Berkshire Healthcare NHS Foundation Trust Community health ...

Berkshire Healthcare NHS Foundation TrustRWX

CommunityCommunity hehealthalth serservicvicesesfforor adultsadultsQuality Report

Berkshire Healthcare NHS Foundation Trust2nd & 3rd Floors Fitzwilliam HouseSkimped HillBracknellBerkshireRG12 1BQTel: 0118 9605027Website:www.berkshirehealthcare.nhs.uk

Date of inspection visit: 7 December 2015 to 11December 2015Date of publication: 30/03/2016

1 Community health services for adults Quality Report 30/03/2016

Locations inspected

Location ID Name of CQC registeredlocation

Name of service (e.g. ward/unit/team)

Postcodeofservice(ward/unit/team)

RWXX3 St Marks Hospital St Mark's Hospital SL6 6DU

RWXX1 Wokingham CommunityHospital

Wokingham CommunityHospital

RG41 2RE

RWX85 Upton Hospital Upton Hospital SL1 2BJ

RWX58 Church Hill House Church Hill House RG12 7FR

RWX86 West Berkshire CommunityHospital

West Berkshire CommunityHospital

RG18 3AS

This report describes our judgement of the quality of care provided within this core service by Berkshire Healthcare NHSFoundation 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 ‘IntelligentMonitoring’ 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 Berkshire Healthcare NHS Foundation Trust andthese are brought together to inform our overall judgement of Berkshire Healthcare NHS Foundation Trust

Summary of findings


Ratings

Overall rating for the service Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Summary of findings


Contents

PageSummary of this inspectionOverall summary 5

Background to the service 6

Our inspection team 6

Why we carried out this inspection 6

How we carried out this inspection 6

What people who use the provider say 7

Good practice 7

Areas for improvement 7

Detailed findings from this inspectionThe five questions we ask about core services and what we found 8

Summary of findings


Overall summaryOverall rating for this core service GOOD l

Overall, this core service was rated as good. We foundcommunity services for adults was good for all the keyquestions of safe, effective, caring, responsive and well-led.

Our key findings were:

• Staff recorded incidents on the electronic reportingsystem with shared learning across the service. Therewas a strategic approach to reducing harm wherethere were concerns, as in the case of pressure ulcers.

• Staff adhered to infection prevention and controlprocedures, the trust used an audit programme tomonitor and improve practice.

• Staff were able to identify safeguarding issues andfollowed the safeguarding procedures to reportconcerns.

• Staffing levels had improved across the service inrecent months and community nursing teams workedcollaboratively to share referrals, prioritise workloadsand meet demand.

• Risk assessment was used to inform care; however, wefound there were inconsistencies in staff practice inthe frequency of review some assessments, such as forpressure ulcers.

• Care plans were evidence based with patient centredoutcome goals.

• Staff were competent for the roles they undertook andthe majority of staff had received an appraisal in thelast year. Supervision was available but the uptakevaried across the teams.

• There was excellent multi-disciplinary working. Staffworked collaboratively to understand and meet theneeds of patients, particularly those with long-termconditions.

• There were appropriate systems and processes inplace for the referral, transfer and discharge of patientsfrom services.

• Consent was sought from patients prior to care ortreatment being provided. Not all staff were clearabout their roles and responsibilities regarding theMental Capacity Act 2005 and Deprivation of LibertySafeguards.

• Patients received compassionate care that respectedtheir privacy and dignity, with patients involved indecisions made about their care.

• The planning and delivery of services took intoaccount the diverse needs of the local population andthose in vulnerable circumstances. Thereconfiguration and integration of some services hadtaken place for the trust to be able to be moreresponsive to patients with complex needs.

• Delayed transfers of care were a priority area for thetrust to address. Work was taking place with partneragencies to improve the situation.

• There was a clear vision and strategy for communityhealth services for adults, in line with the trust visionand goals. Most teams had developed their ownbusiness plans to correspond with the directorateplan.

• Clear management and governance structures were inplace through meetings to monitor performance andservice risks. There was good local leadershipthroughout the various teams with an open, caringand supportive culture.

• The trust used feedback from patients to monitor thequality of the service and to inform change.

• There were good examples of innovation to improvepatient care and wellbeing. Cost improvementprogrammes were in use to ensure sustainability ofservices

Summary of findings


Background to the serviceInformation about the service

Berkshire Healthcare NHS Foundation Trust providesspecialist mental health and community health servicesto a population of around 900,000 within Berkshire. Theservice is provided in an operational locality structure,which is aligned, with the six local authorities. In EastBerkshire this consists of Slough, Bracknell Forest and theRoyal Borough of Windsor and Maidenhead, in WestBerkshire, the three local authorities are Reading, WestBerkshire and Wokingham. Berkshire East CCGs andBerkshire West CCGs, together commission services fromBerkshire Healthcare Foundation Trust.

Community health services aim to support people instaying healthy and to help them manage their long-termconditions. This is in order to avoid hospital admission

and support patients at home immediately followingdischarge from hospital. The range of services providedby the trust included single speciality services such ascommunity nursing, musculoskeletal physiotherapy andspeech and language therapy. There were also specialistservices such as respiratory, heart failure and continenceclinics as well as multidisciplinary teams. There werethree intermediate integrated care teams and an earlysupported discharge service for stroke patients.

Services were provided at multiple sites includingcommunity hospitals, clinics, in patients’ own homes andresidential and nursing homes.

Community services work closely with acute services,commissioners, adult social care services and GPs.

Our inspection teamOur inspection team was led by:

Chair: Dr Ify Okocha, Medical Director Oxleas NHSFoundation Trust

Head of Inspection: Natasha Sloman, Head ofInspection for Mental Health, Learning Disabilities

and Substance Misuse, Care Quality Commission

Team Leader: Lisa Cook, Inspection Manager, CareQuality Commission

The team that inspected community health services foradults included CQC inspectors and a variety ofspecialists including a community matron, occupationaltherapist and a district nurse.

Why we carried out this inspectionWe inspected this core service as part of ourcomprehensive inspection programme of NHS trusts.

How we carried out this inspectionTo get to the heart of the experience of people who useservices, we always ask the following five questions ofevery 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 Berkshire Healthcare NHS FoundationTrust, we reviewed a range of information we held aboutthe trust and asked other organisations to share whatthey knew. We carried out an announced visit over threedays between 8 December 2015 and 10 December 2015.

Summary of findings


During the visit, we held focus groups with a range of staffwho worked within the service, such as nurses andtherapists. We talked with people who use services. Weobserved how people were being cared for, talked withcarers and/or family members and reviewed care ortreatment records of people who use services. We metwith people who use services and carers, who sharedtheir views and experiences of the core service.Specifically for this core service, we visited nine districtnursing teams across East and West Berkshire,musculoskeletal physiotherapy services in East and WestBerkshire, cardiac and respiratory specialist service,diabetic service, integrated intermediate care team,continence service, early supported discharge service ,

nutrition and dietetic service , speech and languageservice and assessment and rehabilitation centre. Duringour visits, we spoke with 67 staff including communitynurses, physiotherapists, speech and languagetherapists, dietician, nurse specialists in respiratory,cardiac and diabetes, community matrons, healthcareassistants, administrators, diabetic eye screeningtechnician and service managers.

We accompanied staff on home visits and in clinics; wespoke with 29 patients and relatives who used theservices, we observed 11 interactions between staff andpatients and reviewed 15 care records.

What people who use the provider sayWe spoke with 29 patients and carers. We spoke withpatients and carers at clinics, at a rehabilitation class,during home visits and on the telephone. Withoutexception, patients and carers praised the quality of careand treatment they received from all staff working incommunity services for adults.

They spoke highly of the way staff involved them in thedecisions about their care and treatment. All patients feltfully informed about their proposed plan of care and feltthey could ask questions if they were uncertain or wishedfor additional information.

Patients told us staff were caring, understanding andsympathetic to their needs, always trying to resolveissues and concerns where they could. Staff wereparticularly supportive of patients with complex or long-standing conditions.

The ‘Friends and Family’ supported these findings data,which showed the majority of patients, would beextremely likely or likely to recommend the service to afamily member or friend.

Good practice

Areas for improvementAction the provider MUST or SHOULD take toimprove

• The trust should ensure that the service reviews theuse of the pressure ulcer risk assessment tool.

• The trust should ensure that equipment ismaintained and fit for purpose

• The trust should ensure that staff are aware of theirresponsibilities in relation to the Mental Capacity Act2005 and Deprivation of Liberty Safeguards.

• The trust should ensure that staff are supported toattend clinical supervision and attendance ismonitored.

Summary of findings


By safe, we mean that people are protected from abuse

SummarySummary

By safe, we mean that people are protected fromabuse and avoidable harm.

We rated safe as good.

Staff followed incident reporting procedures and receivedfeedback following incidents. Learning from incidents wasshared across the service. Staff adhered to infectionprevention and control procedures and staff hadcompleted the appropriate training. An infection controlaudit was followed, to monitor and improve practice.

The majority of staff were up to date with mandatorytraining. Staff were able to identify safeguarding issues andfollowed the safeguarding procedures to report concerns.

Staffing levels had improved across the service in recentmonths and community nursing teams workedcollaboratively to share referrals to prioritise workloads andmeet demand.

Staff took time to ensure all records were up-to-date aspatients had paper-based records in their home and a

centralised electronic record. Risk assessments werecompleted. However, we found there was inconsistency inpractice in the frequency of review of assessments, such asfor pressure ulcers.

Equipment was well maintained. However, in one team,there was a significant proportion of equipment, whichneeded a service, and this was overdue. Some equipmentmay have been overdue for a service. It was not clear fromany records when equipment was due for this. This couldpresent a risk to patient safety.

Detailed findings

Safety performance

• The trust used the NHS safety thermometer to monitorharm free care. The NHS safety thermometer records thepresence or absence of four harms, including pressureulcers, falls, urinary tract infections (UTIs) in patientswith a catheter and new venous thromboembolisms(VTEs).

• During September 2014 to September 2015, the numberof new pressure ulcers per month decreased from 21 in

Berkshire Healthcare NHS Foundation Trust

CommunityCommunity hehealthalth serservicvicesesfforor adultsadultsDetailed findings from this inspection

ArAree serservicviceses safsafe?e?

Good –––


September 2014 to eight in June 2015. However, morerecently the average was 15 per month. The prevalenceof new pressure ulcers was similar to the nationalaverage.

• The trust aimed for a 20% reduction in avoidable gradesthree and four pressure ulcers (ulcers are gradedaccording to the depth of skin and tissue damage, gradeone superficial damage and grade four full skinthickness destruction) and 15% reduction in grade two.Across the trust, the target was achieved, except forgrade two pressure ulcers in East Berkshire, where 127were reported, against a target of 118.

• Between September 2014 and September 2015, theincidence of new catheter related urinary tractinfections was lower than the national average in nineout of the last 13 months, with a monthly average of0.27%, compared with national average of 0.3%. Theprevalence of falls with harm was 0.5%, which was alsolower than the national average of 0.6%.

• Across the trust, the average percentage of patientsreceiving harm free care was 93.3%, which was belowthe national average of 94.1%.

• Twenty seven serious incidents were reported by adultcommunity services between September 2014 toOctober 2015.The majority of these incidents,specifically sixteen, related to grades three and fourpressure ulcers and three related to falls.

• Safety performance data was discussed at all levels inthe organisation, such as, at team meetings, localitypatient safety and quality meetings and the qualityexecutive group meetings.

• Incidents including pressure ulcers were reported on themonthly community-nursing scorecard.

Incident reporting, learning and improvement

• The trust had systems in place to report and recordsafety incidents, near misses and allegations of abuse.

• All staff we spoke with were familiar with reportingincidents using the electronic online system. We sawincidents that had been reported and staff confirmedthey received feedback.

• Pressure ulcers grade two and above were reported asan incident. In response to the higher numbers ofpressure ulcers reported in 2014/15, the trust had

developed a strategy group. A monthly report wasproduced, to monitor progress. Learning fromsignificant incidents was reported to all localities. Forexample, investigations into pressure ulcers identifiedpatients were not always using prescribed equipment ornot using it correctly. The trust had also identifiedpressure ulcer champions in each locality to providesupport and disseminate key messages to staff. Toinform patients, staff provided a laminated card, ’’reactto red’, which provided advice to patients on preventingpressure ulcers.

• The trust recently introduced a bulletin, ‘learning curve’to highlight learning from incidents and complaints.

• Staff said lessons learnt were highlighted at teammeetings and clinical development meetings such asthe district nursing forum.

• The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of‘certain notifiable safetyincidents’andprovide reasonable support to thatperson. Staff had an awareness of duty of candour andtheir responsibilities. The incident reporting form had alink to further information about duty of candour, whichprompted staff to take the appropriate action.

Safeguarding

• Staff were familiar with the trust’s safeguardingprocedures and knew how to recognise the signs ofabuse. Safeguarding contact details for the trust teamwere on display in team offices as a visual reminder tostaff.

• Staff were aware of how to recognise signs of abuse andwhat action to take if they suspected abuse. The districtnurses said they contacted the safeguarding lead foradvice when needed.

• We saw instances where staff had raised an incident andrelated safeguarding alert.

• Safeguarding adults and children training was part ofthe mandatory training programme for staff. Over 85%of staff in adult community health services hadcompleted the training in October 2015; this met thetrust target.

Medicines

Are services safe?

Good –––


• Staff followed medicines management policies (careand control of medicines (April 2015) and standardoperating procedures were followed by staff whenhandling medicines. For example, transport ofmedicines (October 2015). Staff handled medicinesappropriately in patients’ homes and completed recordsaccordingly.

• A system was in place to develop and monitor ‘patientgroup directions’ (PGDs) to ensure they were up to dateand authorised appropriately. PGDs are instructions forthe supply or administration of medicines to groups ofpatients who may not be individually identified beforepresentation for treatment. PGDs such as for drugs usedin emergency and flu vaccines were used by communitynurses, specialist services and physiotherapists to allowlegal administration of specific medicines againstagreed criteria.

Environment and equipment

.

An external supplier was responsible for deliveringequipment to the patients’ home and provided equipmentfor patients’ own use. Urgent equipment, for example, toavoid hospital admission was delivered the same day andrepairs carried out within 24 hours: priority being given tothose at greatest risk. However, staff told us patients oftencomplained about delays in collecting equipment that wasno longer required.

• Staff were able to seek advice on equipment from thespecialist nurse for complex cases. The specialist nursealso conducted home visits if necessary to assesspatients’ needs.

• During our visits to community nursing offices andclinics, we observed equipment had been portableappliance tested to ensure it was safe to use.

• Individual teams had systems in place to log andmonitor equipment which required servicing.Equipment was generally up to date with its servicehistory which was indicated by an adhesive label on theequipment. However, in the cardiac and respiratoryspecialist service (CARSS) and musculoskeletal (MSK)physiotherapy service (West Berkshire) staff said delays

to equipment servicing occurred due to the time whenengineers attended. This did not always take account ofwhen staff were in the office base or the equipment wasin use.

• Staff in the respiratory team (part of CARSS), hadidentified 30 out of 65 pieces of equipment, such asoximeter, thermometer and blood pressure monitors,which were overdue a service, or not known if theservice was overdue. A plan was in place to address andmonitor the situation; however, this potentially posed arisk to patient safety.

Quality of records

• We reviewed 15 care records across different teams andat different locations within community services. Theservices and teams we visited used a combination ofpaper and electronic patient record keeping systems.

• Patients had paper records in their own home, whichcontained basic medical information about the patientand their care plan. Staff were seen to update care planswhen relevant. Summary information on each visit wasthen transferred onto the electronic system. In general,they were easy to read and contained enough detail sothat all specialities involved in the care of the patientwere clear on the care plan and goals for the patient.

• Electronic records were kept secure. Staff used apersonal login to access the electronic records system.Staff logged out of the system after use, to preventunauthorised access to patients’ records.

• Patients’ records reviewed at the specialist services andearly supported stroke discharge team were verycomprehensive. Records contained initial assessmentsincluding medical and social history, social situation,cognitive abilities, risk assessment, activities of dailyliving and emotional and psychological factors. Careplans were in place and a goal attainment scale (GAS)was completed (GAS is a method of scoring the extent towhich a patient’s individual goals are achieved in thecourse of intervention.) Records were up to date andinformation was objectively recorded. Verbal consent totreatment was noted.

Are services safe?

Good –––


• Staff recognised the importance of keeping theinformation up to date on the system. However, theytold us that due to connectivity problems and the timetaken to complete records online, there was often ashort delay to complete records.

• Until recently the trust used a generic record keepingtool to audit records annually. A new intranet basedaudit tool was introduced in November 2015, whichcould be tailored to the service requirements. However,results of the use of the new audit tool for all serviceswere not yet available. The audit results for the West ofBerkshire MSK service, conducted in May 2015, showedmost areas of record keeping complied with thestandards. There were some problems with records notbeing timed and failure to record discipline at eachtreatment. Actions were taken to address this.

Cleanliness, infection control and hygiene

• All clinical areas we visited were visibly clean and tidy.There was access to hand sanitiser or hand washingfacilities to limit the spread of infection between staffand patients.

• Cleansing detergent wipes were provided to cleanequipment. Patient chairs were wiped clean and clinicalareas had washable floors for ease of cleaning.

• During home visits we observed staff adhering to thetrust ‘bare below the elbows’ policy and there wasappropriate use of personal protective equipment, suchas gloves and aprons, to reduce the risk of crossinfection. We observed staff use sterile gloves whenproviding wound care. Staff in general cleaned theirhands before and after seeing a patient.

• During a rehabilitation session, we observed that staffcleaned equipment with detergent wipes betweenpatients use and at the end of the session.

• There was an annual infection prevention and controlaudit and monitoring programme in place. This covereda range of services and areas. For example, handhygiene, equipment and catheter care.

• The results of the audit of patient equipment (whichincluded cleaning of equipment in the musculoskeletalservice) showed 100% compliance. An audit of urinarycatheter care bundle (February to March 2015) assessed

compliance with National Institute of Health and CareExcellence (NICE) quality standard. Those teams scoringless than 100% had action plans in place to addressconcerns.

• Quarterly hand hygiene audits showed over 90%compliance in all the areas we visited. A repeat audit ofsharps handling and disposal of sharps in 2014/15showed improvement on the previous year’s results withthe majority of community services scoring 100% orover 90%, except for two teams in East Berkshire, whereareas of non-compliance were identified for follow up.

Mandatory training

• Mandatory training for staff was via a mix of e learningand classroom based sessions. Mandatory training forall staff included infection prevention and control,information governance, and safeguarding children andadults at risk.

• The Berkshire community nursing scorecard for October2015 showed 93% of staff had completed theirmandatory training, although some teams were slightlybelow the trust target of 85%.Overall for adultcommunity health services the achievement was abovethe trust target of 85%.

• The trust learning and development system identifiedadditional mandatory training requirements for staffdependent on their role and grade. For example,community nurses were expected to undertake trainingin medicines management and pressure ulcermanagement and prevention.

• Staff had access to their training record with email alertsent to the individual when training was due

• Attendance at training was monitored by managers andat locality patient safety and quality (PSQ) meetings.

Assessing and responding to patient risk

• Risk assessments were undertaken as part of the initialassessment when a patient was referred to the service.For example, during a first home visit we observed fullinitial assessments were undertaken including anassessment of risk of pressure ulcers (Waterlow),malnutrition universal screening tool (MUST), movingand handling and falls. For specialist services,assessments including additional subjective andobjective measures were undertaken.

Are services safe?

Good –––


• We were told the Waterlow risk assessment wasundertaken at a patient’s first assessment and thenrepeated every three months and more frequentlydepending on the risk score and clinical judgement.There was no clear guidance on the frequency of thereview of the Waterlow pressure ulcer risk assessmentwhen the scores were high. District nurses across allteams were clear a review of the score would take placebut the frequency varied when the score was high. Twocommunity nurses told us the risk assessment would berepeated monthly. However, we saw two patients’records that had scored more than 20 (‘very high risk’)on the Waterlow scale and the risk, assessment wasrepeated no more frequently than three monthly.

• We reviewed the audit of records in October 2015, whichshowed 99% of records showed the MUST, and Waterlowrisk assessments were completed every three months.However, the audit did not show the risk score and theexpected frequency of repeating the Waterlow riskassessment.

• In East Berkshire, district nurses aimed to respondwithin 2 hours for patients with a blocked catheter. Forpatients at the end of life this was within 4 hours forurgent referrals and within 24 hours for routine referrals.In West Berkshire, staff aimed to respond to blockedcatheters and end of life symptom control within 2hours.

• We observed during a cardiac rehabilitation session,patients’ status was assessed at specific points throughthe exercise programme. This was to ensure they werefit to continue at the same pace.

• We observed two district nursing staff handovers, whichtook place daily. Patients’ needs were discussed andrecommendations for referral to other services weremade. For example, the community matronrecommended referral to social services and the hightechnical equipment specialist for one patient.Feedback to the GP about another patient’s change incondition was also highlighted to keep the GP informed.

• Emergency equipment was available. For example, inthe facility where cardiac rehabilitation classes tookplace. Staff we spoke to had received training incardiopulmonary resuscitation (CPR) and were aware ofthe procedure for getting assistance in an emergency.

• Staff used the alert system on the electronic recordingsystem to record immediate risks, both medical andsocial for patients. This included recording of key codesto enable staff to access patient’s homes. This meantthat all staff had access to this information to helpensure staff and patient safety.

Staffing levels and caseload

• The community nursing teams in East Berkshire hadexperienced a high degree of staff turnover in theprevious six months. The staffing situation hadimproved and experienced peers supported new staff. Amember of one team which had undergone a significantnumber of staff changes in the previous six months, said“…We are now learning new ways of working, thingshave improved and there is more workloadsharing…getting everyone united again.”

• The community nurse scorecard for end of October 2015showed sickness absence was above the 3% target inthree out of six localities and there were vacancies ofmore than 10% in three out of six localities. One locality,Reading, had high rates of vacancies and sickness. Thiswas managed across teams to meet service demand.

• All the localities used a triage system to allocatereferrals. Newbury also operated an urgent care modelwhere an allocated district nurse managed the urgentreferrals. Different teams use the approach, which suitedthem to meet patients’ needs.

• Some community nursing teams had introduced alocally developed colour coded capacity tool toestablish the number of staff needed based on thenumber of units required for a task. One unit equated to20 minutes. This allowed team leaders to see at glancethe shifts when demand exceeded capacity and ifneighbouring teams had capacity to assist. However, wewere told band 6 district nurses completed the tool andif they were not available, the data was not uploaded. Intwo community nursing teams in East Berkshire wherethe tool was used, staff said it was helpful in allocatingurgent work and supporting staff, who were working atfull capacity. The use of the capacity tool was new tosome teams and was being rolled out and tested acrossthe trust. Where it was in use, it was reviewed weekly.

• Generally, community nursing teams operated on adaily handover and workload meeting to ensurereferrals were allocated and responded to appropriately.

Are services safe?

Good –––


• Staffing in the musculoskeletal, cardiac and respiratoryspecialist services and intermediate care service hadimproved over the last month. This was evident as wespoke to a significant number of new staff across allservices and the waiting time data we reviewed showedservices were meeting their targets.

Managing anticipated risks

• The 2015 winter plan set out the arrangements for themanagement of system pressures during this time.

These included the identification of the main risks andexisting control measures, planning and action phases,roles and responsibilities and details of supportingplans and arrangements made with other agencies.

• Community nursing staff told us they had tried andtested procedures in place to ensure the mostvulnerable patients were prioritised in cases ofemergency. For example, in inclement weather or severestaff shortage, patients who required medication suchas insulin would be prioritised.

Are services safe?

Good –––


By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.

Summary

By effective, we mean that people’s care, treatmentand support achieves good outcomes, promotes agood quality of life and is based on the best availableevidence.

We rated effective as ‘’good’’.

Staff provided care to patients based on national guidance,such as National Institute for Health and Care (NICE)guidelines. Care plans were evidence based and outcomegoals patient centred. Patient outcomes were monitoredand reviewed by individual services.

Staff were competent for the roles they undertook andthere was evidence of appropriate supervision in place forstaff. The majority of staff had received an appraisal in thelast year.

Staff assessed patients’ pain needs and managed thisappropriately. There was excellent multi-disciplinaryworking. Staff worked collaboratively to understand andmeet the needs of patients, particularly those with long-term conditions.

There were appropriate systems and processes in place forthe referral, transfer and discharge of patients fromservices.

Consent was sought from patients prior to care ortreatment being provided. However, not all staff were clearabout their roles and responsibilities regarding the MentalCapacity Act 2005 and Deprivation of Liberty Safeguards.

Detailed findings

Evidence based care and treatment

• Staff provided care to patients based on nationalguidance, such as National Institute for Health and CareExcellence (NICE) and from the relevant professionalbody.

• Introduction of NICE guidance was through the trustclinical effectiveness group and a system was in place toimplement and monitor implementation of NICEguidance.

• NICE guidelines on the prevention and management ofpressure ulcers 2015 were used to develop a carepathway. Staff were aware of NICE guidance and we sawan example where a community nurse showed ananxious patient the NICE guidance on microbial washingof wounds, to allay their fears of washing the wounds.This resulted in on going good compliance with washesand reduction in pain reported by the patient.

• At another visit, staff provided catheter care inaccordance with the Berkshire pathway.

• The cardiac rehabilitation programme provided data forthe national audit of cardiac rehabilitation. It wasworking towards accreditation.

• We spoke with specialist teams across the trustincluding the early supported discharge stroke serviceand rehabilitation and assessment clinic (RACC). Theseteams used best practice guidance to inform the careand services offered. For example, the early supporteddischarge team was established to promote earlydischarge of a patient with stroke from hospital byproviding support from therapists. Patients receivedintensive support for approximately six weeks, ifrequired, to help them with their rehabilitation in theirown home.

• The RACC offered urgent multidisciplinary assessment,including a medical assessment. Examples of the workoffered by the RACC was evidence based intensivesupport by speech and language therapists andphysiotherapists for patients with Parkinson’s disease.

• The diabetes services in East and West Berkshire wereaccredited for the education courses they offered. Forexample, East Berkshire had ‘quality institute for self-management education and training’ (QISMET)accreditation and West Berkshire was accredited with ‘X-PERT Health.’

• The diabetic eye screening service implementedchanges to their procedures in line with guidance fromthe national diabetic eye-screening programme.

Pain relief

Are services effective?

Good –––


• The physiotherapy musculoskeletal service offered awide range of physiotherapy techniques to reduce painincluding manual treatment, exercises andacupuncture. Physiotherapists could also refer thepatient back to their GP to make changes to analgesia ifnecessary.

• We saw pain control charts were completed. Patientstold us that they were asked about any pain they wereexperiencing and steps were taken to manage this andwe observed this on visits. They said nursing staff triedto make them as comfortable as possible.

• The community nurses referred to the specialist servicessuch as end of life team to manage patients’ pain ifneeded.

Nutrition and hydration

• Patients nutritional and hydration needs were assessedusing the malnutrition universal screening tool. Therewas a clear action plan for patients who werenutritionally at risk, for example if supplements werenot tolerated by the patient referral to the dietician wasindicated.

• Patients identified with having swallowing difficultieswere referred to speech and language therapists forswallowing assessment.

Technology and telemedicine

• Tele-monitoring technology was used for remotemonitoring of patients with long-term conditions suchas chronic obstructive pulmonary disease and heartfailure. This was achieved through patient-recordedobservations, such as pulse rate, blood pressure andoximetry, coupled with electronic responses to keyquestions.

• The dietetic service employed the use of tele-health tooffer patients an alternative option for consultations.

Patient outcomes

• Patient outcomes were measured as part of the specificservice performance metrics. This included participationin national audits.

• The Berkshire East and West pulmonary rehabilitationservices contributed to the first National ChronicObstructive Pulmonary Disease Audit Programme:Resources and organisation of pulmonary rehabilitation

services in England and Wales 2015.This audit measuredperformance against quality standards. Both teamsdemonstrated good compliance with quality standardsand identified a small number of areas forimprovements. The clinical audit report for 2014/15included the national chronic obstructive pulmonarydisease, Sentinel Stroke National Audit Programmeaudit and Parkinson’s audit. The trust registered for 157local audits and completed 87.The clinical audit plan for2015/16 included national audit of intermediate careand COPD.

• Three community teams participated in the SentinelStroke National Audit Programme (SSNAP) report forpost-acute organisation audit for October 2015. Resultsshowed response times for the early supporteddischarge team for stroke patients were better than thenational average. The SSNAP report maderecommendations, including on the multidisciplinarynature of team and ensuring that carers of people withstroke are provided with written information about thepatient’s diagnosis and management plan. They hadsufficient practical training to enable them to providecare.

• The Berkshire West musculoskeletal service used apatient specific functional scale, which was astandardised outcome measure for patients self-reporting. The results for June to October 2015 showedan average 87% patients reported improvement inperformance.

• The speech and language therapy service usedstandardised tools to monitor outcomes, for example,Grade Roughness Breathiness Asthenia Strain scale.

• The trust had services to provide intermediate care. Thiswas to facilitate hospital discharge and preventunplanned admission. They contributed to the NationalAudit of Intermediate Care (NAIC). Although it wasacknowledged in, the 2014 report that ‘minimal datawas provided by Berkshire Health Care Foundation Trustfor effective evaluation’. One of the issues was therelatively low (21%) number of teams that providedinformation on shared assessment frameworks and careplans. We reviewed the December 2015 provider report,which compared the performance of services thatprovided intermediate care provision nationally. It


Good –––


reported that the time from referral to initial assessmentfor home based intermediate care services providedwas longer than the national average of six days. It wasbetween 10 and 14 days.

Competent staff

• Staff in all services said they had excellent opportunitiesfor training. One community nurse said, “Training isfantastic.” Another told us she was being supported toundertake the advanced clinical skills course. During ahome visit, we observed one community nurse usingadvanced clinical skills to carry out examinations.

• Staff said they received support from peers and theirmanagers through team meetings, one to one meetingsand annual appraisals, where learning needs wereidentified.

• Overall data on the proportion of appraisals completedfor staff in adult community services was not available.However, appraisal information was collated onindividual teams. For example, the Berkshire communitynursing scorecard for October 2015 showed staffappraisals at over 90%, which was above trust target of85%.

• We saw attendance at clinical supervision took placeevery six to eight weeks on an individual or group basis.The community nursing attendance log for 2015 showedvariable uptake. For example, some community nursingstaff attended every eight weeks and other staff had norecord of clinical supervision attendance since January2015. The supervision attendance logs for specialistservices and intermediate care staff showed highattendance rates.

• New staff in the musculoskeletal service said they weresupported through induction, mentoring and monthlyin-service training.

• Staff in the diabetic eye screening service, qualified as‘graders’ were assessed monthly to ensure they wereperforming in line with accepted standards.

Multi-disciplinary working and coordinated carepathways

• Community nurses had good access to specialist teams,which facilitated effective multidisciplinary working.

• We observed three community nursing handovers, oneof which also had a community matron in attendance.

There was clear exchange of information, opportunity toobtain advice and discuss patients with peers beforereferring to other services. There was also handover ofpatients from the community matron to the communitynursing team.

• Specialist nurses such as the tissue viability nurses wereavailable for advice. When necessary joint visits tookplace, which was in line with the pressure ulcer pathway.Staff valued the input of the high technical specialistteam for patients with complex needs who may benefitfrom specific equipment.

• The respiratory and heart failure nurses said they haddirect access with the hospital cardiac and respiratoryspecialists to support them with patients care.

• A number of teams were, by their nature,multidisciplinary, to meet the needs of patients. Forexample, the diabetes team and the early supporteddischarge service for stroke patients. Staff in theseteams said collaborative working amongst differentprofessionals was very effective.

• In the records we reviewed, we saw evidence of goodmulti-disciplinary and multi-agency communication.

• Data showed that a range of referrals were made by thedistrict nursing teams, the most common being to thecommunity matron and end of life team.

Referral, transfer, discharge and transition

• The majority of referrals to community services thatoriginated from external referrers were received into thetrust via the ‘Health Hub.’ The exception to this werescheduled services in the West. The Health Hub acted asa single point of access to community services and wassupported by clinical nurse advisors who triaged callswhen necessary.

• Community nurses said there had been on-going issueswith patients discharged from one local acute hospital,such as incomplete or inaccurate referral information,relating to medication or care needs. This issue hadbeen raised with managers and the trust was incommunication with the hospital to improve thesituation.


Good –––


• There were transition arrangements in place to supportyoung people, who needed care, as they moved fromchildren and young person services to the districtnursing team.

• In East Berkshire a supportive discharge matron workedwith hospital services to facilitate discharge.

• The musculoskeletal service followed a standardprocedure to handover patients within the service. Thisensured an effective transfer.

Access to information

• The community and mental health services used thesame electronic patient record system. Staff said theability to access the mental health records was a recentdevelopment and had significantly improved access toinformation and integration of the services.

• Although the electronic patient record system was inuse, community teams continued to use a mixture ofpaper and electronic records. This was to ensuresufficient information was available in the paper recordin the patient’s home. This enabled visiting healthcareprofessionals to have a clear understanding of thepatient’s needs.

• Staff told us, and we observed, that connectivity to theelectronic system was sometimes an issue, particularlywhen working outside of trust buildings and whereinternet connections were poor. This meant access to,and uploading patient information could be delayed.The system was being developed to allow staff to work“off-line”; they would be able to write their records at thetime of the consultation and then have them reconciledto the system when connectivity was available.

• Some teams preferred to be more ‘paper-light’. Forexample, we saw in West Berkshire a community nurse

had a portable scanner and was able to scan a writtenassessment that was uploaded onto the computer andonto the patient’s electronic record. The patient keptthe paper copy in their home.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• We observed staff explaining procedures, giving patientsopportunities to ask questions and seeking consentfrom patients, before providing care or treatment. Verbalconsent to treatment was recorded in the patients’records. We observed that the nurse read out her notesfor the patient, so they were informed before obtainingconsent.

• Staff provided information and obtained writtenconsent before photographs of a patient’s wound weretaken.

• Two out of five community nursing staff we spoke within one of the teams in East Berkshire did not have aclear understanding of mental capacity. For example,they said they would ask relatives for consent if thepatient was not able to give consent. One staff told usthey would undertake an initial assessment and thenrefer to the memory clinic if needed.

• Data for October 2015 showed 86% of staff in adultcommunity health services had Mental Capacity Act(MCA) and deprivation of liberty safeguards (DoLS)training and 65% had dementia awareness training.However, in some teams, uptake was comparatively low.For example, in Windsor community nursing team, 11out of 26 (42%) staff were overdue MCA and DoLStraining.

• Staff in the rapid assessment clinic, had a clearunderstanding of their responsibilities under the MCAand were able to describe how it applied to theirpractice.


Good –––


By caring, we mean that staff involve and treat people with compassion, kindness,dignity and respect.

Summary

By caring, we mean that staff involve and treatpatients with compassion, kindness, dignity andrespect.

We rated caring as good.

Patients were treated with compassion and respect.Feedback from patients and their carers was consistentlypositive about the care they received and how staff treatedthem.

Patients were engaged in their care in a meaningful way.Staff spent time talking to patients, ensuring theinformation was presented in a way the patient couldunderstand.

Staff cared for patients holistically and took into account oftheir physical and emotional needs. Group exercisesessions were held, so patients and carers could developsupport networks.

Detailed findings

Compassionate care

• All the patients we spoke with praised the quality of carethey received from staff. They told us staff wereprofessional, caring and sensitive to their needs.

• Three different patients and one relative made thefollowing comments: “They make me feel it’s verypersonal to me”, ‘’ I am satisfied with the service I amgetting’’, ‘’the service I receive is excellent’’, “My partneris having outstanding care from a wonderful team”.

• Patients receiving care from the pulmonaryrehabilitation service said, “Friendly and professional.…they made me feel very much at ease”.

• Throughout our inspection, we saw patients beingtreated with respect and their privacy and dignitymaintained whilst care was being provided.

• During home visits, we observed staff interactions withpatients to be friendly and respectful. We observedsensitive and compassionate care provided to patientswith complex needs and at end of life.

• During a cardiac rehabilitation session, we saw staffwere able to engage with patients and facilitate alighthearted atmosphere to encourage exercise.

• Patients valued the continuity of care and werereassured: “Every nurse that visits from the team seemsto know exactly what has been said and done at lastvisit.”

• Feedback for the rapid assessment clinic was 100%positive and 93% of patients who attended thecontinence advisory service rated their care as good orexcellent.

• We spoke with two patients who attended the diabeticeye screening service. Both were positive about theirexperiences and one patient said “10/10 for staffsupport.”

• The results of the Friends and Family Test survey for 1stApril 2015 to 30th June 2015 showed 94% of users ofadult community services would be extremely likely orlikely to recommend the service they were seen by tofriends or family. In October 2015, the results hadimproved to 100% of patients in the majority of services.

Understanding and involvement of patients and thoseclose to them

• Patients told us they felt involved in their care. Onepatient receiving care from specialist nurses said “I feelI’m involved and in the driving seat, where I can makethe choice.”

• Patients participating in the cardiac rehabilitationprogramme said they were involved in setting their owngoals from the outset. One patient said, “It’s good, itmakes you realise what you can do without gettingfrightened about over exertion.” Patients told us and weobserved, clear explanations were provided about careplans and treatment.

• We observed a patient receiving care from the earlysupported discharge service who gave positive feedbackon the programme of exercises they had followed andthe improvements shown. We saw staff listened topatient concerns and provided onward advice about thesupport available.

Are services caring?

Good –––


• We saw one community nurse involved the patientwhen ordering equipment and clearly explained theneed and potential benefits.

• Patients said they were given sufficient verbal andwritten information about their care and treatment.

• Patients were always provided with the opportunity toask further questions at the end of their assessment,both during home visits and at outpatient clinicappointments. Patients said they were listened to andwere able to express concerns they had.

• Patients cared for by the district nurses, in general, knewhow to speak to a member of staff in an emergency orwho to contact outside the normal working hours of theservice. We observed a patient being given contactdetails as part of their first visit by the district nurse.

• One patient who attended the diabetic eye screeningservice said care was explained to them and they hadbeen given leaflets to read at home.

Emotional support

• We observed that patients were provided with holisticcare, their personal wellbeing and emotional state wasconsidered. A patient was visibly upset due to the lengthof time taken for their wound to heal. The nurse tooktime to reassure the patient through further assessmentand demonstrated an empathetic and professionalapproach.

• A patient who was particularly appreciative about thecommunity nurses, who had provided their care for overa year said; “They are more like trusted friends… sounderstanding….been my lifeline.”

• We saw patients who attended the cardiacrehabilitation programme had requested input from thetalking therapies service and this had been arranged aspart of the educational component of the programme.

Are services caring?

Good –––


By responsive, we mean that services are organised so that they meet people’sneeds.

Summary

By responsive, we mean that services are organised sothat they meet people’s needs.

We rated responsive as good.

Services were developed to meet the needs of thecommunity in the local area. A number of services hadrecently been reconfigured to become integrated andresponsive to patients with complex conditions.

Services were planned and delivered in a way that met theneeds of the local population. Patients were seen at homeand in outpatient clinics which were provided countywide.Services had made changes in response to patientfeedback, including access to appointments, at a time,which was convenient to the patient.

Staff were mindful of the need to ensure their service wasaccessible for all and we saw good examples of howpatients who were non-English speaking, had a disability,or were living with dementia, were supported. Care planswere co-ordinated across different services. Clinics wereheld in locations, which were accessible to all.

The directorate were working with other health and socialcare providers in the area to reduce the number of delayedtransfers of care.

Complaints were handled in line with the trust’s policy andwere dealt with in a timely manner. Staff received feedbackfrom complaints in which they were involved and learningwas shared at team meetings.

Detailed findings

Planning and delivering services which meet people’sneeds

• The trust operated in a complex commissioningenvironment, with six local authorities and sevenclinical commissioning groups. The trust operating planfor 2014-16, identified priorities such as improvingservices for people with dementia and diabetes, in linewith the local priorities. It also highlighted thedevelopment of collaborative community pathways ofcare to provide enhanced out of hospital care. This was

evident in some of the teams we visited which hadrecently been reconfigured, such as the integratedintermediate care team, rapid assessment clinic and thecardiac and respiratory service.

• The integrated intermediate care team in West Berkshirelocality had recently reconfigured and its aim was tofacilitate hospital discharge and prevent unplannedadmission to hospital, by providing urgent assessment,short-term care input and urgent equipment provision.

• The assessment and rehabilitation clinic was a one-stopshop. It provided multidisciplinary clinics for falls andParkinson’s disease. It aimed to provide a responsiveand patient centred service of interdisciplinary medical,nursing and therapy professionals.

• A joint physiotherapy, speech, and language therapygroup for Parkinson’s disease patients providedintensive therapy. A patient’s partner who had seen animprovement in health said “gets us out moving andconversing.”

• The early supported discharge service for strokepatients aimed to see patients within one day of referraland provide six weeks of intensive rehabilitation in linewith the National Institute for Health and CareExcellence guidance.

• The heart failure, respiratory and cardiac rehabilitationspecialist services had all recently merged into oneservice to become the cardiac and respiratory specialistservices. Staff in the new service had recently co-locatedand were developing a more integrated approach.

• The East Berkshire diabetes service had developed agestational diabetes education session to meet thespecific needs of the population, where there was ahigher than average prevalence of gestational diabetes.

• The continence advisory service had reviewed itsprovision in response to its waiting times and developedgroup education and exercise sessions to improveaccess for women. The service had received positivefeedback from patients. It was nationally recognised asan exemplar of good practice.

Are services responsive to people’s needs?

Good –––


• The West Berkshire musculoskeletal service hadincreased its opening hours. Treatment times allowedpatients to attend appointments before work if theypreferred, from 7.30am and also on Saturday mornings.

Equality and diversity

• Staff told us how they planned services to ensure theywere accessible to all. This included holding clinics atlocations, which were accessible to people with adisability.

• Equality and diversity training for staff was part of themandatory training programme. However, the staffsurvey results showed the trust was in the bottom 20%of trusts for percentage of staff who had receivedequality and diversity training. The trust had a plan inplace to improve the situation and staff did not show alack of awareness in this area.

• An information booklet on religions and cultures inBerkshire was available. This gave staff an awareness ofhow to behave when visiting or providing care andtreatment in a culturally appropriate manner.

• Interpreting services were available and staff said theybooked an interpreter if needed and occasionallyrescheduled appointments if it had not previously beenidentified an interpreter was needed.

• Patient information, including exercise sheets wasavailable in different languages to suit patients’ needs.

Meeting the needs of people in vulnerablecircumstances

• The musculoskeletal service in West Berkshire offeredhome visits for patients with a learning disability tomeet their needs in a more suitable environment.

• The continence advisory service offered patients with alearning disability, individual appointments as opposedto group sessions, to ensure they received the right levelof support.

• The trust had developed resources for people withdementia including memory clinics and a booklet tosupport carers of patients with dementia.

Access to the right care at the right time

• The majority of referrals to community health serviceswere directed through the ‘Health Hub’. The trustmonitored waiting times for treatment, which showedthat between 1 January 2015 and 31 March 2015, allservices had met the national and local targets.

• The community nursing team saw urgent referralswithin 4 hours. Data for October 2014 and September2015 for East Berkshire showed an average wait to firstappointment from referral for community nursing wasless than 2 weeks, physiotherapy musculoskeletal 2.8weeks, speech and language therapy 4.8 weeks,intermediate care 5 weeks and continence advisoryservice was 10.4 weeks.

• Data for West Berkshire for the same period showedaverage wait for community nursing was less than oneweek, speech and language therapy was 5.1 weeks,intermediate care 2.8 weeks, West Berkshiremusculoskeletal 4.1weeks and continence service was6.6 weeks.

• The cardiac and respiratory service did not operate awaiting list. They provided rapid access for patientswithin 2 hours and 5 days for non-urgent referral.

• The intermediate care service aimed to respond within 2hours to prevent a patient’s admission to hospital. Staffsaid when the service was not able to meet demand,new referrals were not accepted and this was reportedas an incident. Difficulties in organising social carepackages for patients led to delays in discharge fromhospital.

• The trust reported on the number of avoidableemergency admissions to hospital as part of the NHScommissioning for quality and innovation scheme(CQUIN). For the period 1 April 2015 to 30 June 2015,100% of urgent referrals were seen within 2 hours for therapid response team and 99% of urgent referrals wereseen within 2 hours by the community nursing service.

• The diabetic eye screening service was performingabove its targets, for example, 94% patients for urgentreferrals were seen within four weeks (target 80%) and99.9% of patients were informed of their test resultswithin three weeks.

Learning from complaints and concerns

• Staff provided patients with information at their initialassessment on how to complain. Complaint information


Good –––


was on display in clinics and hospitals for patients toaccess. Patients we spoke with said they never hadcause to complain, but most recalled a leaflet or beinginformed about their rights to complain.

• Staff were aware of how to respond to complaints andconcerns. The service manager was responsible forinvestigating complaints unless it was more appropriatefor the investigation to be conducted external to theservice.

• When there was a need for improvements or changes,an action plan was produced which containedrecommendations, actions and target dates forcompletion. Complainants received a response inwriting, which includes an invitation to contact the trustagain if they are dissatisfied with the response.

• The sharing of learning from complaints took place atteam meetings. The trust recently introduced a bulletin,‘learning curve’, to share learning from incidents andcomplaints.

• Staff were aware of changes to procedures, for example,appointment system and the introduction of e-referrals,following complaints by patients.

• For the period August 2014 to July 2015, 37 complaintswere received by community health services for adults.Of these, eight were upheld by the trust; there were nocomplaints that were referred to the Ombudsman.

• The director of nursing presented a quarterly patientexperience report to the trust board. This included ananalysis of complaint response times and themesidentified. For the period July 2015 to September 2015,five complaints had been received relating to the districtnursing/ community matron service, this was out of 145complaints. There were no specific trends identifiedfrom complaints about the community adult services.


Good –––


By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.

Summary

By well led, we mean that the leadership,management and governance of the organisationassure the delivery of high quality person-centredcare, supports learning and innovation, and promotesan open and fair culture.

We rated well-led as good.

There was good local leadership provided throughout theteams and services we visited and staff were very positiveabout the support they received from their team leadersand managers.

Clear management and governance structures were inplace through meetings to monitor performance andservice risks.

There was a clear vision and strategy in place forcommunity health services for adults, in line with the trustvision and goals. Most teams had developed their ownbusiness plans to correspond with the trust goals.

Quality performance was monitored and reported at boardand directorate level, with action taken in response toareas of poor performance. There were local risk registersin use and teams discussed safety performance at theirteam meetings. Audits were used to monitor performanceand improve quality. Policies and standard operatingprocedures were in use, but we found some of these to beout of date.

Patient feedback was collected and used in make changesto a number of the services we visited. These includedpatient survey feedback and learning from complaints.

There were good examples of innovation to improvepatient care and wellbeing. Cost improvementprogrammes were in use to ensure sustainability ofservices.

Detailed findings

Service vision and strategy

• Service managers in the community health services foradults were clear about their priorities and strategicplans. Staff understood the trust vision and values.

• Service leads and staff were knowledgeable about theclinical areas in which they operated.

• Service business plans for 2015 were known as a ‘planon a page’ and these were on display in offices. Theseshowed the five trust strategic goals and expectedindividual team objectives to be aligned with thesegoals. For example, under goal 3 ‘be the provider ofchoice for people who use and commission ourservices’, West Berkshire community service had‘securing the contract for musculoskeletal services inthe West of Berkshire.’ Another example was the EastBerkshire musculoskeletal service, which had undergoal 4, ‘establish a comprehensive range of integrated‘out of hospital’ services and ‘continue linking in withthe west physiotherapy service to ensure consistencyacross teams and shared learning’.

Governance, risk management and qualitymeasurement

• A number of services in community health services foradults had undergone change. This included thecommunity nursing teams, rapid response, heart failurerespiratory and cardiac rehabilitation. Changes includedrelocation and/or reconfiguration of teams andmanagement changes. During this transition, the trustprovided additional support to the teams, such as peersupport, coaching and additional development time.This also included away days to facilitate the changeprocess and reduce risks to the service. The seniormanagers had provided stability through this period.Generally, we found staff were positive about the waychange was handled and they said they were optimisticfor the future.

• Community teams had regular meetings whereinformation was shared and issues escalated to thelocality patient and safety quality (PSQ) group. Thisgroup met monthly and considered the issues for eachof its services. It was chaired by the locality clinical

Are services well-led?

Good –––


directors. Information from this group was provided tothe quality executive group (QEG) which was chaired bythe chief executive and attended by each locality andclinical director. Minutes of the meetings showed thatconcerns were escalated, followed up and feedback wasprovided. The QEG of 14/09/15 highlighted 10inappropriate discharges from a local acute hospital,reported by the Windsor and Maidenhead (WAM) PSQ.The minutes of the WAM PSQ for 25/11/15 showed ameeting had taken place with senior staff at the acutehospital to improve the situation. Another exampleidentified in Bracknell related to staffing issues andmeasures managers had taken to mitigate the impact ofstaffing problems. The following month’s QEG minutesprovided an update on the staffing situation inBracknell.

• Risks were discussed at team meetings and captured ona risk register. Some teams recorded their risks on ateam register, for example, Windsor and Maidenheaddistrict nurses. Others logged issues directly on thelocality risk register, for example in Reading. Staff wespoke with were not always clear how frequently riskswere monitored and managed and when they wereremoved from the register.

• The community nursing service had a scorecard tocollate performance and safety issues and this wasdiscussed at locality meetings.

• The trust audit plan was monitored at the auditcommittee. Audit findings and action plans werediscussed at the quality executive meetings and localitymeetings.

Leadership of this service

• Each team or service had a team leader who providedday-to-day operational management. The team leadswere managed by locality managers. All staff told ustheir team leads and service managers were supportiveand would raise concerns on their behalf.

• Staff were well supported by their line managers and felttheir role was valued by senior management.

• The trust supported staff to develop leadership andmanagement skills. For example, all band seven andabove staff would be enrolled on the trust managementcourse.

• Where leadership or management issues were identifiedindividual staff and teams were supported to seekresolution.

• Managers listened to their staff concerns or suggestionsand escalated these when appropriate.

Culture within this service

• Staff described an open culture where they wereconfident to raise concerns with their managers or moresenior if needed. One staff said about the managers“genuinely care and ‘don’t want to hide things.”

• Staff spoke about their value, which were consistentwith those of the organisation. We saw that staff werededicated and that they placed strong emphasis onsupporting patients to be independent at home andavoid hospital admission.

• Staff were provided with lone worker alarms and tookappropriate precautions, for example, at night theyconducted visits in pairs and if there were known risksabout a patient or family.

• During our inspection and visits to a range of teams staffshowed professional respect for colleagues and placedvalue on collaborative working.

Public engagement

• Patients’ views were captured through surveys,complaints and compliments. All services obtainedfeedback from patients, through the Friends and Familytest or through specific surveys. There was a high levelof patient satisfaction.

• The trust participated in the ‘listening into action’change management initiative, which engaged withstaff and patients to effect change. One outcome of thisresulted in the introduction of text reminders forpatients to reduce non-attendance at appointments.

• An example of changes that had been introduced, inresponse to patient complaints included betterinformation about booking appointments for themusculoskeletal service.

• Data on complaints and accolades for the directoratewas reported on a monthly basis at the localitymeetings and quality executive group. This was sharedwith the board.

Staff engagement


Good –––


• The trust was proud of four consecutive years ofimproved feedback from staff in the NHS staff surveyresults. This positioned the trust in the top 20% ofmental health NHS trusts. The Friends and Family Testresults for April 2015 to June 2015 results showed 68%of staff would recommend the trust as a place to work,which was also above the national average of 63%.

• Staff said that when they raised concerns, the concernswere addressed. For example, staff in one team said thetrust had listened to their concerns about travel time.Subsequently they had been provided with a base nearthe area they worked. Another team said that asuggestion to provide community nurses with scannersand printers to improve record keeping had beenimplemented.

• Staff told us where two teams had relocated to the samesite, there were initial tensions in the different workingpractices. However, this had been acknowledged andsupport was provided to resolve differences.

• Information was shared with staff electronically innewsletters and the intranet, as well as face-to-face andat team meetings. We saw from the notes of theBracknell district nurse forum, that an issue had been

raised, where designated staff to authorise equipmentorders had not been available. This was due to staffleaving and this was recognised needing urgentresolution.

Innovation, improvement and sustainability

• The adult community services were working toimplement the 2015/16 cost improvement plans. Forexample, to improve mobile working for staff in order toincrease productivity. Service reviews had taken place tomove towards more integrated and resilient services toimprove sustainability.

• Innovation was encouraged, for example, thecontinence advisory service had introduced groupsessions, which reduced waiting times and resulted inpositive patient feedback. The service was recognisednationally as an example of best practice.

• Staff were empowered to share ideas and developevidence-based models of care. For example, the earlysupported discharge service for stroke patients, and theintensive multidisciplinary clinic for patients withParkinson’s disease.


Good –––


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