children’s and young people community services of high caseloads and understaffing, risks to people who used services were assessed, monitored and managed on a day-to-day basis. Staff managed medicines consistently and safely.
  • Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and reports incidents and near misses.
  • There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse, using local safeguarding procedures wherever possible. The trust had a strong presence in multi-agency safeguarding teams to support identification and act upon people who were open to abuse across Birmingham, including the multi-agency safeguarding hub.

Effective

Good

Updated 27 May 2020

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

  • Patients overall had good outcomes because they received effective care and treatment that met their needs. Patients care and treatment was planned and delivered in line with current evidence-based guidance, standards and best practice.
  • The board had improved systems to understand front line services and senior leaders understood the reality of services they delivered. The strategy supported key aims and objectives in the five divisions to improve outcomes for patients and families but there was further work to be undertaken to see the full impact.
  • Staff, including volunteers, had the skills and experience to carry out their roles effectively. The learning needs of staff were identified and training was provided to meet these needs. The trust had improved the numbers of staff who accessed supervision and appraisal. There was a clear approach for supporting and managing staff when their performance was poor or variable. But in some teams, staff told us that managers were not always visible to provide support but the trust were addressing this through their leadership development.
  • Patients discharge and transfer plans were assessed early with the involvement of necessary staff, teams and services. They had identified that it was a key player to support transition between acute hospital services and the community, and were working with external partners to improve the flow of patients back home.
  • Staff were consistent and proactive in supporting patients and families to live healthier lives. There was a focus on early identification and prevention and supporting people to improve their health and wellbeing. Patients were supported to make decisions about their care and treatment and where necessary, staff assessed mental capacity appropriately.

However:

  • IT did not always support staff to record and share best practice of care and treatment for patients. This was a work in progress and the trust were prioritising IT systems to support staff to record relevant information to improve care and treatment.

Caring

Outstanding

Updated 27 May 2020

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

  • Patients were truly respected and valued as individuals and were empowered as partners in their care, practically and emotionally, by staff, teams and the trust as a whole. From staff through to the board, there was a passion to ensure patients and families received the best care possible even when staffing numbers were a concern. Staff worked in areas of deprivation and culturally diverse communities and adapted their approach to ensure patients had their needs met, even when they were at risk when working alone.
  • Feedback from patients and families across most services was continually positive about the way staff treated them. On many occasions staff went the extra mile to support care and treatment. There was a strong, visible person-centred culture.
  • Staff recognised that patients and families required access to, and linked with, support networks in the community and they supported people to do this. Staff ensured that patients’ communication needs were understood and shared this within teams.
  • Patients and families were treated with dignity by those involved in their care and treatment. Staff considered privacy and dignity and this was embedded in everything they did, including awareness of specific needs such as communication and disability. Staff and the trust were committed to and enabled patients to remain as independent as possible.

Responsive

Requires improvement

Updated 27 May 2020

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

  • Some services did not meet people’s needs. Children and families were waiting too long for neurodevelopment assessments. This was a critical time in the early lives of children and assessment would support better outcomes for them. This would allow them to access the right levels of care with regards to health and education throughout their life. Action to address this was not taken quickly enough and was not effective.
  • Feedback from patients and families reported in the friends and family test that it was difficult to make appointments and generally get through to some services.
  • Not all freedom of information requests were completed in a timely way however when the trust could not provide the information, they apologised.

However:

  • Most services understood the importance of flexibility and informed choice for patients. Patient and family’s needs and preferences were considered and acted upon. Most services delivered care and treatment where preferences were considered and delivered in a consistent way.
  • The trust did not own all the buildings where care was delivered and staff worked flexibly within external premises, such as GP centres.
  • The needs and preferences of patients and families were taken into account when delivering and coordinating services. This included people who were approaching the end of life, those with protected characteristics such as disability, and those in vulnerable circumstances.
  • Patients’ and families knew how to give feedback to the trust and services and were confident their concerns were taken seriously and treated in a compassionate way. The complaints system was working well and the board were keen to learn from complaints and concerns.

Well-led

Requires improvement

Updated 27 May 2020

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

  • The trust still has further work to improve the experience of patients, families, the local population and staff.
  • Most of the board were new to the trust therefore they were still embedding ways of working together that would improve services. The trust were only at the start of the process of training 600 managers who required leadership development and this had not yet impacted on the delivery of care or ensured that front line staff were supported appropriately.
  • Further work was required to embed governance systems and for divisions to work effectively with each other.
  • There were still high caseloads and staff morale was poor in health visiting teams. This had an impact on care delivered to families who required universal services.
  • The experience of staff, in particular from black, Asian and minority ethnic staff remained a problem that the trust were trying to address. Representation from minority groups was not reflected in senior positions from band 8A and above. The staff survey of 2019 showed a decrease in responses from staff and the trust needed to do more to increase the numbers of staff who feedback on their experience of working int the trust.
  • IT systems were not consistently used across the trust and staff were not using them effectively. The trust recognised this problem and were working towards improvement.
  • Quality improvement was not embedded across the trust.

However:

  • The trust had revised the vision, values and strategy and this was a positive change for staff. The trust had engaged patients, families, the wider community, external stakeholders and staff to develop the strategy and we could see that it would bring effective and sustainable improvement. Progress against delivery of the strategy and local plans was monitored and reviewed. The challenges to achieve the strategy, including relevant local health economy factors were understood and action plans were in place to address them.
  • The majority of leaders at every level lived the vision and values of the trust and promoted compassionate and sustainable care. Candour, openness, honesty and challenges to poor practice were the norm. concerns were investigated sensitively and confidentially and lessons shared within divisions. When something went wrong, people received an apology and told what actions the trust would take to prevent it happening again.
  • The trust managed its finances well. The board had identified a shortfall in funding of children’s and young people services and that partnership working was not effective to deliver safe, quality services. As a result, the trust worked with external stakeholders and partners to improve the delivery of care within the service and we saw evidence that improvement had occurred.
  • The board worked well with the council of governors and they provided sufficient challenge and scrutiny to the trust. The governors had the skills and experience to undertake their work but required an improved approach to recruitment in order to ensure representation of the diverse communities of Birmingham.
  • Appraisals and supervision for staff had improved since 2018. Staff were supported to develop their skills and knowledge through training and supervision.
  • Across the trust, we saw a culture of collective responsibility and in most services teams and services had positive relationships with each other. The trust had promoted engagement with staff and overall they reported that executives of the board were visible, listened and took a genuine interest in the work they did.

Checks on specific services

End of life care

Good

Updated 30 September 2014

End of life services were good within the trust, we identified some excellent care.  Staff demonstrated a level of compassion and willingness to ‘go the extra mile’ for patients and families. We saw that innovative work was undertaken by the service, where staff had identified areas where their input resulted in improved outcomes for the patients and or their families.

We found the service to be safe. The trust undertook via each division and department audits which enabled conclusions to be drawn about activities. Where improvement or learning was required this was undertaken and shared appropriately with staff and relatives if need be.

We found the service was effective at meeting the needs of the patients on an end of life care plan. The services were highly personalised and holistic. The trust had developed a tool called the Supportive Care Plan for use with patients with a life limiting disease to help them achieve this. Multi-disciplinary team working was used to good effect for patients. 

The end of life service was caring. We found evidence of a level of care which demonstrated excellence.  Staff anticipated patients and family needs. We found that other staff within the team worked to an equally high standard.

The service was responsive to patient needs. The trust understood the needs of its client base, ensuring for example that translation services were readily available to patients whose first language was not English.  We saw that religious practices informed staff interactions so not to cause offence and so they were able to offer advice with these customs in mind.

We found the end of life service to be well-led. At team level staff were well supported, line managers knew their staff well and effectively managed them. Information was shared about the individual services and the trust as a whole. Staff felt they were part of the trust and represented the vision and strategy of the service.  Senior management was effective; governance arrangements were in place to plan for service provision and ensured that actions were disseminated appropriately.     

Community health services for children, young people and families

Requires improvement

Updated 27 May 2020

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

  • The health visiting service did not have enough staff to care for children and young people and keep them safe and staff did not always manage control of infection risk well.
  • The trust’s new models of planning and delivering care to meet the needs of local people had not been fully implemented and staff were not always aware of how these new ways of working could improve their planning and delivery of care locally.
  • People could not always access the service when they needed it and sometimes waited too long for treatment, in particular, children and families waited far too long for a neurodevelopment assessment.
  • Staff did not always feel respected, supported and valued by senior managers and were not always clear about their roles and accountabilities within the new models of planning and delivering care.

However;

  • Staff had training in key skills, understood how to protect children, young people and their families from abuse, and managed safety well.
  • Staff assessed risks to children and young people, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave children and young people enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children, young people and their families, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children and young people, families and carers.
  • Senior managers ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work
  • Staff engaged well with children, young people and the community to plan and manage services and all staff were committed to improving services continually. They were focused on the needs of children and young people receiving care.

Community health services for adults

Good

Updated 27 May 2020

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

Community mental health services with learning disabilities or autism

Good

Updated 27 May 2020

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

  • The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented plans of care informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood the principles underpinning capacity, competence and consent and managed and recorded decisions relating to these well.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service was easy to access and staff and managers managed waiting lists and caseloads well. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly and those who did not require urgent care did not wait too long to receive help.
  • The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

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.