Salford Royal NHS Foundation Trust

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1 Salford Royal NHS Foundation Trust RM3 Community health services for children, young people and families Quality Report Stott Lane Salford Greater Manchester 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 children, young people and families Quality Report 27 March 2015

2 Summary of findings Ratings Overall rating for Community health services for children, young people and families Are Community health services for children, young people and families safe? Are Community health services for children, young people and families effective? Are Community health services for children, young people and families caring? Are Community health services for children, young people and families responsive? Are Community health services for children, young people and families well-led? Good Good Good Good Requires Improvement Good 2 Community health services for children, young people and families Quality Report 27 March 2015

3 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 children, young people and families Quality Report 27 March 2015

4 Summary of findings Overall summary The community health services include all those provided for babies, children, young people and their families in their homes, schools and community clinics. The services we visited included: Universal health services and health promotion such as health visiting and school nursing Specialist and enhanced care and treatment, including specialist nursing services for diabetes and children with disabilities, multiple and complex needs and long term conditions. Therapy services such as physiotherapy and speech and language therapy; community paediatrics; a secure unit for young people and services for vulnerable children and young people. Services that provide and/or coordinate care and treatment for children and young people with longterm conditions, disabilities, multiple or complex needs and children and families in vulnerable circumstances. 4 Community health services for children, young people and families Quality Report 27 March 2015

5 Summary of findings Background to the service The community children s services were delivering universal screening and health promotion services via schools, clinics and community children centres. They were also providing and co-ordinating, via the Diana team, targeted packages of care and support for children with long term or complex health conditions. These services were provided so that children and their families could avoid repeated visits to a medical centre or hospital and the children could remain with a package of care at home. There were no in-patient facilities in the trust for children requiring a hospital stay but there was a paediatric assessment and decision area, the Panda service, and children requiring a hospital stay were transferred to a hospital, normally in Bolton or Manchester. We visited community services for children and young people with health visitors, school nurses and specialist nurses. We attended clinics and drop-in centres at schools and children centres where occupational, physio and speech and language therapies were available and health promotion screening sessions were being delivered. We spoke to staff involved in working with looked after children and we attended the Barton Moss Young people s secure care centre and the youth offending service. We also accompanied health visitors and specialist nurses service on home visits where targeted services were provided for conditions such as diabetes and for vulnerable children with complex needs and long term needs. We visited the orthoptics service and spoke a nurse from the acute unscheduled care team and with the (Unicef) baby friendly project manager. 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 one CQC inspector, one specialist nurse and a health visitor. 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 of acute services 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 between 13th and 15th January Community health services for children, young people and families Quality Report 27 March 2015

6 Summary of findings During the visit we held focus groups with a range of staff who worked within the service, such as nurses, doctors, therapists. We talked with people who use services. We observed how people were being cared for and talked with carers and/or family members and reviewed care or treatment records of people who use services. We met with people who use services and carers, who shared their views and experiences of the core service. Where we have visited services which predominantly provide primary medical services (General Practitioners) or young offender services, we have utilised our acute hospital or community health service inspection methodology. We have not assessed the full provision of services provided by general practitioners or by young offender services. We have considered the services provided by staff employed by Salford Royal NHS Foundation Trust only. What people who use the provider say Children, young people and their families spoke positively about the care and treatment they received from the range of community based children's services. Words such as "Caring", "Professional", "Friendly", "Reliable" and "Knowledgeable" were used extensively during the inspection to describe the services and staff. Good practice Our inspection team highlighted the following areas of good practice: We saw good practice in a number of areas including the leadership team, diabetes service, baby friendly initiative, Barton Moss and physiotherapy. Delivery of the Healthy Child Programme. Areas for improvement Action the provider MUST or SHOULD take to improve The trust should review existing pathways to ensure that children who were not in mainstream education were appropriately identified in order that their health and development needs can be identified and assessed in line with national programmes. 6 Community health services for children, young people and families Quality Report 27 March 2015

7 Salford Royal NHS Foundation Trust Community health services for children, young people and families Detailed findings from this inspection The five questions we ask about core services and what we found Are Community health services for children, young people and families safe? By safe, we mean that people are protected from abuse Good Summary There were well developed systems in place for reporting and investigating incidents and we found evidence that learning from incidents was taking place and was being shared within the service. The learning was used to improve services. Incidents were also used to inform the risk management process and we found that there was a common understanding of the top risks. Action was being taken to anticipate and mitigate risks and effective risk management processes were in place. We found that the equipment used was safe and appropriate and was clean and well maintained. Staffing levels were a challenge, particularly in the Diana team, acute unscheduled care and in health visiting and therapies. A restructuring was taking place to maximise the support for the services and make better use of the available resources. Safeguarding arrangements were thorough and roles and responsibilities were clear. However, the high level of work resulting from essential safeguarding and child protection responsibilities was limiting the health promotion activity that could be undertaken. The School Nurses reported that they couldn t always achieve attendance at meetings for Level 3/Child in Need Family Support meetings. The trust had introduced conditions that ensured all staff received mandatory training and there was a high level of compliance in community children s services. 7 Community health services for children, young people and families Quality Report 27 March 2015

8 Detailed findings Incidents, reporting and learning The Trust provided us with an analysis of the 69 incidents reported between August to October 2014 in the community health services for children, young people and families. The majority occurred in community paediatrics. The reason given for most incidents in the period was communication with documentation/records as the second most frequent reason given. Incidents were discussed at the children s clinical governance board and serious incidents were escalated through to the divisional governance board and the executive board. All serious incidents were investigated in detail and an action plan drawn up for the serious incident action review committee. We heard of two particular incidents, one involving a baby with tonsillitis and the use of penicillin and anther involving a complex package of care. Lessons had been learnt and shared from both incidents and incidents informed risk management. A physiotherapist said that they always reported a child s fall on the datix reporting software and they also reported near misses. They also reported when they were unable to offer a child an appointment within an appropriate period. Two incidents were reported in July 2014 in Paediatric Speech and Language therapy. One where the patient notes were not available in time for an appointment and another where the therapist had not been informed of the patient s change of address. Therapists had been advised to check patient details at appointments and update electronic system accordingly. We found that incidents were reported routinely and they were used to promote learning and improve the safety of the service.the Assistant Director of Nursing and Allied Health Professionals for Children s Services of nursing said: the culture is now to be open and transparent about incidents it is all about learning rather than looking to apportion blame A further incident, also reported in July 2014,revealed a grey-area. This was whether non-life threatening paediatric traumas cases should be managed by Salford Royal s trauma staff or transferred immediately to Royal Manchester Children Hospital. This was discussed and the protocol clarified. As a result of the learning from another incident it was agreed that all referrals should go through the nurse coordinator. Another incident involved somebody from the children s community nursing team leaving a faulty photocopier, because they could not fix it, whilst it still had information in its memory. The team were informed and advised to alert somebody should this happen again. Cleanliness, infection control and hygiene Cleaning of equipment was through using blue roll, disinfectant spray and wipes. We saw evidence of effective hand washing, for example, at a meeting between a physiotherapist and a patient, during home visits with health visitors and nurses, at a child health screening session and during immunisation session at a local school. Hands were washed and hand gel applied. We were informed that toys were cleaned in the therapy clinics by using disinfectant wipes. There was a rota that we saw, to ensure that this cleaning was completed regularly. We observed good hand hygiene during the immunisation session at a local school. Hand gel was used between all injections and all procedures observed. Maintenance of environment and equipment We were informed that beds were serviced yearly and checked for wear and tear. We saw evidence of safe practice such as brakes being engaged on a bed before commencing physiotherapy. The diabetes service was making good use of technology to improve the service for children and families. Insulin pumps were used alongside a Medicines management Nurses in the community teams were trained and able to administer medication, including antibiotics, in the patient s home. 8 Community health services for children, young people and families Quality Report 27 March 2015

9 We saw from the patient s notes that specialist nurses were involved in providing complex care in the home for children requiring long term ventilation using a tracheostomy and gastrostomy or nasogastric support or tube feeding. There were just five medicine related incidents reported in the period August to October We accompanied the diabetes nurse on a visit to a patient and their mother in their own home. The nurse was highly competent, experienced and reassuring. Some of the discussion was about a gradual transfer of responsibility for administration of the young patient s diabetes medication from the mother to the teachers in the patient s school. This would enable the mother to work. The nurse was acutely aware of the mother s anxiety about the transition and was careful to acknowledge the mother s concerns and adopt a pace with which the mother was comfortable. The nurse was going to visit the school and offer further guidance to the teachers to ensure they were confident and happy to manage the medication process. This transition was being managed to reduce the risks. Safeguarding All clinical staff were trained to level 3 in safeguarding. Managers monitored that everyone was up-to-date with their training and they received electronic alerts when they are not. We met with the school health clinical lead that was also the clinical safeguarding lead. She said that she received monthly safeguarding profile data from all the services and therapies and she conducted an analysis of the workload pressures, actions and outcomes. She could see the whole picture and could escalate if the team needed additional support. Safeguarding supervision was being offered by the safeguarding team. The safeguarding supervision model involved a one to one session with the caseload holder three times a year. In addition, there was group supervision for other health professionals also three times a year. The link officer said that the organisation was supportive when they need to escalate concerns to senior managers. We attended a child protection meeting where the police had raised concerns about the neglect of a child. The meeting was attended by the social worker, mother, school nurse, teacher and interpreter. Notes were written up, letters sent and child s name placed on the child protection register. The meeting was conducted professionally. One of the school nursing teams informed us that capacity was the biggest challenge. So much of their work involved dealing with the high levels of work arising from child protection and safeguarding and this left little time for health promotion work. A specialist nurse told us that there was a lead nurse meeting on the first Monday of every month and this was attended by community nursing teams and representatives from the safeguarding team. We were informed that there was plenty of interaction and members of the safeguarding were always available to give advice and support. There were processes in place for ensuring that where children failed to attend a planned outpatient appointment, this was escalated back to the child s general practitioner or referring health care professional. Where safeguarding concerns were considered or identified, referrals were made to the relevant safeguard authority. Records systems and management Whilst the parts of the trust dealing with hospital or acute care used electronic paperless records, the children s service, in the main, used paper records. Letters from therapists, all paediatric out-patient clinic letters and community nursing services were uploaded onto an electronic system. Some parts of community children s services were also using the electronic patient record system alongside paper records. The diabetes service was using electronic systems and was involved in a working group who had designed a care plan that was adopted by Diabetes UK and rolled out nationally. We were informed that the paper records were held by the health visitors or school nurses and that the records followed the child to community appointments. However, with so many services and service locations, this meant that sometimes the records were not where 9 Community health services for children, young people and families Quality Report 27 March 2015

10 they were needed, Occasionally, health care professionals would need to see the child without being able to refer to the notes. This may mean that the health care professional would not have the full details and history relating to a case and they would not be able to make contemporaneous entries directly into the notes. When this occurred it was recorded as an incident on the datix incident recording system. This was also the most serious risk recorded on the risk register for the service. This risk was recorded as: Dependency on paper records for our patients who are working with a range of services. We were informed that the trust was looking to procure new electronic systems, but that they had not yet identified a system that would meet all the needs of the services. Records in physiotherapy were paper based and files were kept in a locked cabinet. A member of the team said that they used computers in a number of bases. Sometimes it was difficult but IT support was effective. Health Visitors notes were shared across the services. They were bar-coded and if physiotherapy, paediatrics or other health professional wanted them they had to formally request. This meant that they could keep track of the notes. We looked in detail at three sets of notes from the school health team. All the notes provided good evidence and examples of appropriate documentation such as a chronology of significant events, records of attendance at review meetings, signed consent forms and a copy of a report prepared for the court. However, we noted that, when a child transferred to the school health team the notes of the mother, family and child were combined. We noted that, health visitors and school nurses used notes differently. Some health visitors wrote up the child s issues in the family notes. This may become an issue if, at 18 years old, the patient wanted to access their own notes. The Acute Unscheduled Care Team A member of the acute unscheduled care team said that referrals came from the Panda unit by fax. They said that this was an inefficient process as it also involved two phone calls to ensure that the right person was standing by the fax and to confirm that the fax had arrived. We looked in detail at six sets of notes from the Diana team. The notes, other than the very recent ones, had a photograph of the patient, a care plan, a care diary and document entitled All about me and my health action plan. There were also signed forms giving consent for treatment and consent for home visits. A relative we spoke with said we could not manage this without the nurses and carers. The records we saw in therapies were kept confidentially in locked cabinets. We saw that notes taken out of the office were placed in a carrier. Community health and learning disability patients had a health passport. Any order or advance directive advising not to attempt resuscitation would usually be generated by the Diana Nursing Team, community paediatrician or general practitioner; support from the local hospice was also available to support children, families and health care professionals. Mandatory training We were informed by the Chief Executive in his presentation and by many staff and managers throughout the trust that, if staff were not up-to-date with their mandatory training, they would not receive a pay increment and they would be suspended from duty. The staff we spoke with were positive about this initiative and the associate director of nursing said that there was 98% compliance across the service with mandatory training as of November This was confirmed in the notes we saw of the directorate operational meeting. They also said that they had never had to suspend a member of staff from duty due to noncompliance with their mandatory training. Lone and remote working During one focus group nursing staff reported that their lone working arrangements were supported by a range of systems including a sky guard device, mobile phones and electronic diaries. The immunisation team and the learning disabilities team said that they often worked out of hours and always visited patients in twos. At the first visit a risk assessment would be conducted. We spoke with a Physiotherapist who said that the whole team conducted home visits. The service had access to an electronic system (called sunrise) that 10 Community health services for children, young people and families Quality Report 27 March 2015

11 raised alerts and incidents. A risk assessment was conducted prior to visits and two members of staff would visit if the case was new or of concern. Often this would be an occupational and physiotherapist working jointly. They said that they used a paper diary system and all staff had a mobile telephone and were required to call into the office when arriving and leaving a visit. Several teams, including the children s community nurses, were using a personal electronic safety alarm system linked to an incident management centre. In the speech and language therapy team they said that they would text or back to the office at the end of a visit. The nurses working in the youth offending service had been issued with standard mobile telephones and they did not link to electronic diaries. They said that mobile technology needs investment if it is support remote working. Assessing and responding to patient risk The senior operations manager gave an overview of the top risks identified within the service. When we spoke with staff, we found that there was a common understanding of these risks across the service. The first of the top risks was the dependency on paper records. We found that this risk was well understood by staff and, where possible, electronic systems were being used. Some services, such as the diabetes service, were already making good use of electronic systems. Where there were no electronic options, paper files were tracked and moved around the system to arrive in time for appointments. The service was looking to procure an electronic system and make use of the electronic patient record to allow all the services to share patient information electronically. The second of the top risks was described as, robustness of care packages provided for our children with complex care needs. The Assistant Director of Nursing and Allied Health Professionals for Children s Services said that this was linked to a particular case where a vulnerable child had required a 165 hour care package and a carer was unexpectedly absent. This prompted a complaint from the child s relatives and an investigation of the issues. Action taken included careful controls when recruiting care staff and a new escalation process for this type of scenario. There were 33 open risks at the time of our visit. The trust provided us with details of the 20 risks classified as medium or serious. There was a close correlation between the incident reports and the identification and management of risks. There were also risks identified in relation to staffing levels. This was the case, in the Diana service where the children were vulnerable and may have to be moved to a hospital setting if staffing could not be guaranteed for children requiring a complex package of care. A nursing governance report had been prepared in August 2014 and a gap analysis was conducted in December 2014.This work raised safety concerns because the service was: unable to guarantee stability and patient safety of the caseload the caseload of children with chronic conditions are not being proactively managed and developed and may not get nursing needs met in community and will need to attend hospital for clinical procedures or stay in hospital longer. There were also risks identified in other areas in relation to recruiting and retaining health visitors, for example, to achieve the target of 69 (wte) by 31 March 2015 as part of the healthy child programme. Staffing levels and caseload Staffing levels were an issue in several areas of the service including the Diana community nursing team, the orthoptics service, physiotherapy, occupational and speech and language therapies and health visiting. There were 5.1 (wte) consultants overall covering the service. In response to this there was an annual plan priority across the division to restructure leadership for paediatric services and to rationalise the number of sites from which children s services were operating. Work was underway to organise the community nursing services for children with acute conditions under a 11 Community health services for children, young people and families Quality Report 27 March 2015

12 single funding stream. This would include children with chronic long term conditions, those receiving palliative care and those needing ventilation over an extended period of time. In order to manage the staff shortages in the Diana community nursing team the resources were being managed jointly with the resources of the continuing healthcare service. Of the three senior nursing posts (band 6) in the Diana service, one was on long term sick leave and one on maternity leave. There were also vacancies in the continuing healthcare service. There were currently 4 nurses in the in the Diana team covering Monday to Friday 8.00 am to 8.00 pm. There were two patients receiving palliative care and receiving daily visits that would be for a minimum of an hour. This was limiting the time available for patients with chronic long term illness. The team leader for the Diana unit said that the service would like more health care assistants to support families with respite. Staffing shortages in the orthoptics service were due to maternity leave and long term sickness. Every year they visited schools and screened every four year old child in Salford from October to July. They also delivered adult services and, when they were short of staff, they prioritised clinics over screening. Staffing levels in physiotherapy and occupational therapy were improving and recruitment was becoming easier. We were informed that locum staff were being sourced through a physiotherapy bank with which the trust had an agreement. This meant that they were using familiar locums and it was less costly. In addition, numbers were below the target set nationally for the health visitors as part of the Healthy Child programme. The target number of health visitors for Salford Royal was 69 (wte) and the number in post at the time of our visit were (wte). The diabetes service was run by two experienced specialist nurses with a total caseload of 104 patients. The service could also call upon the services on a consultant, dietician and a psychologist. The two nurses shared the on-call rota to offer telephone advice in the evening and at weekends. They said it worked well. The four members of the speech and language therapy team informed us that demand exceeded their capacity to respond and they would benefit from additional therapy and administrative staff. We spoke with four school nurses and they said, because of the numbers of safeguarding issues to deal with, they did not do much health promotion work. We checked with the Assistant Director of Nursing and Allied Health Professionals for Children s Services and she said work was underway to re-design the role to allow the school nurses to place greater emphasis on the public health promotion part of the role. This would involve streamlining attendance at case conferences. Managing anticipated risks We saw that these risks were also being managed and monitored through the divisional scorecard and that controls and an action plan were in place. One of the actions was a clear escalation process for any cancelled shifts and a business case had been submitted for additional funding. Actions taken to mitigate the risk to patients of staffing shortages included: staff working flexibly to cover the service and caseload; continued use of staff from the bank; and information was being gathered for a service review and redesign. In addition, any referrals or episodes of care that were refused by the service due to staffing levels were being documented, recorded on the incident recording system and monitored. Staff were also being offered additional individual and team meetings to provide extra support to the hard pressed team. The Diana team leader identified the most pressing risks as staffing, audits and safeguarding supervision. Major incident awareness and training The Assistant Director of Nursing and Allied Health Professionals for Children s Services informed us of exercises that had taken place in the trust, following integration, on major incident awareness that had created a community focus. The Assistant Director of Nursing and Allied Health Professionals for Children s Services also said that there 12 Community health services for children, young people and families Quality Report 27 March 2015

13 were business continuity plans for issues such as snow, failure of telephones and electronic communication systems and they had used one when industrial action threaten the supply of petrol. 13 Community health services for children, young people and families Quality Report 27 March 2015

14 Good Are Community health services for children, young people and families effective? By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Summary Staff worked to deliver assessment and treatment in accordance with standards and evidence based guidance. There was some monitoring of outcomes for patients and plans were in hand to redesign the services to make better use of resources and improve effectiveness. Multi-disciplinary team working was effective. Staff were competent and working well as an integrated team in the interests of patients. The contribution framework had placed a greater emphasis on the need for mandatory training, staff development and performance appraisal. Detailed findings Evidence based care and treatment We found that the service made effective us of evidence based care and treatment. For example, they were using NHS England s Healthy Child programme and the UNICEF s Baby Friendly initiative best practice standards at level 3 to support breast feeding. The service was following the Healthy Child Programme. This was a NHS England programme for the early life stages and focused on universal preventative services, providing families with a programme of screening, immunisation, health and development reviews, supplemented by advice around health, wellbeing and parenting. The trust had achieved commitment to and accreditation for the baby friendly community award in half the time taken by other trusts. This initiative is evidence based and dependent on response rates, achievements of standards and improvements in terms of the number of mothers breast feeding. In involved training for health visitors in practical skills, the creation of champions, and engagement from mums. The diabetes service had achieved the paediatric best practice tariff. This meant it was receiving additional funding for achieving required levels of care as described by the Paediatric Diabetes Networks the Department of Health. We attended a child screening session with members of the health improvement team and as part of the National Child Measure Programme. This is a Public Health England programme where children aged 4 5 and years have their height and weight measured during the school year and this forms part of a national and local data set. Pain relief Pain management in patients was assessed and the trust used visual analogues on a scale of 1 10 or the Wong-Baker Scale.This scale has a series of faces to enable children to describe their level of pain. The physiotherapists also said that they asked parents. If a child s pain persists the therapist will make a referral back to the GP.T hey can all access the hydrotherapy pool at Salford Royal. Approach to monitoring quality and people s outcomes We were informed that all children from 9 months to 5 years old were provided with free vitamin D by the trust. We saw evidence of the service monitoring performance and outcomes. For example, we saw the monitoring figures for the healthy child programme. The service was counting the number of mothers who received a first face to face antenatal contact with a health visitor at 28 weeks or earlier. Similarly, increases in the rates for breast feeding were being monitored as part of the baby friendly initiative. At 10 days 47% of mothers reported breastfeeding in 2012 and this increased to 55.5% in December for. At six weeks the rate had gone from 36.1% in January 2013 to 40.4% in December We saw a white board in the diabetes service on which the nurses were monitoring the Competent staff 14 Community health services for children, young people and families Quality Report 27 March 2015

15 Good Are Community health services for children, young people and families effective? We were informed by the Assistant Director of Nursing and Allied Health Professionals for Children s Services that 92% of staff across the service had an up-to-date performance appraisal. This was delivered as part of the contribution framework. In addition to mandatory training, additional training was available for nurses, either in house or external. There were development days available for middle grade and senior nurses and there was a Salford royal leadership programme. Physiotherapy staff said that they had access mandatory training every year which they booked through the snowdrop electronic system. In addition, they received annual team training and local updates provided by the trust. The physiotherapist we spoke with said that they had worked for another trust and that Salford Royal was a good trust to work for. They said that the recruitment process was smooth and fast interviewed and employed within ten weeks. Human resources and occupational health were both efficient. There was a detailed induction. The physiotherapist said that the trust encouraged continuing professional development and that staff were be encouraged to attend, released from their duties and the trust would pay for courses if they were relevant. During the immunisation session we witnessed in a local school, staff demonstrated their competence and expertise. When a patient fainted they were immediately attended to and a screen used to offer privacy. Paramedics were called as the patient had hit their head when they fainted. Multi-disciplinary working and coordination of care pathways At the focus group the community children s team said that they had support from the nursing team at Greater Manchester West.They said that most teams had a daily safety huddle meeting at 9.00am to discuss the plan for the day and any areas of concern, particularly any safeguarding issues. We visited the physiotherapy team who shared a base with social services. Referrals were taken from consultants, tertiary centres, GPs, allied health professionals, occupational therapists and from colleagues working in education. A physiotherapist we spoke with said that there were benefits to the integration of community services within Salford Royal.They said that integration had provided better access to electronic systems, training and communication within multi-disciplinary teams. They said that they had close links with Manchester Children s hospital. They also received a high number of referrals from Salford Royal s consultant-led Paediatric Assessment and Decision Area known as The Panda Unit. There was multi-disciplinary working with colleagues in community paediatrics, occupational therapists, speech and language therapists and GPs. There was also multi-agency working with social workers, colleagues in education in the early year s team and in schools. We heard evidence of multi-disciplinary working across the diabetes networks involving the community service and the diabetes nurses based at the local hospitals, parents, schools and colleagues from diabetes UK. There was also training in schools four times a year and sometimes with teachers on an individual basis. One member of the speech and language therapy team informed us that there was an overlap and good joint working between the team and health visitors, clinical psychologists and dieticians. Another member of the team said that sometimes it is difficult to get hold of people and not everybody gets engaged. Both members of the team said that the lack of administrative support affects quality and being able to use the electronic patient record system would help. The trust was providing nursing services to a youth offending service which was run by the local authority. 15 Community health services for children, young people and families Quality Report 27 March 2015

16 Good Are Community health services for children, young people and families caring? By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Summary Staff in all the services we saw and visited were providing compassionate, sensitive care. Patients were encouraged to be involved in setting their goals for rehabilitation and in understanding their treatment and care. Patients we spoke with, and their families, felt that they were treated with dignity and respect. Detailed findings Compassionate care Staff we spoke with discussed patients and their families with great compassion and care. We witnessed compassionate care given by all the staff we saw working in children s community services. At the immunisation session we attended a local school, a pupil was distressed and anxious about having the injection. The nurse responded with sensitively and with care and compassion. Health visitors were careful to provide information that was fully understood by the mother and they were responsive to the needs of the mother. For example, we saw a health visitor helping a young mother with the procedure for getting help with the damp in her home. One mother said, My health visitor is lovely, I wouldn t change her for the world. Another mother said, I rely on the nurses and depend on their support. I would not be able to manage without them. Dignity and respect During the immunisation session we attended, a pupil had to remove their shirt so the nurse could access the injection site.the student nurse was called to hold a jumper over the pupil in order that their dignity and privacy was maintained. The National Child Measurement Programme session that we observed was handled sensitively by the school health assistant so that the children, whose parents may have opted out of the programme, were not identified in the screening session. In addition, any measurements requiring a follow-up were not disclosed to the children. Confidentiality was maintained and the emphasis was on healthy eating and lifestyle choices. Patient understanding and involvement The team leader for the Diana children s community nursing team informed us of a patient evaluation audit that had been undertaken in 2010 and which had influenced the redesign of the service at that time; further changes were still in progress at the time of the inspection. This evaluation identified that chronically sick children required holistic packages of care delivered by nursing staff and parents working in partnership. The team leader said that having a named nurse and continuity of care promoted patient understanding and involvement. The patient includes the child and the family. We observed a physiotherapist engaging a patient to discuss and agree the treatment plan. Patient involvement was difficult as the patient was reluctant to engage. The physiotherapist persisted and achieved some engagement with the history, assessment and the treatment plan. We saw a member of the speech and language therapy team engaging with a mother and her child on issues around feeding and swallowing. The discussion was around the current problems and some small improvements. The mother was given reassurance and encouragement. Goals and plans were set and agreed jointly with the mother. We witnessed a caring approach from the nurse working a Barton Moss, a secure care centre. The approach was empathetic and the boys at the centre were encouraged to give their feedback about the service and were listened to. Emotional support We visited a patient with complex health needs in their own home. We visited with a nurse from the Diana team. The mother of this patient said I don t know what I would do without the nurses. My main support is through the nursing staff and from our GP 16 Community health services for children, young people and families Quality Report 27 March 2015

17 Good Are Community health services for children, young people and families caring? Promotion of self-care The work we saw in the diabetes service was all about encouraging the promotion of education, self-care and the careful management of diabetes. The visit we attended with the diabetes nurse demonstrated how the responsibility for the management of the diabetes was with the patient and their family with the support of the nurses. Similarly, we witnessed the work of the speech and language therapists and the occupational and physiotherapists who were working with patients and their families to encourage rehabilitation. 17 Community health services for children, young people and families Quality Report 27 March 2015

18 Requires Improvement Are Community health services for children, young people and families responsive to people s needs? By responsive, we mean that services are organised so that they meet people s needs. Summary We found that the services were not always planned and or delivered to meet the needs of patients and their families. We found that whilst structures had been redesigned in response to the people s changing needs and the need to manage resources between universal and targeted services, further improvements were required. We found that there was good access to translation services and an understanding of the need to respond to cultural differences in the area. There was an open and transparent approach to complaints and they were treated as an opportunity for shared learning and service improvement. Detailed findings Service planning and delivery to meet the needs of different people Physiotherapy appointments were 40 minutes for the initial assessment and then 40 minutes for a follow up appointment. However, a physiotherapist we spoke with said that the team felt that these initial appointments were not long enough to write a full programme. An audit was undertaken to study this in more detail and, as a result, the initial appointment was changing to 60 minutes with a 30 minute follow-up. Whilst the Diana team felt that they were delivering the care that was needed, one member of the team said that they would like more time, more staff and better quality. Diabetes clinics were being offered on a Monday evening with separate clinics for teenagers on a Wednesday and there was a paediatrics clinic on a Friday. The nurses we spoke with said that they had received awareness training to help them work effectively with the local Jewish community. When they visited an orthodox member of that community they took care to respect some of the practices such as wearing skirt rather than trousers. We attended a school nurse core group and child protection meeting where interpreters were present and used appropriately to improve communication with the family. We spoke with two young people attending a health assessment as part of their work with the youth offending service. The young people said that they valued the assessment and one said it was good to know that there is nothing wrong with me. The school nurses ran a drop-in clinic at one of the local high schools for young people aged This was a weekly event and we observed that it was well attended and the service was well received in the school. Areas covered with students included diet advice, low mood, and sexual health. We were informed at the focus group that too many children were coming to the Panda unit for childhood illnesses because families were not able to access their GP. In this situation patients were deflected by a system of assessment and this prolonged the patient journey as they were diverted back to the GP. In this situation an incident report was created on the date reporting system. The children s senior community team and two school nurses said that they did not have a system to identify children who were not in mainstream education. They said that sometimes we just come across them opportunistically. They said that they may be identified via the GP service but this was not always reliable. They were working on developing a more dependable system. Access to the right care at the right time We were informed that there were waiting lists for therapy. The average wait for a physiotherapy appointment was 3 weeks and 2 weeks for an urgent appointment. We were told that the frequency which patients were failing to attend appointments in some therapies was high. For example, it was at 20% for musculoskeletal patients receiving physiotherapy. We asked what the trust was doing to reduce this rate and they informed us 18 Community health services for children, young people and families Quality Report 27 March 2015

19 Requires Improvement Are Community health services for children, young people and families responsive to people s needs? that they telephoned patients the day before to remind them about the appointment. They also had a policy that, if a patient failed to attend two appointments without reasonable cause, they would be discharged and a new referral would be required. Whilst there was a shortage of staff in the Diana team the team leader said that we have never closed to referrals and never reduced our service hours. These hours were 8.00 am to 8.00 pm, 7 days a week and 365 days a year. The diabetes service was meeting its target where a new patient must be discussed by a senior member of the team within 24 hours of referral. We spoke with a member of the speech and language therapy team and they said that had a waiting list of 2 to 3 months and they currently had ten patients on the waiting list. They said that demand exceeds capacity and they need more staff. At the Barton Moss secure care centre there was a structured assessment for all boys admitted. The Comprehensive Health Assessment Tool: Young Offenders Service (CHAT) had five components that, when fully implemented, were to be delivered within specified times. For example, each new boy admitted should be seen by the nurse in the unit within two hours of admission and a physical and mental health assessment should be completed within a maximum of 14 working days of admission. It is also important to note that the comprehensive health assessment tool for young offender services continues to be rolled out nationally. The trust was providing 18 hours of nursing support to the Barton Moss secure care centre with each week in order that the CHAT: YOS programme could be delivered. Whilst not every boy could be assessed within 2 hours of admission,each young person was seen within 1 working day. The service had attempted to recruit to provide additional resources to support the CHAT: YOS programme but had been unsuccessful. We were informed that NHS England had been informed of the situation and it had been recognised that the CHAT process was not fully operational on either a local or national level as yet. We were informed that the Trust had decided not to compete to provide the nursing service after March Discharge, referral and transition arrangements The trust had a post to facilitate transition between services. This post holder was also responsible for training health care assistants in use of the equipment for complex care packages. Referral into the different community children s services was mainly via the GP, the Panda Unit, other community services, local district general hospitals, Royal Manchester Children s Hospital and local schools. We spoke with a senior nurse in the acute unscheduled care team. This team helped to manage the transition arrangements from the Panda unit back into the community. We were informed that the service was aim for continuity of care from hospital to home. Complaints handling and learning from feedback The Assistant Director of Nursing and Allied Health Professionals for Children s Services told us that all complaints were dealt with in a timely way and involved the patient advice and liaison service at the earliest stage.complaints were discussed at service and directorate meetings and learning shared. We were informed that just three complaints had been received in the service since April 2014; one involving the Panda Unit, another regarding communication within the health visitor team and finally one involving equipment failure within the CCN service. The complaints had been or were being resolved. The Assistant Director of Nursing and Allied Health Professionals for Children s Services said that if the service itself identified an error with practice of lapse in quality, even where there had not been a complaint, they would investigate the matter. The Assistant Director of Nursing and Allied Health Professionals for Children s Services said that they would inform the patient or the family that they were investigating as they felt it was part of openness and transparency. We asked if this had happened and the Assistant Director of Nursing and Allied Health Professionals for Children s Services was able to give an example involving a child with special needs and whether they should have immunisation in school or at a medical centre. 19 Community health services for children, young people and families Quality Report 27 March 2015

20 Good Are Community health services for children, young people and families well-led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. Summary We found evidence of a clear vision and strategy where the top priorities for the trust were safe: clean: and personal. Staff working in community children s services were committed to their work and understood the priorities of the service and their individual teams. The integration of community services into the trust was on-going. There was strong support for the local leadership and staff appreciated the high levels of honest communication. Staff were engaged in the redesign of the services and restructuring of the service overall. Detailed findings Vision and strategy for this service Staff we spoke with in the service had a good knowledge of the overall trust vision and strategy. A nurse in the acute unscheduled care team said it is about safe, clean and personal about being the best trust and somewhere you would want to come for treatment and to work. Overall staff were aware of the aims of community children s service and were pleased to be part of the Salford Royal. One member of staff said, It has improved our profile. We spoke with staff who were committed to providing care for children in the community and, wherever possible, avoiding hospital admission and enabling early discharge from hospital where appropriate. They were also involved in the delivery of specialist support and advice and co-ordination of packages of care to enable children to stay in the community. Staff felt supported by management and commented that they always tried to listen to the wishes of the team, with respect to which base they wished to work in and how long they had worked with various colleagues. The staff we spoke with were aware of the recent restructuring proposals and the new organisation of teams into universal and targeted services. Two teams told us how they had suggested changes to the structure and how these had been discussed and accepted, this was the unscheduled care team and youth services. Governance, risk management and quality measurement The senior operations manager informed us that the service had 33 live risks all with action plans and controls. The service reported 20 risks that they had classified as medium or serious. The risks had been developed from incidents reported through the date reporting system. Each of the risks had a review date. The three top risks had been identified and were: dependency on paper records for patients working with a range of services; reliability of care packages provided for children with complex care needs due to staffing levels and unassigned patient files during transition between services. Risks, complaints and incidents were managed through a hierarchical process involving a children s governance board, divisional governance board and executive board. There were also separate risk registers for the individual services which fed into the directorate and divisional risk register. For example, we saw the risk register for the Diana children s community nursing team had highlighted an issue with staff shortages, due to vacancies, sickness absence and maternity leave, and the risk for patients of not being able to receive the nursing and support services which would enable them to remain at home. This issue had been escalated to the executive board. Leadership of this service There were weekly and monthly meetings for staff at all levels in the service. There was support for the leadership of the trust and of the community children s service. We were informed that members of the senior leadership conducted a walkabout. There had recently been a safety focus and 20 Community health services for children, young people and families Quality Report 27 March 2015

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