Nottingham Citycare Partnership CIC

Letter from the Chief Inspector of Hospitals

Nottingham CityCare Partnership are a community social enterprise caring for patients across a wide range of services, in home settings or close to home in community settings such as health centres, schools and GP surgeries and in an urgent care centre. It covers the city of Nottingham and also provides a school age immunisations programme in the city of Derby. The organisation employs approximately 1800 staff and serves a population of almost 312,000.

This was the organisation’s first inspection using our comprehensive inspection methodology.

We carried out this comprehensive inspection between the 28 November and 1 December 2016. We also carried out an unannounced inspection of the Urgent Care Centre on the 7 December 2016.

Nottingham CityCare Partnership CIC provides the following core services:

• Community health services for adults
• Community health services for children, young people and families
• Community end of life care
• Urgent care services

Nottingham CityCare Partnership has not been inspected since registration in March 2011.

Headquarters has been inspected on two occasions since registration. There were no previous breaches of regulations against this location.

The NHS Urgent Care Centre was previously inspected on 12 May 2016 in response to concerns. We found that the service provided at the centre was not meeting legal requirements and we set two requirement notices in relation to:

• Regulation 17 HSCA (RA) Regulations 2014 good governance, as the provider did not have effective systems in place to monitor and manage risk by having sufficient cover to enable staff to triage and see patients in a timely manner.
• Regulation 18 HSCA (RA) Regulations 2014 Staffing, as the provider did not have effective oversight of staffing requirements in order to deploy sufficient numbers to meet demand and have a systematic approach to determine the correct number of staff and range of skills to meet patients’ needs.

Following this inspection of the NHS Urgent Care Centre by our Primary Medical Services and Integrated Care team it was found the service provided at the centre was now meeting legal requirements and as a result, both requirement notices were closed.

We inspected four core services; the end of life care service was rated as outstanding and the remaining three services were rated as good. 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. On this occasion we found that the provider was working at a level which was consistently good with some elements of outstanding; the provider’s leadership was judged to be outstanding. Therefore, overall we found the provider was performing at a level which led to the judgement of outstanding.

Our key findings were as follows:

• The organisation had a strong focus on quality and safety and providing services that met the local needs of patients. Throughout the inspection we saw how patient safety was at the forefront of the agenda.
• Staffing levels were generally able to meet the needs of patients, although there were some vacancies in the community adults and children, young people and families services. In the urgent care service there had been significant investment in agency staff to temporarily increase staffing levels to a safe level to meet demand in a more timely way. This had made a positive difference on meeting demand and managing workload.
• Patient’s needs were met through the way services were organised and delivered with minimal waiting times across the services. In the end of life care service 100% of patients had died in their preferred place of care. In adult services, between April 2016 and December 2016, the organisation responded to 90% of acute requests within three hours of referral. For referrals that were classed as urgent and requiring a visit within 72 hours their overall performance for the same period was 90%. In the urgent care service there had been a steady improvement in the assessment time of patients since May 2016 with a 17% reduction in the number of patients waiting longer than the 30 minute target time set by the clinical commissioning group (CCG).
• The individual needs of patients were taken into account when planning and delivering services. In the children, young people and families service staff offered home immunisations for hard to reach vulnerable children to ensure they completed their immunisation programme. In adult services a reablement team provided care for patients who required a social care package in order to prevent hospital admission or to facilitate an earlier discharge from hospital. Specialist dementia nurses were available across the organisation to give practical, clinical and emotional support to families living with dementia. The NHS urgent care centre identified carers and those that cared for patients during consultations and were able to signpost support if required.
• The provider had an up-to-date infection control policy, which provided guidance for staff on the prevention and control of infection. Throughout the organisation we observed staff to be compliant with best practice guidelines to prevent and reduce the risk of spreading infection.
• There had been three cases of Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and 23 cases of Clostridium difficile (C.difficile) infection between April and October 2016. Of these, no risk factors or significant lapses in the quality of care provided had been identified.
• Without exception patients were treated with kindness, compassion, dignity and respect throughout all of the services we inspected and feedback from patients, families and carers was consistently positive about the way staff treated them.

We saw several areas of outstanding practice including:

• A medicines compliance review service was available on referral by a health or social care professional for patients who were finding it difficult to manage their medicines due to poor memory, lack of dexterity or swallowing difficulties.
• In addition to the Macmillan specialist palliative care team (SPCT), there was a Macmillan support team. The Macmillan support team was part of a two year pilot which had been brought about because of a lack of provision for patients whose needs were not complex enough to warrant support from the Macmillan SPCT. This enabled patients with cancer to access Macmillan support.
• The end of life service had three virtual hospice beds within the provider’s nursing home. This enabled patients to access respite care 24 hours a day, seven days a week.
• Teams were supportive of each other and aware of the emotional stress of working in end of life care. The Macmillan support team had a ‘sparkling moments’ book, in which they recorded their positive experiences of palliative and end of life care. Although they used this to evidence where they had met their key evaluation points set by the clinical commissioning group (CCG) they also found this a useful exercise to provide positive reflection for the team.
• Nottingham CityCare Partnership along with Nottingham City CCG and Nottingham City Council had won the Health Service Journal ‘Improved Partnerships between health and local government’ award in November 2016. The provider had been recognised for their work in the city’s integrated care programme which aims to provide seamless care for people as well as keeping more people healthier in the community and out of hospital.
• In the NHS urgent care centre the medical director had developed an application which allowed staff to review an anonymised patient record, reflect on the notes and automatically produced a scoring system to highlight areas of good practice. This provided clinical staff with an effective way to self and peer review their decision making, treatment plans and record keeping. This application had been introduced over the last six months and had been utilised voluntarily 42 times by staff (by some staff multiple times) and the final scoring could also be used in appraisals, for development and good practice was celebrated.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated children and young people service as good overall.

We rated caring as outstanding and safe, effective, responsive and well led as good because:

• Nottingham CityCare Partnership had systems in place for recording, investigating and monitoring incidents. Lessons were learned to prevent similar incidents from happening again.
• Safeguarding procedures were in place with clear lines of reporting. All staff were aware of these procedures and their own responsibilities for the safeguarding of children and young people.
• The feedback we had from children, young people and their parents or carers was consistently positive in all the locations and programmes we visited.
• Staff were kind and caring and we observed excellent interactions between them and children and young people and their parents or carers.
• Parents, carers, children and young people we spoke with and met in clinics were overwhelmingly positive of the staff. They told us staff were kind and listened to their concerns.
• Staff ensured people experienced compassionate care, and care that promoted their dignity. Staff coordinated care for the whole family and were committed to helping meet people’s emotional, social and welfare needs as well as their health needs.
• Services were located where people could access them, and offered a range of times to accommodate people’s different preferences.
• Overall, children, young people and their families received timely community health services.
• Services mostly met their performance targets. Where there were waiting lists, there were plans in place to minimise the effect on the children and young people.
• Staff worked in partnership with other agencies such as the local authority, education and voluntary organisations. We saw evidence that partnership working was routinely included in every aspect of their work.
• Staff were proud and passionate about their role and they were continually looking for ways to improve services for children and young people.
• Staff thought the service was well led and staff had a clear vision of the future of Nottingham CityCare Partnership.

We rated end of life care service as outstanding overall.

We rated caring and responsive as outstanding and safe, effective and well led as good because:

• Openness and transparency about safety was encouraged.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and where incidents had been raised actions were taken to improve processes.
• Safeguarding was given sufficient priority. Staff had an understanding of how to protect patients from abuse. Staff described what safeguarding was and the process to follow if they suspected a patient was at risk of avoidable harm or abuse.
• Arrangements to minimise risks to patients were in place with measures to prevent falls, malnutrition and pressure ulcers. We observed staff followed good infection and prevention control practices.
• Staff recognised and responded to the changing needs of patients with anticipatory medications readily available and care needs assessed and reviewed appropriately.
• Specialist equipment needed to provide care and treatment to patients in their home was appropriate and fit for purpose so that patients were safe. Syringe drivers were maintained and used in accordance with professional recommendations.
• End of Life care was planned and delivered in line with best practice guidance. Care and treatment was planned and delivered in a personalised and holistic way and care plans took into account people’s health and social care needs.
• All staff involved in providing end of life care had access to current guidance through the Nottinghamshire guideline for care in the last year of life.
• Staff had access to relevant training and support. All the teams we spoke with valued the expert knowledge of the end of life care team and the Macmillan specialist palliative care team (SPCT) and used this service often as a learning resource and for referrals where patients had complex symptoms that were difficult to manage.
• Our observation of practice, review of records and discussion with staff confirmed there were effective multidisciplinary team (MDT) working practices. Staff worked collaboratively to understand and meet the range and complexity of people’s needs
• Outcomes for patients using the service was collected and monitored on a monthly basis by the end of life care service. For example, the service collected data on the number of patients who achieved death in their preferred place. Between April 2016 and October 2016, 100% of patients who died, achieved death in their preferred place of care.
• The provider used an electronic palliative care coordination system (EPaCCS). This is an electronic computerised information system which contains essential information about patients who had been identified as being in the last year of life. All health care professionals involved in the patient’s care could access the information. The local emergency ambulance service could also access this information.
• Staff understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005.
• We observed a holistic person-centred approach to patient care. Patients were treated with compassion, kindness, dignity and respect.
• Without exception, feedback from patients was positive. Staff were not only committed to providing sensitive care to patients, but also for the well-being of their families.
• Patients were supported to maintain their independence. Where possible, staff promoted self-care, self-management and independence. They were empowered to be partners in their care.
• Staff provided emotional support for patients and their families, but appropriately signposted them to other sources of support where appropriate.
• Services were developed in such a way as to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care.
• The provider engaged with external organisations and the local community to ensure the services met the needs of patients and those close to them who required end of life care.
• The provider was proactive in its approach to understanding the needs of different groups of people and to deliver care in a way that promoted equality. Patients who were vulnerable or had complex needs could access the service.
• Patients could access the service in a timely manner and services that suited their individual needs.
• There had been very few complaints in relation to end of life care services.
• The leadership, governance and culture mostly promoted the delivery of high quality person-centred care.
• Although there was no published strategy, there was a vision and a work plan for the future of the service, and throughout our inspection, we could see that much of the work plan had already been implemented. We could see that the work plan had been developed in line with the provider’s vision and values.
• The locality leads, clinical nurse specialists and general district and community staff were able to articulate the purpose of their service, to provide care and support for patients in their last year of life, and their role within the integrated locality team. All staff, including very senior managers understood the importance of end of life care.
• There were good governance structures in place for end of life care through the integrated governance structure.
• The lead for end of life care was visible, and there was good local support and leadership for end of life care. Staff had confidence in their managers to ensure training and expert knowledge was available to improve end of life care experiences for patients and those who were close to them.
• There was good public and staff engagement throughout end of life care services.

However, we also found:

• There was no safety performance dashboard related to end of life care.
• There was no programme of audit in place for ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms. We were therefore not assured that decisions surrounding DNACPR orders were being appropriately monitored. During our inspection, we reviewed nine DNACPR forms. Our review showed eight forms had been appropriately completed in line with national guidance.
• The strategy and strategic objectives for end of life services were still in development. The service lead was working with all stakeholders to develop the service strategy but it had not been completed and published.
• There was no service level agreement in place between the provider and the specialist palliative care unit that was providing specialist out of hours advice and guidance about symptom control. This meant the provider had no protection from this service being withdrawn.

Overall we rated community health services for adults as good.

We rated safe, effective, caring, responsive and well-led as good because:

• The service protected patients from avoidable harm and abuse.
• Staff understood their responsibility to report incidents and we saw evidence that actions were taken as a result of these.
• Staff anticipated and managed risks to patients who used services and had a good understanding of how to safeguard people from abuse.
• Clinic areas were visibly clean with staff demonstrating a good understanding of infection prevention and control.
• Staffing levels and caseloads were planned and reviewed on an on-going basis to ensure safe levels of care were provided.
• Care records were up to date accurate and legible.
• Care and treatment was planned and delivered in line with current evidence based guidance and standards and staff had the skills knowledge and experience to deliver effective care.
• Many referrals to the service were handled by a single point of access either by telephone or electronically.
• Most patients had a single electronic patient record which ensured all staff had access to information with multi-disciplinary and integrated care pathways in place.
• Multi-disciplinary working and integrated care pathways were in place.
• Staff demonstrated a good understanding of the Mental Capacity Act.
• Without exception feedback from patients was positive about the care and treatment they received. Staff showed consistent respect and compassion for patients and their relatives and involved them in the planning and delivery of care.
• Services were in the majority of cases planned and delivered to meet the needs of people with patients receiving ‘joined up’ care from different teams when appropriate.
• The provider had an overall vision with values that staff were aware of and demonstrated.
• There was positive feedback from staff about the director of nursing and allied health professionals who was visible and line managers were supportive to their staff.
• There was an effective governance structure in place and staff felt proud to work for the service.

However, we also found:

• Systems to resolve issues were not always standardised across community care delivery groups and staff did not always understand why processes had changed to improve patient care.
• In addition staff did not always adhere to best practice guidelines in regards to code of dress.
• Confusion could arise with the use of multiple paper records for patients receiving care from more than one community team.