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Salford Royal NHS Foundation Trust RM3 Community health services for adults Quality Report Stott Lane Salford M6 8HD Tel: Website: Date of inspection visit: 13, 14 and 15 January
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Salford Royal NHS Foundation Trust RM3 Community health services for adults Quality Report Stott Lane Salford M6 8HD Tel: Website: Date of inspection visit: 13, 14 and 15 January 2015 Date of publication: 27 March 2015 This report describes our judgement of the quality of care provided within this core service by Salford Royal NHS Foundation Trust. Where relevant we provide detail of each location or area of service visited. Our judgement is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Salford Royal NHS Foundation Trust and these are brought together to inform our overall judgement of Salford Royal NHS Foundation Trust 1 Community health services for adults Quality Report 27 March 2015 Summary of findings Ratings Overall rating for community health services for adults Outstanding Are community health services for adults safe? Good Are community health services for adults effective? Good Are community health services for adults caring? Outstanding Are community health services for adults responsive? Are community health services for adults well-led? Good Outstanding 2 Community health services for adults Quality Report 27 March 2015 Summary of findings Contents Summary of this inspection Overall summary 4 Background to the service 5 Our inspection team 5 Why we carried out this inspection 5 How we carried out this inspection 5 What people who use the provider say 6 Good practice 6 Areas for improvement 6 Detailed findings from this inspection Findings by our five questions 7 Page 3 Community health services for adults Quality Report 27 March 2015 Summary of findings Overall summary We visited a sample of Community Adult Services on 13/ 14th January We held two focus groups with a range of staff who worked within the service. We talked with about 35 people who use services (including 13 telephone interviews) and four carers. We spoke with six managers, and about 20 registered and four unregistered staff. We observed how people were being cared for in clinics and in their own homes and reviewed care or treatment records of people who use services. We judged that Community Adult Services were outstanding. This was because we found that there arrangements to ensure that patients were safe, and that there were systems to report, investigate and learn from safety incidents and near-misses. We found that care and treatment was based on current guidance and best practice and there were arrangements to monitor the standards of care. Patients told us that they were treated with kindness and empathy and that their dignity was upheld. Services were arranged to respond to patients individual needs and could be accessed when they were required. We found that services were well-led, with a positive culture with a clear vision, values and strategy which staff were engaged in and identified with. There were robust governance systems that ensured information flowed freely between the various levels of management, including the executive team and front-line staff. 4 Community health services for adults Quality Report 27 March 2015 Summary of findings Background to the service Community Adult Services in Salford are provided by Salford Royal NHS Foundation Trust, a combined acute and community trust. The majority of Adult Community Services formed part of the Division of Salford Health Care and were managed by the Intermediate Care Directorate. Community Dentistry and Renal Services were managed by other divisions which integrated acute and community services. Community Adult Services in Salford included: Bladder and Bowel Services Community Rehabilitation and Falls services Community Nursing, including out-of-hours services and clinics Rapid Response team Supported Discharge team Tissue Viability team Community Dental services Satellite haemo-dialysis units. Services were provided in patients homes or in one of three Gateways at Eccles, Walkden and Pendleton and at a variety of health centres and medical centres. There were satellite haemo-dialysis facilities at Bolton and Wigan hosted by local hospitals. Our inspection team Our inspection team was led by: Chair: Professor Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission Team Leader: Heidi Smoult, Deputy Chief Inspector of Hospitals, Care Quality Commission The team included CQC inspectors and a variety of specialists including Why we carried out this inspection We carried out this inspection to complement our comprehensive inspection of the services provided by Salford Royal Hospital. Our methodology included an unannounced visit carried out on the evening of 27 January 2015 and a public listening event. At the public listening event we heard directly from approximately 60 people about their experiences of care. How we carried out this inspection To get to the heart of people who use services experience of care, we always ask the following five questions of every service and provider: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? Before visiting, we reviewed a range of information we hold about the core service and asked other organisations to share what they knew. We carried out an announced visit on 14 and 15 January During the visit we held two focus groups with a range of staff who worked within the service, such as nurses, health care support workers and students. We talked with about 35 people who use services (including 13 telephone interviews) and four carers. We spoke with six managers, 5 Community health services for adults Quality Report 27 March 2015 Summary of findings and about 20 registered and four unregistered staff. We observed how people were being cared for in clinics and their own homes and reviewed care or treatment records of people who use services. We visited Walkden Gateway where were reviewed the general clinic, community nursing and podiatry services, Eccles Gateway where we looked at the general clinic and dental services, and Pendleton Gateway where we visited audiology and dental services. We visited Burrows House where reviewed the community rehabilitation service and the falls service. At Lower Broughton Health Centre we looked at the general clinic and community nursing, and at Sandringham House we reviewed the evening community nursing service. We visited the Salford Royal Foundation Trust satellite haemodialysis unit at Bolton General Hospital. What people who use the provider say Patients and carers we spoke with were overwhelmingly positive about the care and treatment they received from Community Adult Services. Words and phrases such as Excellent, Fabulous, Friendly, Incredible, It s a very good service, The best in Britain, were used extensively in their feedback. We looked at the results of two patient surveys, the National Audit of Patient Reported Experience Measures (PREM), and the Patient Experience Feedback District Nursing Teams September The national audit showed results that were better than national averages. The overall feedback showed that patients felt they were treated with empathy and kindness and that their homes and belongings were treated with respect. They also felt that they were aware of the goals of their treatment and that they were involved in discussions and decisions about their care and treatment. Good practice Our inspection team highlighted the following areas of good practice: The system of daily safety huddles, and intra-team situation reports. The team-based audit programme and the monitoring of results and actions. The Community Assessment and Accreditation System, and arrangements for gathering patient feedback. The mandatory training and professional registration monitoring systems.. The system of competency assessment and associated records. The use of the Butterfly Scheme for people living with dementia. The arrangements for ensuring the safety and security of lone workers. Areas for improvement Action the provider MUST or SHOULD take to improve The provider should consider arrangements for the management of patient records at Walkden Gateway. The provider should consider how discharge information between the acute and community sectors could be made more effective. 6 Community health services for adults Quality Report 27 March 2015 Salford Royal NHS Foundation Trust Community health services for adults Detailed findings from this inspection The five questions we ask about core services and what we found Good Are community health adult services safe? By safe, we mean that people are protected from abuse Summary We judged that Community Adult Services achieved a good standard of safety. This was because we found that there were robust methods of reporting, investigating and learning from incidents and near-misses that were well understood by staff and were embedded in their daily work. There was a risk register that ensured potential risks were known and assessed and appropriate controls implemented. There were plans to deal with a major incident or events that would disrupt the delivery of care. We saw that there were processes and systems that protected patients from the risk of infection, and the risks associated with equipment used in their care and treatment. Overall, there were safe systems of medicines management, although we found that systems ensuring the security of prescription pads were not clear. There were adequate numbers of suitably qualified, skilled and experienced staff to meet people s needs and we noted that staff completed their mandatory training. It was acknowledged that a number of nursing vacancies placed some pressure on existing staff but we saw that action had been taken. This included a review of staffing numbers, an active recruitment programme and there were arrangements to ensure that any staffing shortfalls were managed on an on-going basis to minimise the impact on patients. Records were found to be accurate, comprehensive and current and they supported the delivery of safe care. However, the mix of electronic and paper records used caused some staff frustration and carried potential for inaccuracies. Incidents, reporting and learning Incidents were reported using an electronic reporting system which also provided reports for managers on reporting activity and incidents. All staff we spoke with 7 Community health services for adults Quality Report 27 March 2015 were aware of the system and told us they were confident in its use. Staff indicated that they felt empowered to report any safety incident or near-miss without any fear of reprisal. We saw that records were kept regarding all safety incidents and near misses reported in Community Adult Services. These included details of the incident and how and why it occurred. We saw that actions to mitigate against recurrence had been formulated and noted that these were appropriate to the incident described. We analysed the incident data for the period October 2013 March The majority of incidents (38.8%) were related to treatment procedures, with the second highest number being related to patient accidents. It is worth noting that no incidents at all were related to infrastructure, including staffing and facilities, and the two incidents relating to implementation of care was also very low. 89% of all incidents reported were of low or no harm to the patient. We reviewed the root cause analysis of an incident which occurred in October We saw that there had been a thorough investigation and analysis of the incident. Learning points had been identified and actions were underway to address care issues that had been identified. We saw a root cause analysis that as part of its template included actions that would ensure that the service s obligations with regard to their duty of candour were met. We noted that these actions had been completed and that the patient and their family had been informed of the harm done, that an investigation was underway and that a copy of the investigation report was to be provided. There had been one never event reported in Community Dental Services in April Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. In this incident a wrong tooth was extracted by a student. We saw that following thorough investigation, the procedures used had been changed to include the supervising tutor dentist to identify that the correct tooth for extraction and to observe the procedure until completion. A check-list based on the World health Organisation Surgical Checklist had also been introduced. We saw that this new procedure was displayed on the clinic wall. Dental staff we spoke with were aware of this incident, of the learning points identified and the changes to procedures which had been made. This showed that there was learning from never events which resulted in action to further reduce the risk of recurrence. We saw the notes of team meetings and safety huddles which demonstrated that incidents, their analysis, lessons learned and practice or process changes were discussed with and communicated to staff. Staff we spoke with told us that the discussion and consideration of safety events was frequently part of their routine Community Adult Services participated in the National Safety Thermometer programme, a national prevalence audit which allows us to establish a baseline against which we can track improvement. Data submitted since October 2013 showed the number of catheter associated urinary tract infections was fairly steady over the period October 2013 October 2014 with an average of 8 reported per month. The number of pressure ulcers was also steady over the same period with an average of 59.9 reported. Falls with harm have been generally low, aside from the period August 2014 and September 2014 with an average of 3.4 reported per month. Cleanliness, infection control and hygiene Overall we found that Community Adult Services were compliant with the Code of Practice on the prevention and control of infections and related guidance issued by the Department of Health in Mandatory training records dated December 2014 showed that 85.89% of eligible staff working in Community Adult Services had completed mandatory Infection Prevention and Control training, below the trust target of 95%. The target had been achieved for hand hygiene training with a rate of 98.92% had completed but had not been achieved for Aseptic Non- Touch Technique with 83.88% of eligible staff completing training in (range 0-100%). There had been no reported cases of MRSA detected by community adult services since April Community health services for adults Quality Report 27 March 2015 We saw that facilities where patients were treated were clean and hygienic. We saw cleaning schedules that clearly set out how and when premises and their equipment should be cleaned. Patients told us that they had no concerns regarding the cleanliness of premises. One said that the clinic they attended was Spotlessly clean. We observed that an officer from NHS Properties, the contracted cleaners was carrying out an audit checking against National Cleaning Standards. There were Infection Control Audits for Primary Care Premises carried out; we saw an audit for Higher Broughton Health Centre that was carried out in December 2014 and saw that an overall green rating of 93% was achieved and that a further audit in 2015 had been scheduled. This demonstrated that cleaning standards were monitored to ensure they met national specifications. We saw that shared equipment such as blood pressure machines, scales and trolleys was labelled with a distinctive label to indicate it had been decontaminated and was ready for use. We observed that clinic environments had supplies of personal protective equipment (PPE) which staff used appropriately. We also observed that staff had adequate supplies of, and used PPE when they visited patients at home. We saw that premises had adequate hand-washing facilities and supplies of hand sanitizer for staff and the public to use. We saw that hand hygiene compliance was audited and the results did not raise any concerns. We noted that disposable curtains were used and were changed at the recommended six-monthly intervals. However, at one location where we found that the change date had been exceeded by about two months. We reviewed the decontamination processes for dental instruments. Instruments were decontaminated off-site in a central unit. For those elements of the decontamination process were completed at the dental clinic, for the storage of sterile supplies and the maintenance of a safe water supply we noted that the requirements of the Department of Health guidance, HTM 01-05: Decontamination in primary care dental practices (2013) were being met. We found that all surgical instruments used by the Podiatry department were single use only, removing the need for decontamination and reducing the risk of infection of patients. We saw that the instruments were all stored in clean and dry conditions, in sealed packs to ensure they remained sterile. We saw that clinical and domestic waste was segregated and that waste bins were covered and operated by foot pedal. We observed that contaminated clinical waste awaiting collection was stored securely and safely in a locked metal store. This ensured that there could be no unauthorised access or interference with this hazardous material. Sharps waste was disposed of in appropriate receptacles which were properly labelled, although we found some isolated examples where assembly details were not completed. Overall, we found that the conditions of the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 were being met. We looked at the latest results of the Community Assessment and Accreditation System appraisals for eight teams. We saw that all achieved a green rating in standard six relating to Infection Prevention and Control. As part of this assessment 14 elements of the service were assessed. Four of the assessments found one area where compliance was not reached but there was no common theme, and the breach of the standard did not affect the overall score. Maintenance of environment and equipment We found there were systems to ensure that staff were trained and competent to use the equipment used in their daily work. Mandatory training records dated December 2014 showed 93.89% of staff in Community Adult Services were up-to-date with medical equipment competencies. We saw records at one unit which showed that the specific competencies for each staff member were recorded, and the dates when this competency was formally assessed and then reassessed either by self or other assessment methods. We looked at records which showed that equipment was identifiable and traceable, and that service dates were recorded. We saw separate records that showed that syringe drivers were tracked and that their last and 9 Community health services for adults Quality Report 27 March 2015 next service dates were recorded to ensure that they were maintained in line with manufacturers recommendations. We noted that these service dates were current. However, at one location we found that one item of equipment appeared not to have been registered and another was known to be two months past its due service date. We saw that equipment used for dental x-rays at two sites had local local rules outlining its safe use as required by the Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) and these were displayed to enable staff to reference them easily. We also saw a service certificates from an external contractor for the machines, although these were undated they was current as the next services due wer
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