All inspections: Central London Community Healthcare NHS Trust

Central London Community Healthcare (CLCH) NHS Trust was established 1 November 2010. It is one of only two NHS trusts in London that specialises in delivering out-of-hospital community-based NHS services. CLCH provides community and inpatient services to over 2.8 million people across London and Hertfordshire. CLCH delivers integrated sexual health services along with a sexual health charity, pathology services and online sexual health service.

We last inspected the sexual health services in 2015 as part of the children and young person core service inspection. It has not been rated before as a community health service.

As part of this inspection we visited Falcon Road and Patrick Doody Clinics in the South West London service. We also visited the Hertfordshire service’s Watford clinic and interviewed staff from the Stevenage clinic.

We completed this inspection to review how the trust had implemented improvements following an incident regarding Intrauterine device (IUD) removal that led to a perforated bowel in 2021. We found that the service implemented improvements and staff were very aware of learning arising from the incident. We rated this core service as good for each key question and overall.

Overall summary

This core service has not previously been rated. We rated it as good because:

This was a comprehensive inspection of sexual health services in Central London Community Healthcare NHS Trust. We completed this inspection to review how the trust had implemented improvements following an incident involving an intrauterine device (IUD) removal that led to a perforated bowel in 2021. We found that the service had implemented improvements and staff were very aware of learning arising from the incident.

The mandatory training was comprehensive and met the needs of patients and staff. Staff completed mandatory training in key skills. Staff had training in and understood how to protect patients from abuse. Staff completed required competencies. Clinical staff we spoke with had a good understanding of their role and professional responsibilities.

Patients gave overwhelmingly positive feedback about their interactions with staff. During the inspection we observed staff in clinics, and they demonstrated exceptional compassion and kindness towards patients. They articulated the treatment patients needed well with a clear and very detailed understanding of the individual needs of patients. Staff treated patients with consideration and respected their privacy and dignity.

Staff felt the trust recognised the efforts they made to contribute to services with staff awards.

Patient records were comprehensive. Patient notes and care plans were clear and concise. Staff could consistently and readily access pertinent patient information in a timely way. For example, we saw staff consistently recorded evidence of risk management plans and safeguarding concerns.

We saw positive developments in the service such as ‘Chat to Pat’ and text message advice line. There was a focus on continuous learning and improvement though projects including addressing issues raised by patients. Staff used quality improvement methods very effectively to make improvements in care and the quality of service provided to patients.

However:

Staff expressed concern about the culture in the South West London service. Some staff felt that they did not feel safe to raise concerns about senior clinical leadership without retribution. Some staff did not feel respected, supported, and valued. Concerns were raised but not limited to bullying, racism, homophobia, and cronyism. An external investigation had been commissioned and the report of findings and recommendations was due at the end of November 2023.
Some patients felt that communication could be improved especially about how long they would be waiting when they attended the walk in clinics. Some patients said they were waiting over the recommended 40 minutes to see a clinician. The trust had a project underway to address keeping patients updated on waiting times when attending clinic appointments.

Some patients we spoke to expressed concern about missing test results. There had been incidents reported of the processing of laboratory requests not being completed; lost samples; not receiving test results and delayed results. The trust had added the outsourced laboratory diagnostic service to their risk register for close monitoring. The service had introduced a sexual health sample and results standard operating procedure to strengthen this processes.

Staff in Hertfordshire and South West London services felt that communication from senior leadership needed improvement. Some staff felt there was no meaningful engagement with staff, especially when introducing changes or processes in the sexual health service.

Some staff felt they could not easily access the trust’s sub-contracted human resources (HR) department and get timely responses to issues which needed to be addressed. This included errors with on boarding processes and payroll queries not being sorted. Some staff we spoke to felt this had affected the recruitment of health advisor assistants and medical staff in the Watford team, which in turn placed additional pressure on the team.

What people who use the service say

We spoke with 18 patients and received 5 comments cards from patients that had used sexual health services.

Patients we spoke to stated that they found that the service provided quick results, staff were nice, caring, and professional. The staff made people feel at ease throughout the whole process. The reception staff were said to be particularly caring and understanding. Patients felt happy that they could get same day appointments and easily contact the clinics when they needed to. Staff listened very well and took the time to understand the problem. However, some felt there were times when it is difficult to get through to someone as phone lines were busy. Some felt that communication could be improved. At times results were missing and 6 of 18 patients said there were long waiting times for an appointment.

Central London Community Healthcare (CLCH) NHS Trust provides community health services across London and Hertfordshire.

This inspection focused on community health services for adults provided by the trust in the London borough of Harrow. This was a focused inspection reviewing one key question: is the service safe?

We completed this inspection to review how the trust had implemented improvements following an incident in 2021 in which a member of staff did not follow the correct procedures. Following the incident, the trust implemented a Quality Action Team to drive improvement in the Harrow community nursing team. There was a primary focus on the community nursing teams during this inspection however we did also visit tissue viability, podiatry and rapid response services.

Community services for adults covers services provided to adults in their homes or in community based settings. This includes planned care, ongoing and intensive management of long-term conditions, coordination and management of care for people with multiple or complex needs, acute care delivered in people’s homes, and health promotion.

We last inspected the trust’s community health services for adults in September 2017. At this inspection, we rated the core service as good overall, with safe, effective, caring and responsive rated as good and well-led rated as outstanding.

Our inspection was conducted by short announcement (with 48 working hours’ notice) to enable us to observe routine activity and to ensure that everyone we needed to talk to was available. Before the inspection visit, we reviewed information that we held about these services and information requested from the trust.

As part of the inspection we visited:

Honeypot Lane Health Centre
Alexandra Avenue Health and Social Care Centre

Our rating for the community health services for adults did not change and remained as good overall.

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

The community nursing service did not have enough nursing staff. All the locality teams had high vacancies. The trust was trying to recruit new staff and had ensured few visits were deferred, but staff and managers told us that vacancies placed them under pressure and were impacting their ability to complete all tasks.
Staff did not always complete records with enough detail and some handover meetings were brief and lacking in detail. This meant staff did not always have access to all the key information to keep patients safe.
There was a lack of leadership oversight for the localities. Audits and supervised visits were not occurring regularly, which meant leaders did not have sufficient oversight of the skills and issues within the teams. The trust had identified the need to increase oversight and was recruiting six new band seven team lead roles. Three of whom were already in post.
Staff were not consistently documenting capacity decisions.
We identified one incident where a referral was not made to the local authority when other people using the service could have been at risk of neglect.

However:

The service provided mandatory training in key skills to all staff and made sure everyone completed it.
Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse.
The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. Staff kept equipment and their work area visibly clean.
The design, maintenance and use of facilities, premises and equipment kept people safe. Staff managed clinical waste well. When providing care in patients’ homes staff took precautions and actions to protect themselves and patients.
The service used systems and processes to safely prescribe, administer, record and store medicines.
The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.

We did not change ratings at trust level at this inspection.

CQC temporarily suspended all routine inspections on 16 March 2020 to support and reduce the pressure on health and social care services during the COVID-19 pandemic. CQC, as well as providers, want to be able to prioritise keeping people safe during this time. This inspection was already underway at the time of the suspension and therefore couldn’t be completed in the usual way.

This report includes the findings from the completed service level inspection of the trust’s community health services for children and young people, but the well-led inspection was not completed. CQC is only able to update findings on well-led at the overall trust level or update the other trust-level ratings when we have inspected the well-led component. As a result, the ratings for the overall trust and five key questions included in this report are from a previous inspection.

We completed an inspection of the trust’s community health services for children and young people, which we rated as good overall. For more information on our findings from this inspection, please see the community health services for children and young people section.

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

Since our last inspection in 2017, compliance with mandatory training and staff appraisal had improved. All team managers routinely monitored training and appraisal compliance.
The service ensured staff understood how to protect children, young people and their families from abuse.
Risks to children and young people using the service were assessed and their safety was managed so they were protected from avoidable harm.
The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Managers monitored the effectiveness of the service. The service planned care to meet the needs of the local population and when there was a gap in service provision managers escalated this appropriately.
When families were waiting for treatment, most services ensured they kept in contact and invited children, young people and their families to group sessions.
Staff provided a good standard of care and treatment. Staff were hardworking and ensured they consistently gave compassionate care to children, young people and their families. They took account of a child or young person’s individual needs and helped them understand their condition.
Leaders ran services well using reliable information systems and supported staff to develop their skills.
Staff understood the service’s vision and values and were focused on the needs of children and young people receiving care.
Staff were committed to improving services and worked on new initiatives to improve their service.

However:

The Brent health visiting team did not have enough staff to deliver care safely. High vacancy rates and large caseload sizes meant they were not completing important baby and child reviews mandated in the Healthy Child Programme (HCP). At the time of the inspection, the team had 69 families awaiting allocation to a health visitor. The team was not monitoring these families. The lack of monitoring and oversight of children, young people and their families put them at risk.
Staff did not always complete or review treatment records in a timely manner with important information. Information such as allergy status was not always recorded clearly, and some children and young people did not have an up to date care plan in place. This put children and young people at risk of not receiving the right treatment at the right time. Whilst the trust was providing new technology to enable staff to complete records during visits, this was not yet delivering consistent improvements.
Lone working processes were not robust and did not ensure that staff whereabouts were monitored whilst out in the community. Staff told us that they did not always wear their personal safety alarms. This put staff at risk of being unable to escalate a concern when working alone.

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

There had been a focus on continuous improvement across the service since our last inspection. There was now improved governance in end of life care, with a clear structure of accountability and audits and outcome measures in place.
Appropriate measures were in place to keep patients safe from avoidable harm. Incidents and safety monitoring results were collated and shared to improve the service.
Policies, procedures and ways of working had been brought into line with local and national guidance. Risk assessments and care planning for patients at the end of life had improved since the last inspection.
There was good team working and morale across the service. Local managers supported their staff in their roles, with chances for professional development offered. Staff received the right additional training and support to care for patients at the end of life.
Patients were provided with compassionate and person centred care, which took account of their individual differences and needs. Relatives and friends were involved in care planning wherever appropriate and recognised as part of the caring team. Volunteering roles and initiatives focused on adding extra value to the patient experience across the service.
Staff across the trust worked hard to build effective partnerships with external agencies in order to coordinate care for each patient and improve patient pathways. Referrals into the service were managed appropriately and patients were seen in a timely manner.

However:

Not all staff in the service had received their mandatory training or an annual appraisal.
Although documentation had improved since our last inspection, there were still some problems with the consistency of patient records across the trust. In addition, there was currently no formalised consent process in place for the administration of bisphosphonate infusions at the Pembridge Unit.
We found some minor issues with infection prevention control at the Pembridge Unit and staff did always not follow the procedure for monitoring the fridge temperature in the body store correctly.
Some junior staff reported that the senior management team were not always visible.

Not all staff in the service had received their mandatory training or an annual appraisal.
Not all staff had up to date paediatric basic life support (PBLS) training.
Overall staff vacancy and turnover was high.
At the last inspection, health visiting (HV) staff caseload exceeded the Lord Lamming 2009 recommended caseload level of 300 families per whole time equivalent (WTE) health visitor for the majority of staff. The children’s services had introduced safer staffing tool for case load management since last inspection. Post inspection we were informed that the average caseload per HV were not comparable to a traditional caseload as the trust was using skill–mix model. The trust was working with tri-borough local authority to improve the caseload management for health visitors by improving the health visiting services skill mix. However, we were not assured that staff were clear of their own caseloads vs their team caseloads and were using the system effectively to manage their caseloads.
Comprehensive father’s details were not linked to the child’s record and we found 13 gastrostomy care plans that were not reviewed since March 2017.

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

Our concerns regarding staffing and high turnover were addressed and managers explained the situation well. The trust was actively recruiting for staff and had managed to fill most vacancies.
All patients we spoke with spoke positively in regards to cleanliness and hygiene. The trust scored a high PLACE score in this category also.
The service had close multidisciplinary team working. There were daily MDT handovers and formal weekly MDT meetings. The service used a MDT progress sheets to record actions and tasks for all relevant professions.
Patients were involved in their own rehabilitation, goal setting and discharge planning from their admission to the wards. Discharge dates were set and agreed as a goal and individual needs and rates of recovery were considered at multidisciplinary meetings.
On all the units we visited, we saw staff were caring and compassionate towards patients. Staff treated patients with kindness, dignity and respect. We found that staff were sensitive to the needs of the patients and their families.
The service took account of patients’ individual needs, such as those living with dementia, patients that had non-English language requirements, cultural and religious beliefs.
The shared governance system used an innovative approach to allow junior staff members and patients to actively engage with the trust’s governance procedures.
The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service.
The service was very proactive in the use of risk assessments, all patients were routinely assessed by nurses and therapy staff. The use of assessments was actively monitored.
The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
Staff we spoke with were aware of how to report incidents and the trust had a robust system of incident investigation and learning.
We found that individual patients’ pain was assessed and managed appropriately, however we found that pain scores were not always regularly completed.
The service used the malnutrition universal screening tool. Patients were screened on admission for malnourishment and the dietician assessed all patients whose nutritional needs were highlighted.
Inappropriate referrals form the acute setting were minimised by the employment of tracker nurses who screened and triaged all referrals.
We observed that staff provided emotional support to patients when they displayed anxiety during rehabilitation activities.
The majority of patients we spoke with confirmed that their care plans had been explained to them and they understood and agreed with the content.
Patients had access to support from a psychiatrist if needed.
The service planned and provided services in a way that met the needs of local people.
During the 12 months prior to the inspection the trust had no bed moves for non-clinical reasons and also did not have any bed moves at night for the core service.
Learning from complaints was discussed in morning MDT handovers and monthly staff meetings
The trust had managers at all levels with the right skills and abilities to run the service.
The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients.
Nursing and allied health staff we spoke with across both divisions told us that the working culture has improved since that last inspection.
The service engaged well with patients, staff and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.

However:

The Inner London division wards did not have a fully functioning call bell system, the service had put in mitigating actions, however all patients we spoke on those wards raised concerns regarding the situation.
Nearly all patients we spoke with across all sites complained that the quality of food provided by the trust was not suitable.
Although there was generally a good quality of documentation, some records we looked at were not completed as they should have been.
The trust set a target of 95% for completion of mandatory training and the inpatient overall training compliance was 91% against this target.
Between July 2016 and June 2017, 86% of permanent non-medical staff and 77% of permanent medical staff within the core service had received an appraisal compared to the trust target of 90%.

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

We rated safe, effective, caring, responsive and well-led as good. We inspected four of the trust’s seven services and rated them 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.

We rated safe, effective, responsive, caring as good and well-led as outstanding. The rating of well-led had improved since our last inspection. Our overall rating of this service stayed the same. We rated it as good because:

The Trust had undertaken a number of effective and innovative measures for staff recruitment and retention since the last inspection.
Staff assessed, monitored and managed risks to patients on a day-to-day basis. Risk assessments were person-centred, proportionate and reviewed regularly.
Evidence-based guidelines, recommendations, best practice and legislation were applied to patients’ treatment and care.
Good multidisciplinary team working helped staff understand and meet the range and complexity of patients’ needs.
Staff were caring and motivated to deliver best quality service for their patients. They spoke with passion about their work and were proud of what they did. Staff treated patients with humanity in a compassionate, caring, and respectful way.
Healthcare professionals of different backgrounds worked well together. Staff worked closely with the GPs and social services when planning care and treatment of patients.
Local leaders were visible, approachable and supportive. They were driven to achieve continuous improvement and motivated staff to succeed.
The vision and strategy for the service was developed and understood throughout the service. The aim was to deliver integrated services on a multi-disciplinary basis, relevant to the local population. Staff were involved in creating the strategic direction of the service.
There was a strong governance framework to support the delivery of the strategy and good quality of care.
There were excellent career development and progression opportunities for all staff levels. Throughout adult community services, we found staff focussed on continuous learning and improvement.

However:

There were high vacancy rates for adult community staffing.
The Friends and Family test result in September 2017 was 92.5% against a trust target of 95% and national average of 96%.
The service did not meet Trust target for patients’ involvement in care and treatment as much as they would have liked and for patients being informed of how to make a complaint or raise a concern.
Waiting times for specialist services from referral to assessment/treatment did not always meet national target

Letter from the Chief Inspector of Hospitals

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We inspected Central London Community Healthcare NHS Trust from 7–10 April 2015 and undertook an unannounced inspection on 29 April 2015. We carried out this comprehensive inspection as part of the Care Quality Commission (CQC)’s comprehensive inspection programme.

We inspected the following core services

Community health services, including:
- Community health inpatient services
- Community adult and long-term conditions
- Community end of life care
- Community health services for children, young people and families
- Urgent care centres.
- Dentists

We sampled locations across Barnet, Hammersmith and Fulham, Kensington and Chelsea and Westminster. The trust is working toward gaining Foundation Trust status and therefore requires a comprehensive inspection.

We did not inspect offender health services or the continuing care services provided by Central London Community Healthcare NHS Trust.

We found that the provider was performing at a level which led to a judgement of good. Our key findings were as follows:

During our inspection, we observed patients and relatives being treated with dignity, respect and compassion. Staff were very considerate towards patients, their relatives and other people. The promotion of self-care was of particular relevance to the care of patients and we observed patients’ independence was promoted during visits from the service.
Managers worked with commissioners of services, local authorities, other providers, GPs and patients to co-ordinate and develop services responsive to the needs of patients. We found patients could access community health services promptly in the areas we visited. Indicators for community services showed that patients were assessed promptly for care and treatment, and this was consistently within the expectations of patients and commissioners.
The trust board placed emphasis developing a vision and strategy, ensuring clear accountabilities and effective processes to measure performance and address concerns, leadership, culture and values. Clinical Business Unit Managers and Team Leaders demonstrated a clear understanding of their role and position in the trust. Local team leadership was effective and staff said their direct line managers were supportive and provided leadership.
The trust had identified and reported incidences of pressure ulcers as an area to improve and in response, the trust had developed Pressure Ulcer Prevention and Management training as an e-learning module, introduced objective structured examinations and distributed resource packs to residential home staff.
The service had infection prevention and control policies in place. Staff followed infection control principles and were generally seen to wash their hands and use hand gel appropriately. Infection control audits were undertaken and staff training on infection control was good across all areas
The safety of children and young people’s services required improvement. This was because there were significant staff vacancies within the division and in some specific roles. Whilst the trust had plans in place to increase recruitment bank and agency staff were used regularly by the organisation to cover vacancies.
There were robust safeguarding policies and procedures in place. Staff received regular safeguarding supervision and were knowledgeable about their responsibilities regarding safeguarding vulnerable people.
Senior managers told us that there were business continuity and major incident plans in place however staff in some services were unaware of these plans. All staff said they would take direction from their line managers in the event of a major incident.
End of life care services were caring and responsive although required improvement to be safe, effective and well-led. On the in-patient unit staffing had been problematic due to recruitment problems. The inpatient service was generally covered in terms of nursing numbers but that the skill mix was affected as agency staff did not generally have specialist palliative care experience. Patients on the inpatient unit were not always having risks assessed in line with trust policy or pain assessments completed in an effective way and we saw that a contributing factor in this was the recent development of an electronic record system that was yet to be fully embedded.
The trust had developed a vision and strategy for end of life care, which was only completed in March 2015, that incorporated 6 key elements around end of life care that included the delivery of end of life care in different settings. We saw that the trust was working on a strategy implementation plan and work streams that involved key staff, including some members of the specialist palliative care team. We were told that these work streams had only just been implemented and not all staff invited to participate had attended a meeting at the time of our inspection. We were also told that while specialist staff were invited to participate in work streams they did not have a lead role in this.
Multi-disciplinary, patient–centred care was evident and involved a range of specialist staff involved in joint visits to the patient. External partners included GPs, housing and social services, police, the prison service, and mental health.
The inspection team noted the improvements that had been achieved on Jade Ward as a result of focussed improvement work and this had now been implemented on Marjory Warren Ward.

We saw several areas of outstanding practice including:

The tissue viability service had developed examples of innovative practice and had taken part in international research and the development of NICE guidance. The service was in the process of updating NICE guidance for national use at the time of our inspection. The service had taken an innovative patient centred approach, focused on the needs of patients and support for the patient’s self-management of their condition.
The inspection team commended the work of the services provided to the homeless in Westminster
The turnaround work undertaken on Jade Ward was noted to have effected significant improvements in delivery of care
One ward manager had organised for patients wishing to attend, to go to church on Easter Sunday and the trust had organised a Christmas carol service on the winter pressures ward which is located on an acute hospital site

However, there were also areas of poor practice where the provider needs to make improvements.

The inspection team noted that were a number of concerns regarding Marjory Warren Ward however the trust were aware of the issues and an improvement plan in place. There were new leadership arrangements in place to take forward the improvement plan for this ward.
Staffing across a number of areas including health visiting and the staffing levels at Pembridge Palliative Care Unit were of particular concern

Importantly, the provider must:

Review recruitment and retention of staff in health visiting, school nursing and occupational therapy.
Review arrangements to support adequate staffing of all community nursing teams to ensure patients are not placed at risk.
The patient record system used within the Pembridge Palliative Care Unit must be reviewed to ensure that all staff are able to participate in recording patient assessments and care plans in a way that meets safety requirements.
Risk assessments must be completed on all patients in line with trust policy.
The trust must develop a timely implementation plan for the development of an end of life care plan/guidance to ensure consistency of care.
The use of pain assessments must be continued to be reviewed to ensure these are being used effectively to assess and manage patient’s pain.
Guidance regarding nutrition and hydration for patients at the end of life must be available to staff caring for them.
The trust’s resuscitation policy must be updated for staff in line with national guidance regarding mental capacity and DNACPR decisions.
There must be clear, consistent and coordinated leadership between the trust and the specialist palliative care service in terms of responsibilities regarding implementation of initiatives and reviews of areas such as the review of clinical guidelines, implementation of patient outcome measures and a replacement guide for the LCP.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service Good

We rated community dental services at this trust as good. Processes and procedures were in place to monitor safe systems within the clinics and in areas such as radiography, cleanliness, decontamination, medicines and safeguarding . Incidents were appropriately reported, staff were aware of how to report incidents and there was learning from incidents. Medications were appropriately stored. The environment and equipment were clean and well maintained. Infection control procedures were in place. Staff had been appropriately trained and there were sufficient staff to meet the needs of the service.

The service used National Institute of Health and Care Excellence (NICE) and best practice guidelines to support the care and treatment provided for patients. Treatment plans were produced for each patient taking into account their personal needs and consent gained for all aspects of the treatment provided from the patient and/or their parent/ appropriate person. Clinical audits were undertaken regularly to monitor and improve performance. Staff were appropriately trained for their jobs and professional development was actively supported and encouraged. Multi-disciplinary working was evident in the co-ordination of patient care.

Patients told us they were treated with dignity and respect when accessing and receiving treatment. Patients and their representatives spoke highly of the care provided and that care was delivered by staff who were compassionate and understanding of their needs. There was good collaborative working between the service and other healthcare services to ensure good patient outcomes.

The service was able to meet the needs of specific groups of the community who cannot access the dental care they need elsewhere and staff were very aware of this. Access to treatment was generally satisfactory. Patient feedback surveys and complaints processes were in place to gather information to maintain and improve the service. There was good collaborative working between the service and other healthcare services to improve the quality of care for patients.

Initiatives had been established to improve the service and use the resources effectively. Staff we spoke with felt supported in their roles and that their managers were approachable and accessible

Overall rating for this core service Good

Central London Community Healthcare (CLCH) NHS Trust provided urgent care services for patients living in, or visiting, the boroughs of Barnet, Hammersmith and Fulham, Kensington and Chelsea and Westminster. There were, on average, a total of 18,200 attendances each month.

We saw that urgent care services were safe, effective, caring, responsive and well-led. All care provided revolved around patient injuries, illnesses and ailments. Feedback from patients and relatives was very positive and we observed staff to be caring and compassionate in their approach. Environments were clean in all areas with well-maintained equipment and all staff followed infection control principles. Patient records were electronic and were completed regularly and consistently. Medicines management was generally good. National guidelines were followed for common conditions and clinical audits were carried out with good levels of compliance. Staff felt involved, were competent, received training updates and continuous professional development. All staff had received appraisals.

A relatively new management structure including centre managers had begun to enable the sharing of good practice across centres. Reporting and learning from incidents was well managed. There had been no reported serious incidents in the past 12 months. Staff were aware of safeguarding principles and followed procedures and almost all staff had received the full range of mandatory training. Most staff felt supported senior managers and directors and described working as part of happy, cohesive teams and they felt empowered and supported to make good clinical and management decisions.

All urgent care centres across the trust met the 4 hour wait targets although there had been a marked increase in demand through referrals to centres by GPs. Staffing levels were planned and flexed to meet demand for the service around busy periods. X-ray services were available on-site at 3 urgent care centres. There had been considerable staff shortages with a high number of vacancies although recruitment processes were well underway. Medical cover was provided by local GP services. Staff worked in partnership with local services and were able to make direct referrals to both primary and secondary care. Ambulance response times had increased for patient transfers to local Accident and Emergency Departments and the trust were in discussion with the ambulance service.

We spoke to 67 patients and 14 visitors who all told us patients felt safe and cared for during their treatment and staff were respectful of their needs and preferences, sensitive to personal and cultural issues and genuinely cared about patients’ wellbeing and to explain the care being offered along with any advice for the future. We observed staff speaking to patients in a sensitive and compassionate manner. Very few formal or verbal complaints were received. Most patient concerns raised were about waiting times. Complaints, when they did occur, and feedback about them were discussed by staff at regular team meetings. Incidents were investigated to identify patterns and trends and lessons were learned in individual centres and across the trust

There were good examples of staff and public engagement and staff told us they regularly spent time with patients to look holistically at their health and give explanations and advice. Staff looked for opportunities to improve the service offered to patients and had made innovative changes to meet need and circumstances in individual centres.

Overall rating for this core service Good

We rated community in patient services as good. We saw that community inpatient services were safe, effective, caring, responsive and well-led. All care provided revolved around patient rehabilitation and reablement. Feedback from patients and relatives was very positive and we observed staff to be caring and compassionate in their approach. There had previously been a high rate of incidents. However, a new and robust management structure and improved quality processes had begun to tackle this effectively. There had been staff shortages and difficulties with recruitment, meaning that there was a heavy reliance on agency staff but senior management had been working to improve this and a new recruitment campaign was due to begin.

Staff told us there was a commitment to good rehabilitation care at all levels and we saw evidence of good multi-disciplinary working across nursing, therapy and medical teams. Medical cover was consistent and doctors were committed to providing good rehabilitation care. Medicines management was generally good but patients were not offered the chance to manage their own medication as a means to prepare for leaving the hospital environment. Patient records were generally well managed and national guidelines were followed for stroke, dietetics, falls and pressure ulcers. Staff felt involved in patient care, their competence was assessed, training was managed well and all staff had received appraisals.

Staff followed infection control procedures and all areas we inspected were clean and environments and equipment were well maintained and suitable for patients’ needs. Food and fluids were within patients’ reach and most patients told us they enjoyed the food provided and were supported if necessary. Patients felt safe and cared for during their stay and staff were sensitive, compassionate and maintained dignity and respect for their patients. They took time to understand patients’ needs or to give explanations. Patients were given sufficient information about their environment and what to expect during their admission. Their opinions were sought and listened to.

Admissions and discharges were well managed although the ward teams sometimes felt under pressure to accept patients who did not meet the full admission criteria, particularly those with dementia or confusion.

Delayed discharges were mainly due to family choice, lack of nursing home places and waiting for packages of care to be put in place.

The trust received very few written complaints but the trust responded to concerns with a positive, problem-solving attitude.

Volunteers, and local community groups were welcomed and involved in patient activities. Staff told us that they would feel confident if a member of their family was being cared for by the teams.

Overall rating for this core service Good

Overall we judged community health services for adults as good.

The service had identified and reported incidences of pressure ulcers as an area to improve and had responded appropriately particularly through training, communication and distribution of resource packs to residential home staff. Incidents were reported consistently across teams and feedback facilitated learning and change of practice.

We reviewed patient records within community sites, patients’ homes and during our observation of patient care. Initial assessments, risk assessments, care plan reviews and consent information were fully completed. The service maintained a risk register of identified risks in community settings and staff demonstrated awareness of key risks to patients and arranged further support when required.

Staffing levels required to achieve safe staffing levels in community and specialist nursing teams reflected the skill mix of staff as well as the number and needs of patients. Although we were told staffing deficits meant staff worked excess hours and extended shifts to cover work allocated to their team.

The service used National Institute of Health and Clinical Excellence (NICE) and Royal College of Nursing (RCN) policies and best practice guidelines to support the care and treatment provided for patients. The tissue viability service had developed examples of innovative practice and had taken part in international research and the development of NICE guidance. We found staff understood their individual roles and responsibilities in the delivery of evidence based care and used nationally recognised assessment tools to screen patients for risks. Recognised assessment tools supported by national guidance were used to support the review of patients.

Multi-disciplinary, patient–centred care was evident and involved a range of specialist staff involved in joint visits to the patient. External partners included GPs, housing and social services, police, the prison service, and mental health.

Referrals to community health services came from a variety of services including GPs, practice nurses, district nurses, patients being discharged from hospital wards and complex cases in nursing homes, residential homes, and police and prison services.

We saw patients were consented appropriately and correctly and consent was obtained before care was delivered. We reviewed consent information as part of our review of records and found this was obtained and recorded appropriately.

During our inspection, we observed patients and relatives being treated with dignity, respect and compassion. Staff were very considerate towards patients, their relatives and other people. The promotion of self-care was of particular relevance to the care of patients and we observed patients’ independence was promoted during visits from the service.

Managers worked with commissioners of services, local authorities, other providers, GPs and patients to co-ordinate and develop services responsive to the needs of patients. We found patients could access community health services promptly in the areas we visited. Indicators for community services showed that patients were assessed promptly for care and treatment, and this was consistently within the expectations of patients and commissioners.

Information for patients about services included information about how to make comments and compliments or raise concerns or complaints and information about the Patient Advice and Liaison Service (PALS). Patients we spoke with were aware of the complaints procedure. In community locations we saw copies of the PALS leaflet were available.

The trust board placed emphasis on developing a vision and strategy, ensuring clear accountabilities and effective processes to measure performance and address concerns, leadership, culture and values. Clinical Business Unit Managers and Team Leaders demonstrated a clear understanding of their role and position in the trust. Local team leadership was effective and staff said their direct line managers were supportive and provided leadership.

Staff were supportive of each other within and across teams. Staff said they were proud to work for their team and enjoyed their role. There was good team working. Staff were enthusiastic and felt involved in the decision making process. They felt they had the time to spend with patients and provide the care required.

Community services had commenced engagement with the public through the NHS Friends and Family test had set up and actively engaged with a number of patient representative groups. The trust had developed a number of initiatives to ensure effective engagement with staff.

We saw the tissue viability service had developed innovative practice and had taken part in international research and the development of NICE guidance. The nutrition and dietetics service provided excellent, patient centred care based on leading and setting standards in dietetics and nutrition including NICE guidance development and facilities for patients.

Overall rating for this core service Good

Overall, the services provided by Central London Community Healthcare NHS Trust to children and young people and to those accessing sexual health services were good.

However, the safety of Children and young people’s services required improvement. This was because there were significant staff vacancies within the division and in some specific roles. Whilst the trust had plans in place to increase recruitment, the impact of vacancies was that many staff were trying to manage caseloads well above nationally accepted caseload numbers. Staff worked hard to minimise the impact on patients however vacancies meant that services were reactive rather than proactive.

Children and young people’s services and sexual health services were effective. Although some performance measures were being missed, care and treatment was evidence based, staff were competent, people using the service were protected from inappropriate care or treatment for which they had not given proper consent. There were policies and procedures in place to support staff and ensure that service were delivered effectively and efficiently.

Services delivered by the trust were very caring. Staff were dedicated to their patients and worked hard to ensure that patients received the best treatment and support possible. Patients were involved in decisions and understood the services being delivered to them. Emotional support was available to patients who were dealing with difficult circumstances.

Children and young people’s services and sexual health services were responsive to the need of the people who used them. Comments, complaints and concerns were taken in to consideration when developing services. On the whole, services were delivered to the right people at the right time within the commissioning framework of the trust. There were services in place to help protect vulnerable young people and children.

At a local level, staff believed they were well led however there were a number of disconnects between front line staff and senior managers and also between Boroughs. Some staff did not feel engaged with the trust as a whole however they were dedicated to their teams at a local level. There were governance arrangements in the division however these were yet to be fully embedded at a local level. We heard mixed reports about the culture of the organisation, with some staff feeling that there was a bullying culture. Other staff had no concerns about the culture of the service.

Overall rating for this core service Requires improvement

End of life care services were caring and responsive although required improvement to be safe, effective and well-led. On the in-patient unit staffing had been problematic due to recruitment problems. The inpatient service was generally covered in terms of nursing numbers but the skill mix was affected as agency staff did not generally have specialist palliative care experience. Patients on the inpatient unit were not always having risks assessed in line with trust policy or pain assessments completed in an effective way and we saw that a contributing factor in this was the recent development of an electronic record system that was yet to be fully embedded. A further contributing factor was the high use of bank and agency nurses and the difficulties this presented in terms of the use of the electronic record system and the specialist nature of the service. The Liverpool Care Pathway had been withdrawn in 2014 and while we saw that staff were reviewing replacement care plans for end of life care, this had yet to be implemented 15 months following withdrawal. This meant that assessment and care planning guidance was limited at a time when the inpatient unit was using a high number of non-specialist nurses.

The specialist palliative care community service was provided by 3 teams of specialist nurses across the region and a community palliative care consultant, all of whom were based at Pembridge Palliative Care Unit. While there were recruitment issues relating to specialist palliative care nurses, the team had addressed some of this by using a triaging system and prioritising referrals based on need.

We saw evidence of services being responsive to meeting patient’s needs and the trust had developed an end of life care strategy that included the identification of specific needs of the local community and there was an implementation plan in development. Staff told us there was a commitment to good quality end of life care at board level within the trust and we saw evidence of this. In some areas however, there appeared to be a lack of clarity in terms of responsibilities for the development of end of life care services between the Pembridge Palliative Care Unit and the trust as a whole. This resulted in some senior staff being unclear of their role in relation to strategy development. There had also been delays in terms of the development of a number of reviews and implementations, including a replacement for the LCP, the use of outcome measures and the review and update of clinical guidelines for use in end of life care. Staff we spoke with demonstrated passion and commitment to good quality end of life care and we saw evidence of good multi-disciplinary working.

Feedback from patients and relatives was mostly positive and we observed staff to be caring and compassionate in their approach. We viewed good initiatives in terms of the development of compassion in care projects, a living well at home group and the development of work streams to focus on the implementation of the end of life care strategy.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

All Inspections

Overall rating for this core service Good

Overall rating for this core service Good

Overall rating for this core service Good

Overall rating for this core service Good

Overall rating for this core service Good

Overall rating for this core service Requires improvement