Good Norfolk Community Health and Care NHS Trust · improvement. For example medicines management, nursing documentation and care planning. There was a Trust wide Quality Improvement

Core services inspected CQC registered location CQC location ID

Community Health Services forAdults

Provider Services Trust HQ RY3X3

Community Health InpatientServices

Colman HospitalOgden CourtNorwich Community HospitalDereham Community HospitalSwafham Community HospitalKelling Hospital

RY311RY386RY312RY319RY386RY335

End of Life Care Colman HospitalOgden CourtProvider Services Trust HQ

RY311RY386RY3X3

Community Health Services forChildren Young People and Families

Little Acorns, Residential RespiteSquirrels, Residential RespiteProvider Services Trust HQ

RY310RY352RY3X3

Community Dental Services Provider Services Trust HQ RY3X3

This report describes our judgement of the quality of care at this provider. It is based on a combination of what wefound when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us frompeople who use services, the public and other organisations.

NorfNorfolkolk CommunityCommunity HeHealthalthandand CarCaree NHSNHS TTrustrustQuality Report

Trust HQElliot House130 Ber StreetNorwichNorfolkNR1 3FRTel: 01603 697300Website:www.norfolkcommunityhealthandcare.nhs.uk

Date of inspection visit: 16-18 September 2014Date of publication: 19/12/2014

Good –––

1 Norfolk Community Health and Care NHS Trust Quality Report 19/12/2014

RatingsWe are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings willalways be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring dataand local information from the provider and other organisations. We will award them on a four-point scale: outstanding;good; requires improvement; or inadequate.

Overall rating for community healthservices at this provider Good –––

Are services safe? Requires Improvement –––

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 4

The five questions we ask about the services and what we found 5

Our inspection team 9

Why we carried out this inspection 9

How we carried out this inspection 9

Information about the provider 9

What people who use the provider's services say 10

Good practice 10

Areas for improvement 11

Detailed findings from this inspectionFindings by our five questions 13

Action we have told the provider to take 51

Summary of findings


Overall summaryWhen aggregating ratings, our inspection teams follow aset of principles to ensure consistent decisions. Theprinciples will normally apply but will be balanced byinspection teams using their discretion and professionaljudgement in the light of all of the available evidence.

We found that the provider was performing at a levelwhich led to a judgement of "Good."

Summary of findings


The five questions we ask about the services and what we foundWe always ask the following five questions of services.

Are services safe?We identified some of concerns regarding the safety of services, andjudged this to require improvement.

Whilst most of the areas we visited were well maintained and clean,we had concerns about Squirrels residential respite unit forchildren. We found it to be in need of maintenance and decoration.Some of the equipment in use was not suitable for the needs ofchildren using the service. The Trust was already aware of the needto refurbish this unit.

Most staff we spoke with demonstrated little or no understanding oftheir responsibilities regarding the Mental Capacity Act 2005.

We found a number of concerns in relation to the management ofmedicines in the inpatient areas. Medicines were not always storedappropriately or securely and there were ineffective stockmanagement systems in place.

The majority of staff were aware of and had access to the Trust’sonline incident reporting system. We saw evidence of learning fromincidents to improve practice.

There were effective safeguarding policies and procedures whichwere understood and implemented by staff. Staff were aware of theTrusts’ whistleblowing procedures and what action to take. TheTrust could not be assured that all faith leaders had been subject toDBS checks.

The Trust had a ‘Safer Staffing Tool’ system to record the numbers ofstaff on duty on each ward/team. There was an escalation policy inplace if the wards were short staffed. We saw the Trust were activelytrying to recruit staff and the impact of this had started to be felt insome areas.

Requires Improvement –––

Are services effective?With the exception of the adult inpatient areas, we judged theeffectiveness of services to be good.

On some of the wards we found a lack of personalised careplanning. Where care plans were in the place they were notindividual and lacked detail. In some care records there were nocare plans to describe how patient’s needs were to be met. The lackof robust care plans meant patient needs may not have been met.

Good –––

Summary of findings


We found patient care and treatment was based on evidence basedguidelines. The Trust had removed the use of the Liverpool CarePathway and implemented interim guidance called, “Caring forpeople in the last days and hours of life.”

A well regarded mandatory training programme was available.Although the Trust was not meeting its planned targets it had set,over 86% of staff were up to date with mandatory training. New staffreceived an induction to ensure they were able to undertake theirrole safely and effectively.

Staff were appropriately qualified, skilled, experienced andcompetent to carry out their roles safely and effectively and in linewith best practice. Specialised dental treatment was undertaken atdedicated centres with the appropriate trained staff. There waseffective multi-disciplinary working to meet patient needs.

Are services caring?Throughout our inspection staff spoke with compassion, dignity andrespect regarding the patients they cared for. We found all of theservices we inspected to be providing compassionate care.

In the children’s service, staff were passionate about providing carecentred on the needs of children, young people and their families.They recognised the importance of engaging with families in orderto understand their situation and the support they required.

Community end of life, inpatient and adult community services werealso delivering a compassionate service which also promotedpatients privacy and dignity. We observed positive interactionsbetween staff and patients in their homes and in every unit weinspected.

People were overwhelmingly positive about the care and treatmentreceived in the community dental service. We found staff werecommitted to providing a specialised dental service for patients.Patients were given clear explanations during pre- assessmentavoiding the use of technical terms and providing diagrams toenhance the patients understanding of planned treatment.

Good –––

Are services responsive to people's needs?We judged the responsiveness of the services as good with theexception of the adult community service which we judged asrequiring improvement.

The Trust monitored the responsiveness of all of its services andmonthly reports were provided to the Trust board. The majority ofpatients were getting a responsive service. The Trust achieved the

Good –––

Summary of findings


18 week referral to treatment target (RTT) with performance of 98%in July 2014. Musculo skeletal (MSK) physiotherapy, podiatry surgeryand specialist nurses epilepsy management were not meeting the18 week referral to treatment time.

Staff told us it was more difficult for patients to access the strokepathway if they didn’t start in it and we saw how this had proveddifficult for one patients who had suffered a stroke. The pathway isowned by the a different NHS Trust and Norfolk Community Healthand care Trust work in partnership with them.

We saw leaflets on how to make a complaint and contact PALS wereavailable on wards and in reception areas. The Trust also kept arecord of all compliments received. Over a thousand complimentswere recorded during 2013/14. Staff told us there was activereflective practice and learning following complaints.

Aspects of the ward environments were dementia friendly. Mostinpatient wards had garden areas with seating where patients andtheir relatives could sit outside. We noted that the wards at NorwichCommunity hospital did not have this space available.

Therapy staff did not work weekends but healthcare assistants hadreceived training to work on exercises with patients. Staff told usthat some patients were admitted to the inpatient wards late atnight. The reasons were generally outside of the Trust’s control butthey did affect patient care.

The service planned and delivered care to meet the needs ofchildren, young people and families. We saw good examples of howservices had developed based on the feedback of patients whichincluded extended service opening times. Health visiting teams didnot always work flexibly and this was resulting in resources beingwasted because patients were not attending appointments.

Are services well-led?We judged the provider as a whole to be well led but the leadershipin the inpatient service required improvement.

There was an effective governance system in place which was madeup of a number of committees that reported through the Trustboard. We found evidence that although quality measurement wastaking place, action was not taken to address the areas identified forimprovement. For example medicines management, nursingdocumentation and care planning.

There was a Trust wide Quality Improvement Strategy in place whichset out the vision and approach to quality for 1014-2016.In addition

Good –––

Summary of findings


there was also an Organisational Development Strategy in place thatwas developed from engagement of staff. The Trust had beenthrough a transformation programme for community services andstaff told us they had been involved in the consultation.

The Trust board received a monthly Integrated Performance Reportwhich rated key risks for the organisation.

Local risk registers were maintained but we found some risks werenot reviewed in a timely manner and had been on the register forsome time. The number of risks on the individual registers variedconsiderably. The Trust took part in a planned Internal Audit reviewof the board assurance framework and risk management controlsduring September 2014. The review identified there were no risks inthe systems and processes for risk management, but there wereseven risks relating to the operating effectiveness of the systems andprocesses. The Trust were already addressing the areas identified inthe review at the time of our inspection and were making goodprogress.

Summary of findings


Our inspection teamOur inspection team was led by:

Chair: Dorian Williams, Executive Nurse and Director ofGovernance, Bridgewater Community Healthcare NHSTrust

Team Leader: Carolyn Jenkinson, Head of HospitalInspection, Care Quality Commission

The team included CQC inspectors and a variety ofspecialists: health visitor, school nurse, GP, medicalconsultant, nurses, specialist palliative care nurse,university lecturer, therapists, social worker, dentist,senior managers and experts by experience. Experts byexperience have personal experience of using or caringfor someone who uses the type of service we wereinspecting.

Why we carried out this inspectionNorfolk Community Health and Care NHS Trust wasinspected as part of the second pilot phase of the newinspection process we are introducing for community

health services. The information we held and gatheredabout the provider was used to inform the services welooked at during the inspection and the specificquestions we asked.

How we carried out this inspectionTo get to the heart of people who use services’ experienceof care, 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?

The inspection team always looks at the following coreservices at each inspection

1. Community services for children and families – thisincludes universal services such as health visiting andschool nursing, and more specialist communitychildren’s services.

2. Community services for adults with long-termconditions – this includes district nursing services,specialist community long-term conditions servicesand community rehabilitation services.

3. Services for adults requiring community inpatientservices

4. Community services for people receiving end-of-lifecare.

In addition, the inspection team also looked atcommunity dental services.

Before visiting, we reviewed a range of information weheld about Norfolk Community Health and Care NHSTrust and asked other organisations to share what theyknew. We carried out an announced visit on 16, 17 and 18September. During the visit we held focus groups with arange of staff who worked within the service, such asnurses, and therapists. We talked with people who usedservices. We observed how people were being cared forand talked with carers and/or family members andreviewed care or treatment records of people who usedservices. We carried out an unannounced visit on 2October 2014 to three of the inpatient hospitals.

Information about the providerNorfolk Community Health and Care NHS Trust delivers arange of community-based services to the people of

Summary of findings


Norfolk. The Trust provides a range of services, whichinclude community hospitals, sexual health, communitydentistry, services for children and families, therapies,community nursing and specialist nursing services.

The Trust has a total of 12 registered locations with theCare Quality Commission. It delivers services in people’shomes as well as from the following main sites. There arenine locations with inpatient beds.

• Norwich Community Hospital• Kelling Hospital• Swaffham Community Hospital

• Colman Hospital• Ogden Court Community Hospital• Benjamin Court• Dereham Hospital• Cranmer House• Little Acorns• Squirrels• North Walsham Hospital

The Trust employs 2,250 whole time equivalent staffworking out of a range of bases across Norfolk with apopulation of 882,000 people.

What people who use the provider's services sayWe received a range of comments from patients and theirrelatives, both through comment cards as well as thosewe spoke with during the inspection. The comments wereoverwhelmingly positive, with patients commenting onthe quality of staff, high standards of care they hadreceived and timeliness of accessing the right care at theright time.

There is no current requirement for community Trusts toadopt the Family and Friends Test (FFT), but Norfolkimplemented the FFT in community services in July 2013.The FTT is a national initiative and aims to ensure patientexperience remains at the heart of the NHS so membersof the public can see what patients think of local services,and that service quality is transparent to all. A simplescore is generated by taking the proportion ofrespondents who would be ‘extremely likely’ torecommend the service, minus the proportion of those

who say they are ‘neither likely nor unlikely’, ‘unlikely’ or‘extremely unlikely’ to recommend it. Patients are thenencouraged to comment on why they gave that score,enabling services to understand what really matters tothem.

The national target is for 75% positive responses and 15%sample size. The Trust had not yet supplied the samplesize. Between July 2013 and March 2014 the Trustreported an overall score of 79% positive responses, thelowest result being 72% in July 2013 and the highestbeing 86% in March 2014.

There have been 140 comments about the Trust on thepatient opinion website, with 128 of these being positivein nature. Of the negative reports, six were regardingstaffing levels and waiting times, three were around staffattitude and three regarding poor care.

Good practice• The care and compassion shown to patients by staff in

all of the areas we inspected.• The service used an Electronic Palliative Care

Coordination System to support the co-ordination ofcare so that people’s choices about where they die,and the nature of the care and support they receivedwas respected and achieved wherever possible.

• 92% of patients died in their preferred place of care.• The Trusts mortality review process which was led by

the medical director was a proactive initiative for acommunity service.

• The level of multi-disciplinary and multi-agency teamworking within the end of life service and children’sservice was exceptionally good.

• A ‘Silver Call’ daily multi-agency discharge planningteleconference had been introduced in the WestLocality. This promoted patient discharges at theearliest stage possible and aimed alleviate any barriersto discharges taking place.

• A daily capacity reporting tool had been developedwhich enabled the managers in the Trust to have an ‘at

Summary of findings


a glance’ overview of the pressures staff were underand it has helped to provide managers with theinformation they need to be able to divert resourceswhere they were needed most.

• The Trust had a ‘Safer Staffing Tool’ system to recordthe numbers of staff on duty on each ward. The Trusthad assessed and established safe staffing levels forolder people’s wards The Trust provided informationpublicly on it’s website on how staffing levels werebeing managed and reported on the staffing levelsbeing achieved.

• There was an outstanding approach to thedevelopment of pathways within the school nursingteam. We noted that practice was already based onNICE guidance but that work had begun on thedevelopment of a suite of evidence based pathwaysfor the team.

• The Starfish plus team within children’s services wasan excellent example of a responsive service;responding to patient referrals in the same day andproviding intensive care and support for children andtheir families.

• The ability of the community dental service to adaptcare and treatment in order to meet people’sindividual needs was very good.

• The Trust was an integrated provider of health andsocial care working with Norfolk County Council.Following a Section 75 of the NHS Act 2006, the Trusthad agreed a joint management structure for healthand social care. Health and social care professionalswill be co-located in teams and will share access tohealth and social care records as well as sharingreferral processes and case management.

Areas for improvementAction the provider MUST or SHOULD take toimproveAction the provider MUST take to improve

• Ensure all clinical staff understand how the MentalCapacity Act applies to their work and develop amechanism to monitor compliance of the MCA.

• Carry out a review of medicines management toensure there are suitable arrangements in place tosafely manage medicines.

• Ensure that all patients have a clear care plan in placewhich takes account of their individual needs andensures their welfare and safety.

Action the provider SHOULD take to improve

• Carry out a review of the Squirrels residential respiteunit and ensure this is fit to care for the children whoaccess the service.

• Carry out a risk assessment of faith leaders who havenot been subject to DBS checks.

• Review the deployment of volunteers working in theday unit to ensure they know what to do in the eventof an emergency.

• Increase the number of nursing staff who participate inclinical supervision.

• Review the need for training for staff on advanceddecision making.

• Review clinical leadership within inpatient settings andensure all clinical leaders have opportunities forleadership development programmes.

• Increase the number of nursing staff who participate inclinical supervision.

• Ensure that missed and cancelled patientappointments, particularly within the health visitingand speech and language therapy teams, areappropriately reported and monitored. And wherepoor service provision or patient outcomes areidentified take action to improve.

• Review the implementation of the Lone Working Policywithin children’s services.

• Review the local audit and patient outcomemonitoring initiatives in place within children’sservices.

• The Trust should review the arrangements in place forthe transition of children between children’s serviceand adults services.

• Review the responsiveness of the health visitingservice so that services are as flexible as possible.

• Review the governance arrangements within Children’sServices and ensure all staff understand theirresponsibilities in relation to reporting, monitoringand analysing incidents and also the reporting andreview of risks.

Summary of findings


• Continue to work with commissioners of the service toconsider the impact that current service gaps andensure services are responsive to patient need. Thisshould include, physiotherapy, podiatry, children’s andadults speech and language therapy, epilepsy andLymphoedema services.

• Develop a process to monitor access to services thatare not part of RTT reporting targets such as familyplanning services.

• Work with commissioners to review access to thestroke pathway for patients who have not started onthe pathway when they first suffer their stroke.

• Continue the action already in place to improve thestaffing levels in the service.

• Carry out an audit to review the Trust performance inrelation to the continuity of nursing staff within thecommunity nursing service.

• Review the bedroom doors at Ogden Court to ensurethey would be safe in the event of a fire.

• Review the storage of cleaning equipment to ensure itis not left in unsecured areas.

• Review how patients meals are stored in the wardrefrigerators.

Summary of findings


* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatoryabuse

Summary of findings

We identified some of concerns regarding the safety ofservices, and judged this to require improvement.

The majority of staff were aware of and had access tothe Trust’s online incident reporting system. We sawevidence of learning from incidents to improve practice.Whilst most of the areas we visited we well maintainedand clean, we had concerns about one of the children’sresidential respite units We found it to be in need ofmaintenance and decoration and some of theequipment in use was not suitable for the needs ofchildren using the service. The Trust was already awareof the need to refurbish this unit.

There were effective safeguarding policies andprocedures which were understood and implementedby staff. Staff were aware of the Trusts’ whistleblowingprocedures and what action to take. Most staff we spoke

with demonstrated little or no understanding of theirresponsibilities regarding the Mental Capacity Act 2005.The Trust could not be assured that all faith leaders hadbeen subject to DBS checks.

We found a number of concerns in relation to themanagement of medicines. Medicines were not alwaysstored appropriately or securely and there wereineffective stock management systems in place.

The Trust had a ‘Safer Staffing Tool’ system to record thenumbers of staff on duty on each ward. We found someinpatient wards were staffed by lower levels of staff thanwas planned. The Trust had an escalation policy inplace if the wards were short staffed. We saw that theTrust were actively trying to recruit staff and the impactof this had started to be felt in some areas.

Regulation 13 Management of medicines

How the regulation was not being met:

NorfNorfolkolk CommunityCommunity HeHealthalthandand CarCaree NHSNHS TTrustrustDetailed findings

ArAree serservicviceses safsafe?e?By safe, we mean that people are protected from abuse * and avoidable harm



The registered person was failing to protect peopleagainst the risks associated with the unsafe use andmanagement of medicines.

Regulation 18 Consent to care and treatment


The registered person did not have suitablearrangements in place for obtaining and acting inaccordance with, the consent of service users in relationto the care and treatment provided for them.

Our findingsIncidents, reporting and learningThere were 318 serious incidents requiring investigation(SIRI) at Norfolk Community Health and Care NHS Trustbetween June 2013 and May 2014.

In July 2014, there were 36 open SIRI’s that were in theprocess of being investigated. The Trusts performance inrelation to the investigation of SIRI’s was generally goodwith 95% of 3 day reports and 100% of 45 day reportssubmitted to the Trusts commissioners.

During 2013/14 the Trust implemented a pressure ulcervalidation group to review the entire reported grade threeand four pressure ulcers. The aim was to determine if theulcer was avoidable or unavoidable. Available pressureulcers in the inpatient units are those that developedwhere there were no appropriate assessment andtreatment/prevention plans in place. In July 2014 therewas one avoidable pressure ulcer in the inpatient units.The Trust had revised their prevention and management ofpressure ulcers policy and the reduction of avoidableulcers had been a priority for the Trust. All grade three andabove ulcers were subject to a root cause analysisinvestigation and we saw evidence that staff had receivedlearning from the outcomes of these.

Staff were aware of and had access to the Trust’s onlineincident reporting system. This allowed staff to report allincidents and near misses where patient safety may havebeen compromised. Staff were aware of what should bereported and were encouraged to do so.

We saw an example of an incident that had been classifiedas serious which had occurred in one of the day units. Wesaw evidence that the incident had been discussed at theclinical governance meeting and a root cause analysis(RCA) investigation took place. There were actions forlearning and development and training was implemented

as a result of this. Staff told us trends in incident reportingwere analysed and training was organised wherenecessary. This meant steps to learn from incidents werebeing taken.

The Trust monitored its performance in pressure ulcers,venous thromboembolism (VTE), falls with harm andcatheters and new urinary tract infections using the NHSSafety Thermometer. This is a national improvement toolused for measuring, monitoring and analysing patientharms and 'harm free' care. The provider’s overall rate forharm free care between June 2013 and May 2014 wasbelow (better than) the England average during the entire11 month period.

We found some evidence of learning from incidents withinthe inpatient service but this was not well embedded.Some staff told us they received feedback if they reportedincidents, but some staff could not recall this. Some staffmeetings recorded where lessons had been learned or thefindings of root cause analysis investigations had takenplace, but this was not consistent for all wards. Whereincidents were reported in the children’s service we sawlearning took place. For example, we noted that individualincidents were discussed at local team meetings and areasfor improvement were identified. One member of staff wasable to describe an incidence of verbal abuse and how theyfed back learning at a meeting. Within the adult communityservice there was openness and transparency when thingswent wrong. Themes from incidents were discussed atlocality Quality and Governance meetings which were heldmonthly. The information was cascaded down to frontlinestaff. For example, the minutes of the meeting on 31 July2014 evidenced a manager being designated to look atpressure ulcer incidents and gave the results of root causeanalysis by the pressure ulcer validation team. This alsodemonstrated the Trust were learning from incidents.

Are services safe?By safe, we mean that people are protected from abuse * and avoidable harm



Cleanliness, infection control and hygieneThe Trust had an executive lead director for infectionprevention and control. In 2013/14, there were threereported cases of Clostridium Difficile against an annualceiling of five cases. All reported cases were subject to RootCause Analysis (RCA) to review lessons learned. There hadbeen no reported cases of MRSA bacteraemia since July2012.

Overall the standards of cleanliness and hygienethroughout the Trust were good with the exception ofSquirrels residential respite unit where we noticed somedusty and unkempt areas. We raised our concerns aboutthe Squirrels unit with the Trust during our inspection sothis could be rectified straight away.

Generally, staff demonstrated a good knowledge ofprocedures for the management, storage and disposal ofclinical waste, environmental cleanliness and prevention ofhealthcare acquired infection guidance. We saw that staffwore clean uniforms with arms bare below the elbow andpersonal protective equipment (PPE) was available for useby all staff. Staff in general were aware of Trust policies andprocedures and knew where to look for them on theintranet, including an awareness of the procedures tofollow in the event of needle stick incidents. However, wefound staff working in the blood clinic were not able to givean account of the steps to take in the event of a needlestick incident. The staff had no knowledge of post-exposureprophylaxis and were unable to show us the policy. Thisexposed staff and other patients to harm in the event of anincident and might create an infection control problem.

The Trust carried out ‘PLACE’ assessments (Patient LedAssessments of the Care Environment). Scores forcleanliness and condition, appearance and maintenanceof estates were below the England average. Teams of staffas well as patient assessors completed the assessments,with patients making up at least 50% of the team. Wefound all of the wards we visited to be visibly clean andtidy. We saw schedules and checks in place to record thatcleaning had been completed. When equipment wascleaned it was marked with stickers to confirm the date itwas cleaned. A range of infection control audits wereregularly undertaken using Department of Health tools.These included hand washing audits and commodecleanliness checks.

We saw that the wards we visited were clean, bright andwell maintained. Surfaces and floors in patient areas were

covered in easy to clean materials which allowed highlevels of hygiene to be maintained throughout the workingday. We saw throughout the clinical areas the general andclinical waste bins were covered with foot opening controlsand the appropriate signage was used. ‘I am Clean’ stickerswere placed on equipment including toilet seats, theresuscitation trolley and the fire evacuation trolley. Thisindicated they had been cleaned and were ready to beused.

We saw cleaning logs of toys within a clinic at St James,King’s Lynn had not been completed. We saw that the lastentry on the cleaning schedule for any toy was 2September 2014 which was 14 days prior to our inspection.It is important that toys are cleaned between patients inorder to avoid the spread of infection.

Community nursing staff told us they had adequatesupplies of sterile wound care packs in order to carry outdressings on patients wounds in their homes. Communitynurses were provided with hand hygiene gel to take aroundwith them.

Where there was a possibility that patients had infectionswe saw that side rooms were used to limit potentialinfections spreading. However at Kelling Hospital a sideroom was being used which did not have an en suitefacility. A dedicated toilet had been identified by a posterbut the patient had to cross a corridor by a nurses stationto access the toilet. We did not think the signage wouldnecessarily ensure that other patients would not use thetoilet. An alternative side room with an en suite toilet wasavailable but was not being utilised for this patient. Thismeant there was a risk of cross infection to patients andstaff.

The patient meals were supplied by an off-site cateringcompany and the meals were required to be stored infridges or freezers within the hospitals. At DerehamHospital, Ogden Court and Norwich Community Hospitalwe saw food supplies were stored in publicly accessibleareas in unlocked fridges and freezers. There was no riskassessment in place to consider and mitigate the risks oftheft, contamination or electric sources being switched off.

There were on site designated decontamination rooms inthe dental services for the cleaning and sterilisation ofinstruments at each of the clinics we saw. In one centre




several treatment rooms shared one decontaminationroom. We observed contaminated instruments weretransported between the treatment and decontaminationrooms in covered containers in line with best practice.

Staff were able to demonstrate and explain the proceduresfor cleaning and decontaminating dental instruments andequipment. Staff demonstrated an in depth knowledge ofHTM 01-05 (a guidance document released by theDepartment of Health to promote high standards ofinfection prevention and control). There were processmaps clearly displayed in decontamination roomsdescribing each stage of the decontamination process forstaff to refer to. We saw all sterilised instruments werestored in sealed pouches and date stamped. There werechecking systems in place to ensure supplies of sterilisedinstruments were in date. We saw records were maintainedof all the safety checks of decontamination equipmentundertaken on a daily basis to ensure equipment waseffective and fit for purpose prior to use.

Reusable sterilised instruments used, for example, inpodiatry clinics were traceable. This meant the equipmentcould be identified if there were any subsequent problemswith infection control.

The Trusts rate for new urinary tract infections amongpatients with a catheter has been above the Englandaverage since October 2013. Staff told us there was noongoing competency checks of how to catheterise apatient but there were clinical guidelines in place. TheTrust monitored all incidents of catheter acquired urinarytract infections and had an action plan to reduce these.

Maintenance of environment and equipmentWe were concerned about the environment andequipment at Squirrels which was a residential respiteunit. We saw that the sensory room in this unit was out ofuse and that equipment within it had not been maintained.The bathroom was extremely dated and there wasinsufficient space to manoeuvre wheelchairs and showertrolleys. The bath appeared to be an adult bath and it wasnoted this could be overwhelming for a child. The gardenwas large but inaccessible due to long grass, mole hills andlack of even surfaces to move wheelchairs. There was alarge broken and rusty swing and a summer house whichhad been turned into a storage unit and was not available

to the children to use for play. The kitchen was dated,poorly designed and difficult to keep clean due to lack ofstorage and surface space. There was a very small area inwhich to prepare gastroscopy feeds.

The environment overall needed improving. We noted thatseveral areas were cluttered with surplus furniture andequipment. All areas required decorating; severalbedrooms had large stickers which were peeling off thewalls and one bedroom was seen to have curtains withmissing hooks. These were ill-fitting and hanging off thecurtain rails. Staff told us that they did not have access toresources to fix basic maintenance problems and that therewas no regular maintenance to the building. We were toldthe grass had not been cut for two months.

We raised these concerns with the senior managementteam in the Trust. They provided us with evidence thatthey were aware of the need to refurbish Squirrels. TheTrust estate was transferred from a former NHSorganisation into Norfolk Community Health and CareTrust during 2013. Following the Trusts due diligence, theTrust carried out a survey of all of the estate. This identifiedthat Squirrels residential respite unit requiredrefurbishment. Capital funding was approved by the Trustboard in March 2014 with an initial plan to have the workcompleted by 31 March 2015. Following our inspection thework was brought forward and was due to commence inOctober and November 2014. We saw evidence the Trusthad obtained costings for the work from architect in July2014 which included refurbishment of the kitchen, toilets,bathroom, sensory room as well as the creation of a clinicroom.

The Little Acorns, residential respite unit was a contrast toSquirrels. It was in better decorative order, the garden andoutside areas were maintained and accessible, and thekitchen and bathrooms were appropriate to meet theneeds of children receiving care and support.

We saw some equipment which staff told us had beendecommissioned. At Norwich Community Hospital therewas no signage was in place to indicate a fridge had beendecommissioned. We found a urine sample in thisdecommissioned fridge which should have been sent tothe laboratory. The unlabelled sample had been in thefridge for four weeks. We also saw a bath which had beendecommissioned for a year but this was not clearly statedso there was a possibility staff would use this.




On Beech Ward at Norwich Hospital, staff told us thatstorage was limited. This meant a patient quiet room wasbeing used to store food and equipment and the room wasno longer used as a patient area. Staff reported to us therewere delays in getting broken equipment repaired. We weregiven examples of a bed being broken for four months. Wesaw one patient was using a chair which required repair.The tracking hoist at Swafham Hospital was out of orderwith no planned repair date. A bed on Beech Ward hadbeen broken for two months. We were given examples ofblinds requiring repair for three months on Alder Ward andat Ogden Court there were two blood pressure machinesthat were not working.

On an evening visit to Ogden Court we observed that somepatients had their bedroom doors open through choice.The doors did not have any closure devices to ensure theyclosed if the fire alarm was activated. We also observedthat some doors had damaged strips which were designedto reduce the spread of smoke should a fire occur. Thismeant there was a risk that patients would not besufficiently protected from the risk of smoke inhalationshould a fire break out on the ward. We asked the Trustsenior management team to review this potential risk.

At our two visits to Ogden Court we found unlockedcupboards containing chemical cleansers and productswhich were considered to potentially hazardous to healthas well as some sharp items. As these were unsecured theywere potentially accessible to patients who might beconfused. This meant there was a risk of harm to patients.

Patients were seen in a variety of settings within the adultcommunity and children’s service. Equipment and facilitiesin the majority of clinic settings that we visited were wellmaintained and met the needs of the children using theservice. Some outpatients’ clinics were in older buildingsand so the layout and facilities were not as suitable as themore modern community health centres. On the whole, theenvironment was clean and reasonably tidy anduncluttered. We noted, however, in the Norwich andCommunity Hospital outpatients’ clinic, one staff office wascluttered with large equipment and staff had to climb overthe equipment to get access to the computer terminals.This was a hazard to staff safety.

Staff working in clinics knew how to report faults or requestmaintenance. We saw risk assessments had been

undertaken in the clinic settings and steps had been takento control the risk. This meant staff were taking steps tomake the environment as safe as possible for both staff andpatients.

Medicines managementAt Priscilla Bacon Lodge, there were appropriate systems inplace to protect patients against the risks associated withthe unsafe use and management of medicines. Stafffollowed clear guidelines for prescribing medicines forpatients receiving end of life care. Records showedanticipatory planning was undertaken to reduce the risk ofescalating symptoms. Appropriate systems for the safecustody and checking of controlled drugs and syringedrivers were in place which reduced the risk ofinappropriate use.

In 2011, the National Patient Safety Agency recommendedthat all Graseby syringe drivers should be removed by theend of 2015. The Trust had undertaken this and theMcKinley syringe driver was now used throughout theservice. We observed a community nurse administeringmedicines through a syringe pump to a patient in theirhome. We saw the completed records which had beensigned and dated following administration.

Medicines were not always stored securely. At NorwichCommunity Hospital we saw medications stored openly ina treatment room which was accessible to housekeepers,porters and other non-clinical staff. Nurses told us this wasdue to a lack of lockable storage being available.

Staff on one ward told us that some bedside medicationlockers were not being used as the keys were lost. A masterkey which fitted the remaining bedside lockers which werein use was also on the lost bunch of keys. This meant therewas a risk that the lockers that were in use were potentiallyunsecure. This had not been reported as an incident.

At Ogden Court there was no lock on the treatment roomdoor. Medicines were locked in cupboards but there weresharps bins and other equipment in this open area whichhad the potential to cause harm to patients. At Pine Lodgethe treatment room door was propped open and unlockedcupboards were found with intravenous fluids and othermedicinal products such as enemas and suppositories. Wefound the medicines refrigerator on Beech Ward was not




locked when we visited as part of our unannouncedinspection. The room was accessible to porters,housekeeping staff and healthcare assistants who shouldnot have access to medicines.

During our announced inspection to Beech Ward we sawthat oxygen cylinders were dirty and highlighted this to amember of staff. On our unannounced inspection wefound this had not been addressed. Staff told us oxygencylinders were brought in from outside by porters but werenot cleaned. There was a risk that dust particles could beinhaled by patients who already had breathing difficulties.Staff on the wards were not clear who checked if theoxygen cylinders were full and there were no records toevidence that checks took place. One oxygen cylinder wasempty at the announced inspection and remained so atthe unannounced inspection.

We saw that there was some recording of fridgetemperatures but it was not consistent in all areas. Onsome wards nursing staff checked fridge temperatures andon other wards housekeepers were delegated this task. Wefound there were days when the temperatures were notchecked. On Beech Ward and Ogden Court thetemperature had exceeded the accepted maximumtemperature for a number of consecutive days but theprocedure to escalate this had not been followed. Ifmedicines are not stored properly they may not work in theway they were intended and they so pose a potential risk tothe health and wellbeing of the person receiving themedicine. In the community dental service we found therewere no daily temperature checks made of drugs stored inthe drug refrigerator. We also found a medicine that wasmarked to be stored in the fridge but was not. In additionto the fridge temperatures, there were no checks in place tocheck and record the temperature of the medicine storagerooms. Medicines are required to be stored at certaintemperatures and if the room exceeds the temperature themedicine can be affected. We saw a medication audit hadbeen completed in 2013 which had highlighted the poorrecord keeping of fridge temperatures. It was rated as a red(High) risk and an action plan for improvement had beenproduced. This meant the findings of the audit had notbeen acted upon.

Most medication administration records were fullycompleted or had occasional gaps apart from SwafhamHospital, where we found three out of the four medicationrecords we looked at had signatures missing to say that the

medicine had been given to the patient. This meant it wasnot possible to confirm if the patient had received theirmedicines or not. Some ward managers auditedmedication administration records and reported omissionof signatures as incidents but this was inconsistent and wasnot part of the Trust’s regime of audits. This meant therewere no Trust wide systems in place that were effective inidentifying medicines omissions. There were no specimensignatures available to ensure that a check could becompleted to establish who had given medications topatients. Some signatures were available in care recordswe were not assured that this included all the agency andbank staff who administered medicines. A specimensignature list of those staff could order medications waskept at the pharmacy.

The Trust policy described that controlled drug stockbalances should be checked weekly. Some wards checkedtheir controlled drugs daily, others weekly and on somewards there were no regular balance checks beingcompleted. At Pine lodge, Colman Hospital, we saw therewas a period of three weeks when no controlled drug stockbalances had been made. At Swafham Hospital we sawmedicines in stock where the pharmacy dispensing labelshad been removed. This meant that it could not beestablished where stocks originated from, the date theywere dispensed, or how they had been obtained.

At Swafham Hospital we found out of date medicines instock cupboards, this meant the stock checks wereineffective and there was a risk patients would be givenmedicines which were out of date.

The Trust obtained supplies of medicines and pharmacistadvice from two nearby acute Trusts. Staff told uspharmacists and pharmacy technicians visited the wardson a weekly basis. The nursing staff we spoke with were notclear on what the role and remit of the ward pharmacistwas.

The Trust had a self-medication policy in place but therewere no patients self-medicating on the wards we visited.

At Norwich Community Hospital staff used a small plasticbasket to transport medicines around the ward. At twoseparate visits to both wards we saw tablet strips and oddloose tablets out of their original packaging. This meantbatch numbers and pharmacy instructions/labels were notavailable. One ward manager told us that this procedurehad been risk assessed but this could not be located.




We observed that staff were kind and patient when givingmedicines to patients. They also stayed with patients toensure that medicines had been taken. “Do not disturb”red tabards were available to encourage staff were notdistracted when giving medicines. On Alder ward weobserved only one out of three staff wearing these whendoing medicine rounds. A staff member from another wardtold us they were not effective at ensuring staff were notdisturbed.

We had concerns about medication systems at Squirrels,residential respite unit. We found that the drugs cupboardwas overfilled with medications (these medications werebrought in by families) and it was felt this made checkingmedication details challenging. We noted that medicationswere prepared on a wooden cabinet which would bedifficult to keep clean. Whilst we noted transcribinghappened and was checked by two members of staff, thedesignation of the members of staff undertaking thetranscribing was unclear.

We found there was an inadequate system for themanagement of controlled drugs at the Squirrelsresidential respite unit. There was no controlled drugsregister and whilst at the time of our visit, no children wereprescribed such drugs, controlled drugs could be broughtin at any time. We were told that a pharmacist had notvisited the unit in the past year.

SafeguardingThere were effective safeguarding policies and procedureswhich were understood and implemented by staff. We sawthe safeguarding policies were easily available for staff. TheTrust had a whistle blowing policy and staff told us theywould feel able to escalate any worries they had. The Trusthad a safeguarding lead and staff knew who this was. Theygave us examples where they had sought advice if theywere unsure of how to handle situations. We sawsafeguarding procedures and incidents had beendiscussed at team meetings. Staff told us they feltconfident reporting concerns about safeguarding and wesaw evidence of this and how local procedures werefollowed. Staff also demonstrated their understandingabout safeguarding children and we saw the children’ssafeguarding policies were also available.

Staff demonstrated a good understanding aboutsafeguarding adults and could describe different types ofabuse and what action they should take. Safeguardingadults and children’s training was mandatory for all Trust

staff. Clinical staff were also required to complete level twosafeguarding training. According to the Trust’s annualquality report for 2013/2014, more staff received training insafeguarding adults and children. In March 2014, 80.82% ofstaff had been trained in safeguarding adults and 86.6% ofstaff had been trained in safeguarding children. Theclinical staff we spoke with all said they had receivedsafeguarding training.

The Trust had a chaplaincy service which was provided bythe Norfolk partnership and covered all of the NHS Trusts inNorfolk. The Chaplains had been subject to Disclosure andBaring Service checks (DBS) checks as part of therecruitment process. DBS checks help employers makesafer recruitment decisions and prevent unsuitable peoplefrom working with vulnerable groups.

The chaplains were supported by multi-faith leaders whoprovided spiritual support as required by patients. Therewere four faith leaders who were regularly called upon toprovide spiritual support; these include the Rabbi, Immam,and a Catholic priest. These religious leaders had been DBSchecked with their employing organisations. There couldbe requests for support from 30 multi-faith leaders whocould be called on from the community but the Trust couldnot be assured these faith leaders had been subject to DBSchecks.

The Norfolk chaplaincy planned to ensure all multi faithcontacts had a DBS check in place by December 2014. Untilthis time the Norfolk chaplaincy had a procedure in placeto ensure that a member of staff oversaw visits by faithleads when they are in direct contact with patients. If thepatient requested a private meeting with the faith lead thiswould occur in a room with a glass observation panel in thedoor and a member of staff would be within callingdistance. If the patient was seen on the ward they wouldhave their call bell to hand. We did not find evidence of thisrisk on the Trust risk register.

During our inspection to the inpatient wards we raisedsome concerns from a patient that had been brought toour attention. The Trust responded to this in accordancewith their own policies.

Records, systems and managementStaff could describe how people’s confidentiality wasprotected. There had been no incidents of breach ofconfidentiality in regard to patients’ records since 2011.




We looked at eleven sets of patient medical notes andreviewed the DNACPR (do not resuscitate in the event of acardiac arrest) documentation. Of the eleven sets of notesnine had DNACPR documentation in place; the other twosets of notes did not contain any DNACPR documentation.We raised this with the staff responsible for the patient’scare who were unsure why the DNACPR form was notreadily available

Of the nine documents we found all were located in thefront of the notes so they could be easily seen. They werelegible and had been completed by a senior doctor. Wesaw four of the nine forms had been discussed with thepatient as well as with family members. One had beendiscussed with family only as the patient was said to ‘lackcapacity’, however, we could not find the patients mentalcapacity assessment in the medical notes. We raised thiswith the staff responsible for the patient’s care who wereunsure why the mental capacity form was not readilyavailable.

The Trust’s audit of DNACPR’s in patients’ medical notes forMay 2013 showed that at Priscilla Bacon Lodge, 100% ofpatient’s notes had a DNACPR in them.

In most areas, we saw that records were secured in amanner which protected patients confidentiality. However,there were some risks to patient confidentiality at nurse’sstations at Swafham Hospital and Norwich CommunityHospital. Here we observed some notes on open workdesks, shelving and unlocked trolleys when no staff were inthe vicinity.

Staff handover information was provided to staff in printedformats. These reminded staff of the importance ofconfidentiality. At the end of each shift, there wereconfidential waste bins available for staff to dispose of therecords.

Our observations of records were mixed. Some recordswere well kept and there was clear and detailedinformation, other records were less clear and there wereomissions and gaps. We noted some of the photocopyingof documents, such as those used for risk assessmentswere of poor quality.

An electronic information data base, communication andbooking system was used by the majority of the children’s’services. We were told that significant improvements hadbeen made to this system since its implementation. Weheard of various projects which had been initiated and

completed by the staff to aid better information sharingand cross-working with other healthcare professionals.Staff agreed that more work was needed but that systemswere improving. It was noted however that in some areasconnectivity to the system could be problematic whichsometimes impacted on the workload of staff.

We looked at staff records within the dental service andsaw appropriate checks had been completed prior toemployment such as checking professional registrationand disclosures to ensure people were cared for by staffwith the appropriate qualifications and who were fit foremployment.

Paper records were stored securely in clinics and healthcentres. We saw community nursing and administrativeoffices had computer terminals as well as paper records.There were key coded locks on the office door foradditional security and electronic records were protectedby password access. Generally, records were storedsecurely in the inpatient areas we visited.

The Trust’s compliance with the Department of HealthInformation Governance toolkit was assessed as 76%,which was rated as satisfactory. Information governancewas included in the two day mandatory trainingprogramme for staff. The training highlighted awareness ofhow to prevent breaches of confidentiality and unwanteddisclosure of confidential information.

Lone and remote workingWe asked about the lone worker policy and were told thatat present the Trust were piloting a lone worker devicewithin the end of life care service. There was a centrallyheld diary for the Palliative Specialist Nurses and the teamswere to telephone into base at the end of each day.

We spoke with a community nurse who often worked inisolation said she knew there was a lone worker policy butstated that this was not always followed in the community.We also spoke with another community nurse about thelone working policy, she said she was aware there was apolicy. The nurses had informal arrangements to check oneach other but there did not appear to be a structuredarrangement as per the Trust policy.

One team of community staff told us they phoned eachother if they were late getting back to the office and twotherapists who worked closely together were in constantcontact with each other daily to update themselves inregard to home visits. We were told staff also used text




messaging to report their whereabouts and to confirm theyhad returned home safely. Staff said this worked well forthem and they felt safe using this system. However, notevery member of staff felt the lone working arrangementswere enough to make them feel safe, especially whenworking on dark evenings in areas where they feltvulnerable. Community nursing staff had access to a workmobile phone.

There were also inconsistencies in how the lone workingpolicy was applied throughout the children service. Somemembers of staff told us that they relied solely on a diarysystem so that other members of staff were aware of wherethey were. Other members of staff told us that had set up abuddy system so that each day members of staff wouldcontact each other to let them know they were safe at theend of the day. When we consulted the Trust’s LoneWorking Policy we found that it said that diary/movementsheets should be in place and where staff worked outsidenormal hours, arrangements should be made for thatmember of staff to make contact with a manager/colleaguein order to let them know they were safe. We noted this wasnot always happening.

Assessing and responding to patient riskWe spoke with two volunteers at the Priscilla Bacon LodgeDay Hospital known as The Rowan Centre Day Unit whohad been volunteering at the unit for the past 12 years. Thevolunteers expressed concern that they were left alone withthe patients for about an hour while the staff all attended astaff meeting. They were unsure what to do in case of anemergency, although one volunteer was aware there werepanic buttons and another volunteer told us they wouldrun to the office where the meeting was being held to gethelp.

Staff used an early warning system to record routinephysiological observations such as blood pressure,temperature and heart rate. These were known as ‘earlywarning scores’, and were a recognised tool used to identifywhen patients were deteriorating. We saw where patientswarning scores had escalated, staff had taken suitableactions to seek medical advice.

There was a standard range of risk assessments availablewhich staff completed. This included moving and handling,bedrails, tissue viability and malnutrition screening. Inmost care records we looked at these were completed andupdated but we did find care records within the inpatientareas where all of the expected risk assessments were not

in place. For example one patient had been identified ashaving sustained a fracture after a fall but they did not havea risk assessment in place to identify and reduce theirfurther risk of falls. We saw another patient whose pressureulcer risk assessment document was not accuratelycompleted so their risk score was not correct. This meantrisk might not be identified, reduced or prevented.

During a home visit, a community nurse was observedreviewing a patient’s care plan and their risk assessments.We saw these were updated accordingly. On another homevisit we accompanied an occupational therapist who wasvisiting a new patient. This patient had been dischargedhome following a fall. The occupational therapist carriedout a detailed risk assessment and provided the patientswith solutions to help reduce their risk of further falls.

We saw a patient who had been discharged into the care ofthe community team. The patient expressed how pleasedthey were to have had a full assessment by an occupationaltherapist. The patient felt the fear of falling again had beenovercome once the therapist explained about fallsprevention and the use of a walking aid. The patient told usthe therapist had helped them regain their independenceand self-confidence.

Staff were able to access equipment for patients if their riskassessment indicated it was required. For example, we sawa patient whose waterlow score indicated a pressurerelieving mattress was required. The nurse was able toorder this equipment and they told us it would be deliveredthe following day.

Individual teams demonstrated ways they assessed andresponded to risk in order to provide a safe service forchildren, young people and their families. For example,health visitors had frequent allocation and caseloadmeetings to discuss individual patients and agreeinterventions for at risk children. Staff we spoke with duringthe inspection were clear about the Trusts “no accesspolicy” and that two missed visits would prompt anescalation to a safeguarding concern. This was goodpractice.

For patients undergoing specialised dental treatment theyattended a pre-assessment visit with one of the dentists tounderstand their medical history and identify anyindividual risks prior to deciding the appropriate course oftreatment. Information leaflets and notices were displayedto remind people of the importance of notifying their




dentist if they were taking oral anticoagulants and theassociated risks. Where people were treated in their homesthe dentist ensured people had written contact detailsabout how to obtain urgent help via the out of hoursservice.

Staffing levels and caseloadThe Trust board were aware of the challenges regardingmaintaining safe staffing levels. A letter had been sent fromthe Chief Executive to all staff in August 2014acknowledging the concerns staff had raised and describedhow they were going to address them. The Trust had a‘Safer Staffing Tool’ system to record the numbers of staffon duty on each ward. This was accompanied by anescalation procedure on how concerns were to behandled. Staff told us that repeated attempts to recruitstaff had been made to address staffing levels but thesehad largely been unsuccessful.

There was a Trust wide safe staffing reporting mechanismin place. This was reported to the Quality Risk and AuditCommittee (QRAC) on a monthly basis. On every shift thenurse staffing levels were reported using a green, amber,red and black alert system (GARB). Each ward had anidentified staffing establishment which was based on theacuity and dependency needs of patients. The Trust hadused a recognised safer staffing tool to help calculate thestaffing levels. If the levels of staff fell below this level or thepatient acuity and dependency increased the nurse incharge assessed the risk and escalated it in accordancewith the Trust policy. For example, a black rating wouldindicate the levels of staff were unsafe and mitigatingactions such as altering staffing skill mix, staggering shifttimes or pausing admissions would be implemented.

The safe staffing report to QRAC for September identified12.5% of all of the 1173 shifts of care across all inpatientand respite units required a variety of local actions to betaken in order to maintain safer staffing levels.

Agency and bank nurses were frequently used to fill gapson staff rota’s. Staff reported there had been someproblems with staff not arriving for work as planned andnot being available to cover shifts at short notice but somestaff told us the bank staff provided good support. Wespoke with one bank nurse who told us she had been madeto feel part of the ward team and had good opportunitiesfor training and development.

The grades of therapists working on wards varied. Somewards had band 5 therapists providing the majority ofpatient care whereas some wards had band 6 therapists.Staff on some wards told us they felt that some therapeuticrisks were not always taken as the junior staff did have theconfidence or experience to take these risks. However thetherapy staff told us they did feel supported and they hadaccess to more senior staff. Therapists had regularsupervision of their practice.

Staff told us that there were delays admitting patients toOgden Court because of the staffing levels. This meant thatalthough patients were not able to be admitted to the unit,steps were being taken to ensure staff could safely care forthe patients who were on the ward. Whilst we were atOgden Court an afternoon admission was refused becauseof the staffing levels and the risk this posed.

There had been a recruitment drive across all healthvisiting teams, particularly in relation to the “Call to Actionplan.” Call to Action was a government initiative to expandand strengthen health visiting services. We saw the Trustwas currently on target to meet optimum staffing levelswithin this team by March 2015. At the time of ourinspection the Trust employed 138 health visitors against aprojected number of 169. The Trust had an agreedtrajectory and action plan in place which was monitored byNHS England.

However, we heard that staffing levels within the healthvisiting team were problematic and were impacting on thedelivery of patient care. We were told by one team that adecision had been made to suspend all antenatal visits fora period of three months in order to meet targets in theHealthy Child Programme. Another team told us due tocapacity they could not see all the children that were dueto have one and two year developmental checks. At thetime of our inspection there were 24 one year old child, and314 two year old child development checks outstanding inthe west locality alone. To ensure children remained safewe noted that a risk based approach was taking place todetermine which visits could be postponed.

Staff also raised concerns with us about the four month oldvisits that were almost never attended and when they were,they were often undertaken by nursery nurses rather thanhealth visitors. Staff felt that these visits were key inassessing early intervention requirements, specificallyaround weaning and development. The number of nurserynurses in post was due to be reduced by 30% by 15 October




2014. There were concerns that the work that was beingundertaken by these members of staff would fall back tohealth visitors and further increase capacity demands thatthey would be unable to deliver.

We were told that caseloads were weighted and based onthe skill mix of staff. We noted that caseloads ranged frombetween 166 and 410 children per health visitor, with theaverage being 299 children. However caseloads weregenerally “corporate” which meant that workloads werebased on staff capacity and case complexity. By allocatingcaseloads in this way, staff were able to respond anddeliver care based on risk ensuring that sufficient time wasallowed for each individual patient.

Concerns were raised with us by the speech and languagetherapy team (SLT) who felt that staffing levels were notappropriate to meet the needs of the children withinNorfolk. Staff told us that there was no consistency with thestaff that children were able to see. It was felt this wasdetrimental to a child’s needs because they were unable tobuild relationships. We saw this had impacted on staffmorale and the service had seen an increase incomplaints. One member of this team who we spoke withtold us they were currently covering two caseloads.

We reviewed an update on children’s SLT services whichwas presented to the executive delivery team (EDT) inSeptember 2014. The paper acknowledged the children’sSpeech and Language (SLT) workforce would have fallenfrom 44 whole time equivalents (WTE) in April 2013 to 28WTE by 1 October 2014. A further 1.1 WTE had beenidentified for removal in September 2016. The Trust hadreceived advice and support from the Royal College of SLTand has implemented a range of changes in order toprovide a service with reduced capacity. For example, atargeted training package for preschool settings to upskillthe workforce and reduce the number of referrals made tothe service and a triage process for all referrals. The reportidentified that there has been a reduction in 20% ofreferred casework and as more initiatives were introducedfurther reductions will be made.

At the time of our inspection we heard that there was ashortage of paediatricians within the service and thatlocums were currently being used to fill gaps. This had animpact on the service’s budget and impacted on continuityof care for patients. We were however told of initiativesbeing looked at to address this issue which included thedevelopment of a nurse consultant role.

Other services such as Starfish and Starfish Plus wereadequately staffed and worked well to meet the needs oftheir patients. The residential respite units were generallystaffed in line with a safe minimum level; however we heardthat on occasion the units had had to close due to a lack ofstaff. This was corroborated by a parent we spoke with whotold us that at Squirrels specifically they felt “nervous”when they left their child. This was because they wereanxious the unit may close and this impacted on the parenthaving a worry free break.

Both the staffing levels in the community dental serviceand the skills of staff were able to meet patient’s needs.The dental services in the Trust were meeting theDepartment of Health’s expectation in dentistry (A reviewinto NHS Dentistry-The Steele Review 2009). The staff toldus they felt their staffing levels were adequate.

Some managers and staff within the adult communityservice did express concern regarding staffing levels andthese had been ongoing for some time. We saw that theTrust were actively trying to recruit community nursing staffand the impact of this had started to be felt in some areas.The Trust were considering a recruitment campaignoutside of the United Kingdom to help them address theirrecruitment challenges. The vast majority of staff as well assenior managers in all of the localities confirmed thestaffing levels had improved recently and staff feltconfident these improvements would continue to improveas more staff were recruited.

It is recognised there is little published guidance in relationto caseloads and staffing levels for community nurses. TheTrust used a private company to help them develop astaffing model for community based services. The outputsof this work were sense checked with senior managers whohad experience of working within the localities. This workran alongside the Trust transformation programme whichwas designed to improve the quality and efficiency ofcommunity services.

The staffing model had been rolled out in the North andthe Norwich localities. We saw how this worked in practiceand spoke to staff and managers about the difference itwas making to both themselves and their patients. Themodel set out the daily capacity available. All referrals forcommunity services were triaged by a hub. The was agroup of experienced staff who decided what theappropriate member and grade of staff should be allocatedto each visit. The model built in break times and time for




indirect activities such as records, team meetings,supervision and training and development. Each teammember had a set level of activity each day. Although itwas recognised by everyone in the Trust that there hadbeen some initial difficulties with the system, staff wereoverwhelmingly positive about it and thought it wouldcontinue to develop further. One member of staff said, “It’sgreat because if I’m getting behind with my visits, the staffin the hub know and they can redirect my work.”

Staff in some of the specialist areas expressed significantconcerns about staffing levels The community specialistclinics such as Dermatology, Lymphoedema and Epilepsywere managed by a maximum of two specialist nurses.Most of these clinics ran without any administrativesupport and problems arose when staff went on annualleave or were off work due to sickness. The staff working inthe community epilepsy service told us they wereconcerned about the sustainability of their service. Wenoted one of the epilepsy nurse specialist had publishedarticles in nursing journals and had won an award for herwork setting up an epilepsy training programme for studentnurses.

The speech and language therapy (SALT) staff in theneurological clinic (St James, King’s Lynn), expressedconcern about their staffing levels. In addition to seeingpatients in clinic, the team of two were also required to visitother patients in the community who required a SALTassessment. At the time of our inspection there were 67patients on the waiting list to be seen by a SALT.

We met with two speech and language therapists providingcare to people within the Norwich and surrounding areas.The team were currently meeting their waiting time targetsof two weeks for urgent referrals and 14 weeks for routinereferrals. However follow up appointments were oftencancelled in order to meet the referral targets. They told usthere was an emphasis on meeting the referral targets fornew referrals. This meant there was a risk people were notreceiving the on-going care and treatment that they wereassessed as needing. Staff told us their administrativesupport time had been reduced and this had impacted onthe team. They felt they had to work additional hours toensure that people’s medical records were accuratelywritten up. These members of staff also raised concernsthat their caseload management time had recently been

reduced to one and a half hours per month. This meantthat one therapist with an average caseload of 130 had lessthan one minute per month to review the treatment ofeach patient they were caring for.

The Neurology Clinic in Wymondham Health Centre wasmanaged by two specialist neurology nurses, supported bythe hospital consultant and four GPs. Patients were seenfor their initial appointment within 6-8 weeks. However thecaseloads of the specialist nurses were large and totalled880 patients. This had resulted in the waiting time forfollow up appointments increasing from 6 months to 8months for patients to be reviewed. The staffing levels hadnot increased to reflect the increased number of patients.

Medical staffing

Medical cover for wards was provided for the working hoursof 9.00hrs 17.00hrs Monday to Friday. Medical cover for outof hours non-urgent needs was provided by GP’s. Formedical emergencies staff dialled 999. Patient’s care wasconsultant led with ward rounds being held weekly. Therewas currently some locum medical staff proving medicalcare for patients due to gaps on the rotational medical staffcover. Staff told us this did affect continuity of care forpatients. The Trust had difficulties recruiting to permanentpositions.

Deprivation of Liberty safeguardsThere were no patients with deprivation of libertysafeguards in place within community or end of lifeservices at the time of our inspection. Staff were familiarwith the process of referral to apply for Deprivation ofLiberty restrictions and a policy was available whichdescribed examples of potential deprivations. Staff gave usexamples of where applications had been made andapproved. Staff also told us about circumstances wherethey had sought advice for the safeguarding lead, forexample regarding the use of bedrails.

Most staff we spoke with demonstrated little or nounderstanding of their responsibilities regarding the MentalCapacity Act 2005 and did not know what to do whenpatients were unable to give informed consent. Not all staffunderstood the concept of Depravation of LibertySafeguards and Best Interest decisions.

On all inpatient wards we found inadequate arrangementsto ensure patient’s rights were protected when they wereunable to give consent to their treatment. The Trust policydescribed that staff in direct patient care would be required




to undertake Mental Capacity Act training every 3 years. Itdescribed that a two stage capacity assessments shouldbe undertaken if it was suspected that a patient might lackcapacity to make decisions. We did not find any completedtwo stage assessments within patient’s records at any ofthe wards we visited despite some records stating that staffregarded patients did not have capacity to consent.

Staff we spoke with showed a poor knowledge of theMental Capacity Act and most said they would undertakememory testing as a tool to establish capacity. In isolation,this is not a robust or recognised method of assessingcapacity and is not decision specific. Staff we spoke withwere largely not aware of the two stage assessmentprocess. Most staff told us that they would refer to medicalstaff or social services to undertake capacity assessments ifthey felt patients lacked capacity. Staff were largelyunaware of their personal responsibility to obtain consentfor the care and treatment they were providing.

The majority of staff we spoke with did not think they hadnot received any training in the Mental Capacity Act 2005and this was not included in the mandatory trainingprogramme. We asked the Trust to provide us withinformation regarding the number of staff who hadreceived training in the MCA. The Trust had records of 787members of staff completing MCA training, either asstandalone training or as part of their induction package.This equated to 59% of all clinical staff working in the Trust.From April 2013 until December 2013 the MCA traininggiven at induction was not recorded. The Trust provided aplan describing how a training programme was to beimplemented by March 2015, which aimed to ensure that90% of staff would be trained in the MCA.

We did not find any evidence to suggest how the Trustmonitored compliance with the Mental Capacity Act.

Generally we found therapists documented how they hadobtained the patients consent. This was less clear innursing records. We found little evidence of consent todifferent treatments being documented such as insertion

of naso-gastric tubes, blood tests or a catheterisation. Wefound the speech and language therapy team at NorwichHospital had a good understanding of the Mental CapacityAct.

We saw an example in a set of care records within theinpatient wards where patients relatives had been involvedin future care arrangements. It was not clear from therecords available if the patient had been consulted, orasked for their agreement regarding their relative’sinvolvement. It was also not clear if the patient hadcapacity to make decisions. In one care record we saw thata best interests meeting had been held without there beingevidence of a mental capacity assessment. We establishedthat this had been completed by the social worker;however, the best interests meeting did not documentclearly what options had been explored for the patient’sfuture care.

Managing anticipated risksEach ward had a resuscitation trolley with a defibrillator.We saw these were mostly checked daily to ensure theywere working. At Ogden Court however these were checkedweekly. All staff received basic life support training as partof the mandatory training so knew how to use theequipment. In the event of a medical emergency, staffdialled the emergency services as the hospitals were notequipped or suitable to provide acute care to patients. Wesaw this happen during our unannounced inspection andthe emergency ambulance arrived to transport a patient tothe acute Trust.

Patient’s wrist bands provided information to staff if theyhad any known allergies.

Major incident awareness and trainingContingency plans were in place in the event major events,such as outbreaks of flu or winter weather affecting staffsability to travel

Each inpatient area had a business continuity plan whichdetailed what staff should do in emergency situations suchas utility failures.




Summary of findingsWe judged the effectiveness of services to be good. Wefound patient care and treatment was based onevidence based guidelines. The Trust had removed theuse of the Liverpool Care Pathway and implementedinterim guidance called “Caring for people in the lastdays and hours of life.”

The care and treatment provided achieved positiveoutcomes for people who used the service.

On all wards we found a lack of personalised careplanning. Where care plans were in the place they werenot individual and lacked detail. In some care recordsthere were no care plans in place to describe howpatient’s needs were to be met. The lack of robust careplans meant patients needs may not be met.

A well regarded mandatory training programme wasavailable. Although the Trust was not meeting itsplanned targets it had set, over 86% of staff were up todate with mandatory training. New staff received aninduction to ensure they were able to undertake theirrole safely and effectively.

Staff were appropriately qualified, skilled, experiencedand competent to carry out their roles safely andeffectively and in line with best practice. Specialiseddental treatment was undertaken at dedicated centreswith the appropriate trained staff and support systemsto ensure patient safety. There was effective multi-disciplinary working to meet patient needs.

Norfolk Community Health and Care NHS Trust was notmeeting the following regulations of the HSCA 2008(regulated Activities) Regulations 2010.

Regulation 9 9(1)(b)(i)(ii) Care and welfare of people whouse services


The provider had not taken proper steps to ensure thatpeople using the service were protected against therisks of receiving unsafe or inappropriate care by meansof the planning and delivery of care and, whereappropriate, treatment in such a way as to:

• Meet the service users individual needs,• ensure the welfare and safety of the service user..

Our findingsPlanning and delivering evidence based care andtreatmentThe Trust’s policies and clinical guidelines were based onthe National Institute for Health and Care Excellence (NICE)guidelines. For example, the Trust pressure ulcerprevention and management guidance reflected NICE (CG179, Pressure ulcers: prevention and management ofpressure ulcers). Clinical Guideline 169 on acute kidneyinjury was also incorporated into guidance for staff. Wesaw the speech and language therapy service used theprofessional standards set by the Royal College of Speechand Language Therapy. Staff knew where to find policiesand local guidelines and we saw these were available onthe intranet.

The Trust reviewed NICE clinical, technical and publichealth guidance through the Trusts governance processes.All new or updated guidance was risk assessed and waspassed to the relevant service for it to be incorporated intoguidance.

The Trusts had removed the use of the Liverpool CarePathway and implemented interim guidance called “Caringfor people in the last days and hours of life.” Trainingconcerning the replacement was still being undertaken bythe Trust and not all of the staff we spoke to were aware ofthe new paperwork in use.

In the end of life service, staff followed guidance set by TheGold Standards Framework (GSF). This was a way ofworking that had been adopted by patients and all thehealth care professionals involved in their care. We sawstaff working together as a team and with otherprofessionals to help to provide the highest standard ofend of life care possible for patients and their families.

Alder Ward at Norwich Community Hospital was dedicatedto providing stroke care. There was multi-disciplinaryworking in place and patients received support fromnursing staff and a range therapists. Staff were familiar withthe NICE (National Institute for Health and Care Excellence)guidance on stroke rehabilitation and they adhered to this.

Staff in the community dental service had undertaken anaudit to monitor performance. The audit looked at thereferrals received to identify if the service was being used

Are services effective?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.

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appropriately. Treatment was in line with nationalguidance, for example National Institute for Health andCare Excellence (NICE), British dental Association (BDA) andGeneral Dental Council (GDC).

In the community, care and treatment was planned anddelivered in a personalised and holistic way. A designatedmember of staff carried out an initial assessment. Peoplehad care plans which covered their health and social careneeds.

We found that care records and handover recordscontained a significant amount of information aboutpatients but these were not always being used to generatecare plans in the inpatient areas. Care plans were core withsome space for personalisation to the patient’s needs. Wesaw that these were mostly incomplete and just had apatient’s name label on the top of each sheet. The lack of ameaningful plan of care with details of the patient’s needsmeant that staff would need to read the whole file toextract relevant information about the patient’s careneeds. From reading the information in care plans andtalking with staff, there was a sense that they were notvalued by staff. We spoke with a ward sister who told us thecare plans were just another form filling exercise that theydid not have time to do properly. We found in many of thecare records we looked at the care plans did not describehow staff were to meet the patient’s needs. For example wesaw one patient with a potential infection without a careplan in place to detail how this patient should be cared for.Another patient had a pressure ulcer but it was notrecorded what dressings were required or what frequencythe dressing required changing. This patient did not have apressure ulcer prevention management plan. We sawanother patient who did not have a personal hygiene planin place. Conversely, most of the night care plans we sawdid contain some personalisation regarding the patient’spreferred routines. We did note the care plans for patientsat Ogden Court were personalised.

There was an online system in place for pathologylaboratories to report back on test results. Locum doctorstold us they did not have access to this system so therewere some delay in results being received as they had totelephone for results. Staff we spoke with were not clear asto whether this was going to be addressed.

Children and young people’s needs were assessed andtreatment was delivered in line with current legislation,standards and recognised evidence-based guidance. For

example, the Trust had a family nurse partnership (FNP).The FNP is a voluntary health visiting programmeunderpinned by internationally recognised evidence basedguidelines for first time mothers.

Health visiting and school nursing teams aimed to work inaccordance with the Healthy Child Programme. TheHealthy Child Programme is an early intervention andprevention public health programme that offers everyfamily a programme of screening tests, immunisations,developmental reviews, and information and guidance tosupport parenting and healthy choices. The Healthy ChildProgramme identifies key opportunities for undertakingdevelopmental reviews that services should aim toperform.

All health visitors, therapists, clinicians and nurses wespoke with were aware of the guidelines relevant to theirscope of practice and were working to support theirsuccess. We saw evidence of the Edinburgh Post NatalDepression Scoring Tool in use and evidence that relevantNational Institute of Clinical Excellence (NICE) guidelinessuch as Enuresis and Childhood Obesity were worked with.The SALT team was observed to use evidence basedpractice such as the Nuffield Dyspraxia Programme andclear reference was made to the Early Support principalsbeing implemented. Early Support is a way of working,underpinned by 10 principals that aim to improve thedelivery of services for disabled children, young people andtheir families.

The children’s service had reached UNICEF Baby FriendlyLevel 2 Accreditation. This meant The facility has createdpolicies and procedures to support the implementation ofthe standards and these had been externally assessed byUNICEF UK to demonstrate that staff had been trained andthe standards implemented. Plans were in place for theservice to reach level 3 accreditation by March 2015. Thiswas also supported by an agreed CQUIN (commissioningfor quality and innovation indicator) for 2014/15.

Pain reliefPatients within end of life services had their pain controlreviewed daily. Regular pain medication was prescribed inaddition to ‘when required medication’, which wasprescribed to manage any breakthrough pain. This is painthat occurs in between regular, planned pain relief. We sawthat care followed the national Institute for Health and Care


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Excellence (NICE) Quality Standard CG140. This qualitystandard defines clinical best practice in the safe andeffective prescribing of strong opioids for pain in palliativecare of adults.

We observed a community nurse following the prescribedmedicine protocol for pain relief and administering themedicines prescribed through a syringe pump. We noted acommunity matron promptly visited a patient when a callcame through to the community centre where the nursesfrom the Coastal Integrated team (West locality) werebased. A syringe pump had become blocked and theproblem was resolved promptly.

One patient we spoke to at the day hospital demonstrateda good understanding of their pain medication, and told usthe staff had explained everything very well. The patient’srelative told us they thought their relative’s pain wasmanaged appropriately.

We talked to patients about how well they felt their painwas managed. Patients were positive about this. They toldus that pain relief was offered and given immediately it wasrequested. For one patient we saw that there was no stockon the ward of a particular pain relieving medicine whichthey were prescribed. This meant that if the patient was inpain the medication prescribed was not available.

Dentists explained the benefits and use of localanaesthesia prior to its administration and ensuredpatients understood what effects they may experience. Weobserved time was given for localised anaesthesia to takeeffect prior to proceeding with treatment. Inhaled orintravenous pain relief was administered according toplanned treatment that had been agreed with the patient.These types of pain relief were only used where the staffhad the skills and facilities to ensure patient safety.Following treatment, dentists gave verbal advice aboutpain relief and provided information leaflets whichincluded advice about pain relief.

Nutrition and hydrationThe care records we reviewed showed staff supported andadvised patients who were identified as being at nutritionalrisk. The two patients we spoke with confirmed that theyhad received advice and support from the dietician andwere very happy with the food.

Across all of inpatient services we saw patients werescreened for the risk of malnutrition on admission usingthe Malnutrition Universal Screening Tool (MUST). Where

risks were identified the risk assessment included a sectionto describe the actions to be taken to reduce the risks.When patients were admitted their food intake wasmonitored for three days to assess if this was an area ofconcern. We saw where it was assessed necessary, fluidbalance charts were kept to monitor patient’s fluid intakeand output. The completed ones we saw indicated thatpatients were offered fluids regularly and the charts weretotalled up at the end of each day to monitor the level ofintake/output. We observed a routine review of a patientscare plans in the community which had included a riskassessment using the Malnutrition Universal ScreeningTool (MUST) score. The community nurse demonstratedhow the MUST tool was used to assess the patient’snutritional needs. The nurse told us if they had concernsabout a patient’s nutritional and hydration needs thepatient would be referred to a dietician or speech andlanguage therapist via their GP.

All wards operated a protected mealtime where staff andvisitors gave patients the space and time to eat. This didnot preclude relatives visiting who had a role in supportingtheir family to eat and we did see relatives who werecontinuing in this role. The Trust provided cook/chill mealswhich were delivered to wards every few days. These wereheated at ward level. We observed good stocks of food andsnacks on all wards. Staff told us they had adequate stocksof foods and snacks and they could easily request specialdiets if they were needed.

A ‘red tray’ system was in use to alert staff that patients maybe nutritionally at risk. Most patients were supported wellat mealtimes, however we observed one patient with a redtray who received little support from staff and noted thatthey ate very little. We saw plate guards, large handled andangled cutlery available to enable patients to eatindependently.

Most wards had photographs of the foods that were servedto help patients make a choice. As food is largely apersonal choice we received a variety of comments on thequality and choice of foods. Some patients told us that thechoice of meal offered was limited if they were one of thelast patients to be asked. On one ward patients in the baystold us the choice offered was frequently limited aspatients in the dining room were asked what they wouldlike first. The majority of patients we spoke were positiveabout the foods served.


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We accompanied a community nurse who was visitingpatients who suffered from diabetes. The patients requiredinsulin injections before they had their meals. In the courseof these visits the community nurse prompted each patientto maintain a healthy diet. During another home visit, weobserved an occupational therapist asking a new patient ifthey were eating and drinking well. The therapist advisedthe patient and gave a booklet on hydration and nutrition.

Approach to monitoring quality and people'soutcomesEvery year the Trust set a number of quality goals. TheTrust reported on its achievement of the 2013/14 qualitygoals. For example, the Trust stated is had achieved:

• Development of mortality review panel - Monthly reviewmeetings in place, proforma developed, Palliative carereviews, and standards that mortality will be reviewedagainst Development of End of Life care implementingnew national guidance Board seminar provided ondeath and dying provided

• Essence of care - Reporting system of quarterlyreporting agreed. A number of the 12 outcomes arealready captured through clinical audit, patient safetythermometer and existing strategies e.g. reducingpressure ulcers - Essence of Care audits completed for:Pressure Ulcers and Privacy and Dignity.

This meant the Trust had made improvements to thequality of the service being delivered to patients.

Between January to March 2014, the Trust’s bed occupancywas 86.5% compared to the England average of 87.4%. It isgenerally accepted that when occupancy rates rise above85%, it can start to affect the quality of care provided topatients and the orderly running of the hospital.

We saw evidence that end of life services monitored theperformance of their treatment and care. Data showed thatbetween April and July 2014, there were 494 deaths ofpatients within the care of the community nursing andtherapy teams. Of these 494, 266 had indicated theirpreferred place of care, and of these 245 (92%) died in thispreferred place. This meant that for the majority ofpatients, services were being provided to meet people’sindividual wishes.

The National Bereavement Survey (VOICES) was conductedby the Office for National Statistics on behalf of theDepartment of Health. The aims of the survey were toassess the quality of care delivered in the last three months

of life for adults who died in England and to assessvariations in the quality of care delivered in different partsof the country and to different groups of patients. Thesurvey results suggest that the Trust is at least in line withthe national average in all areas and above average interms of :

• GPs and hospital doctors providing excellent care,• Sufficient help and support for family at time of death• Involvement of families and patients in decisions.

Specific outcome measurement tools in children’s serviceswere not widely in use. When we asked this question acrossmany of the teams there was an agreement thatimprovements were needed in the way that patientoutcomes were evidenced. We read in the Trusts QualityAccount that children’s services used the East KentOutcomes System to monitor patient outcomes. Howeverthis was not articulated by staff during our inspection.

The starfish team told us that they monitored patientprogress through using a goal based assessment tool. Wesaw goal setting approaches being used across servicesduring our inspection in order to focus and agree onoutcomes with children, young people and their families.

Recent audits had been undertaken regarding post-operative care and referral processes within communitydental services. Post-operative information for patients hadbeen revised which had resulted in a reduction in thenumber of patients returning with post-operativecomplications. To improve referral processes the standardreferral form had been revised. There were mixedresponses from staff regarding its effectiveness. Some stafftold us they received more patient information aboutpatients referred for treatment as a result of the revisedreferral form. Other dentists reported the actual number ofinappropriate referrals had not reduced as a consequence.

Staff undertook regular audits of clinical records andconsent processes, the results of these were reported atmonthly staff meetings to ensure shared learning andagree actions to improve standards of record keeping.Other previous audits had included the prescribing ofantibiotics.

Adult community services monitored the quality of theservice they were providing through a range of different


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audits. Audits on leg ulcer care, assessment of the safe useof insulin, the management of the diabetic foot as well as aTrust wide audit of record keeping and management wereundertaken in the last 12 months.

Performance of services was monitored through a localitymanagement structure which reported to various subcommittees of the board and subsequently into the Trustboard.

The Trust had developed a mortality review policy whichwas approved by the Trust board in September 2014. Weconsidered this to be an area of good practice for acommunity Trust. The aim of the policy was to have aconsistent approach to review patient mortality across theTrust and to provide a clear reporting structure to escalateany concerns. All inpatient deaths were reviewed andincluded the cause of death, the length of admission, thecategorisation of death and any concerns were noted.Further scrutiny was applied where concerns wereidentified and there was a clear process for escalation inplace. The mortality review group was led by the Trustsmedical director who provided strong leadership for theinitiative.

Competent staffThe Trust recorded a compliance score of 87.1% for itsmandatory training programmes in 2013/14 against atarget of 90%. This meant that the majority of staff hadundertaken the Trusts mandatory training programme.Staff spoke positively about the mandatory trainingprogramme which was delivered. In addition to theclassroom based mandatory training some training wasavailable as e-learning packages. Attendance at trainingwas being affected by short staffing levels. On three wardsduring our visit staff told us that attendance at plannedtraining had been cancelled as staffing levels wereinsufficient to allow them to be released.

We were told that following a successful implementation ofa similar model in adult services, this year had seen theintroduction of family-centric training (“Faye Milly”). Thiswas block training and captured multiple items ofmandatory training in one session and was specifically forchildren’s services staff. However, staff did not get access totraining such as infection control, medicines management,mental capacity and deprivation of liberty safeguards.

The results of the 2013 NHS Staff Survey are organised into28 key findings. The Trust performed better againstquestions regarding staff receiving job-relevant training,staff being appraised and staff receiving health and safetytraining.

Staff that had recently gone through the inductionprogramme were positive about it. Staff told us they wereable to access professional training in line with theirspecialism. We spoke with a senior manager who wasresponsible for one of the localities and they showed usevidence that staff were able to undertake differentprogrammes of non-mandatory study to enhance theirpractise. We saw they monitored this to ensure access tostudy was fair and equitable across all staff groups.

Staff’s experience of clinical supervision was variableacross teams and some staff were not accessing regularprotected time for facilitated in-depth clinical supervision.Clinical supervision is a way of supporting staff in thedevelopment of their practice. The director of nursing toldus they were aware that clinical supervision was patchy,particularly amongst nurses. Initiatives were in place to tryand improve access to supervision such as groupsupervision being available. All therapists told us theyreceived regular clinical supervision regarding theirpractice and the director of nursing reinforced this and toldus that uptake of supervision amongst therapists was verygood.

Most staff we spoke with told us they had had an appraisalwithin the last 12 months and staff thought it was asupportive and valuable process. Records showed that theTrust’s appraisal rate dropped below 90% to 66.6% in May2014. The North locality had the highest level ofcompliance with a rate of 74.8%, whilst the South localityhad the lowest rate at 51.4%. The most recent informationfrom September 2014 indicated that 67.43% of staff havecompleted performance development reviews in the pastyear. This meant there had been little progress made sinceMay 2014.

The results of the 2013 NHS Staff Survey are organised into28 key findings. The Trust performed better againstquestions regarding staff receiving job-relevant training,staff being appraised and staff receiving health and safetytraining.

The Trust provided over 400 training placements forstudent nurses and therapists across the organisation. One


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nurse told us they had only recently qualified but the Trusthad support mechanisms in place to supervise andsupport them until they felt competent to work alone in thecommunity.

The Trust employed 27 (17.63 whole time equivalent)doctors and confirmed all of these were compliant withrevalidation. Dental staff were registered with the GeneralDental Council, (GDC). The GDC is an organisation whichregulates dental professionals in the UK. We saw evidencethat clinical staff participated in Continuing ProfessionalDevelopment (CPD) in line with their GDC requirements.

Use of equipment and facilitiesAvailability of equipment in the community was noted tobe a particular issue. We heard from more than onemember of staff who had bought their own equipment inorder to support the children on their caseloads. We weretold that there was not an adequate process in place toreplace or buy new equipment which would assist a childduring their treatment.

We observed dental equipment was used appropriatelyand for the purpose it was intended. The centres hadmodern treatment rooms and x ray facilities. We sawrecords of regular maintenance and servicing of specialistequipment by the manufacturer to ensure it was fit andsafe for use. Staff said they had access to sufficientequipment to provide care and treatment.

A community nurse showed us a diabetic blood glucosemonitor that had been issued for the nurses to use. Eachnurse was responsible for checking the monitor to ensure itwas in good working order and was giving the correctreadings. We observed the blood monitor being used forthree patients who had diabetes. We saw the nursefollowed the Trust policy and recorded the quality tests in alog book. This meant equipment was checked so it did notcompromise patient safety.

We saw that urgent equipment, such as special mattressesfor the prevention of pressure ulcers, would be delivered toa patient’s home within 24 hours. Staff told us the Trust hadchanged their equipment supplier and there had beensome “Teething,” problems with the new service. Staff toldus these were being “Ironed out,” and they had beenadvised to report any problems with the service throughthe incident reporting system.

Multidisciplinary working and co-ordination ofcare pathwaysOur observation of practice, review of records anddiscussion with staff confirmed effective multidisciplinaryteam (MDT) working practices were in place.

Effective MDT working was clearly demonstrated withregard to the Hospital Home Care Service (West locality),where the community virtual team had worked closely withanother NHS Trust and the local authority. A trained nursefrom the virtual team visited the acute wards of the localacute NHS Trust and assessed patients suitable for earlydischarge using co-ordinated care pathways. This meantpatients could be discharged home earlier whilst they stillreceived appropriate care and treatment at home.

In the South and West Localities the community matronsassisted in caring for people with complex healthcareneeds. They ensured that people had all the care theyneeded at home, including the input of GPs, communitynurses, therapists and social care staff. This meant thatpeople had their care delivered in a co-ordinated waywithout duplication of services.

The community nurses and therapists in the South localitytold us they worked closely with other care co-ordinatorsfunded by the local authority. These care co-ordinators hadaccess to electronic information about the patients whichmeant they were able to cross reference with other careagencies to ensure patients received appropriate care atthe right time.

In the end of life care service, staff told us there waseffective communication and collaboration between teamswho met regularly to identify patients requiring visits or todiscuss any changes to the care of patients. The meetingsfollowed the principles of the Gold Standards Framework.As a minimum the service held a full MDT reassessment ofpatients led by a named senior medic every three days.There were also ongoing daily reviews of all patients.

The service used an Electronic Palliative Care CoordinationSystem to support the co-ordination of care so thatpeople’s choices about where they die, and the nature ofthe care and support they received was respected andachieved wherever possible. This enabled key medicalinformation and conversations about end of life carewishes to be communicated across areas and with externalproviders and services.


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Communication and coordination between all the healthcare professionals within end of life services was enabledthrough the use of the electronic palliative carecoordination system known as “Systm one.” This wasaccessed by all the professionals who were caring for thepatient including the District nurses, specialist nurses,Macmillan nurses, and some hospital services. It enabledstaff to record and share information necessary to ensurethe on-going needs of the patient, including decisionsabout their care, could be widely accessed.

Within the adult community integrated care team weeklymeetings were held between the nursing staff, socialservices, the housing department, allied healthprofessionals and members of the voluntary sector. Thisallowed the opportunity to discuss individual patients whohad complex needs and were requiring end of life care.

We observed some staff handovers, these were effectiveand comprehensive in ensuring staff had information onpatient’s needs. Nursing staff described close workingrelationships with occupational and physiotherapists.

Staff worked in partnership with other specialists to ensurea patient focused service. For example, they liaised withgynaecological, ophthalmic and podiatric specialistsregarding patients scheduled for treatment under GeneralAnaesthetic (GA) to minimise the number of GA’s a patientreceived. There was a general anaesthetic treatment

pathway that meant the patient from referral to the dentalpractice for pre assessment to treatment under generalanaesthetic at the local hospital was cared for by the samedentist.

We attended multiagency meetings within the children’sservice and found there was a good evidence basedapproach to how these meetings were conducted. Theywere clearly based around the needs of the child and clearoutcomes were identified and agreed. The Trust ran a keyworker service. This service was available to children andyoung people from birth to the age of 19 who had complexor high levels of needs and saw at least three specialisthealth care professionals from at least two otherorganisations. The role of the key worker was to be thepoint of contact of the families to ensure they could accessall the support services they needs. They made sure allagencies worked together to meet the needs of the child,young person and their family.

We noted an excellent approach to the development ofpathways within the school nursing team. We noted thatpractice was already based on NICE guidance but work hadbegun on the development of a suite of evidence basedpathways for the team. There was a good use of skill mix inthis development and we noted that other relevantexpertise’s (such as from the local acute hospital) had beensought.


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Summary of findingsThroughout our inspection staff spoke with compassion,dignity and respect regarding the patients they caredfor. We found all of the services we inspected to beproviding compassionate care but it was outstanding inthe community dental service.

In the children’s service, staff were passionate aboutproviding care centred on the needs of children, youngpeople and their families and recognised theimportance of engaging with families in order tounderstand their situation and the support theyrequired.

Community end of life, inpatient and adult communityservices were also delivering a compassionate servicewhich also promoted patients privacy and dignity. Weobserved positive interactions between staff andpatients in their homes and in every unit we inspected.

People were overwhelmingly positive about the careand treatment received in the community dentalservice. We found staff were committed to providing aspecialised dental service for patients. Patients weregiven clear explanations during pre- assessmentavoiding the use of technical terms and providingdiagrams to enhance the patients understanding ofplanned treatment.

Our findingsCompassionate carePeople who used the service were treated with kindnessand compassion. Almost all the people we spoke with werecomplimentary about the staff and the care and treatmentthey received.

We observed positive interactions between staff andpatients in their homes and in every unit we inspectedPatients were treated with compassion and empathy. Weobserved staff speaking with patients and providing careand support in a kind, calm, friendly and patient manner.The patients we spoke with were very complimentaryabout staff attitude and engagement. One person told us

they could not praise the staff more, they said that ‘thestaff in the day hospital are fantastic and very caring, theygreet you with a hug and a kiss.” Another patient and theirrelative told us, “The care here is fantastic.”

We spoke with seven patients and six relatives. All wereconsistently positive about their experience within the endof life services.

We attended home visits during our inspection. We sawthe community staff treated patients with compassion andcared for the patient as well as their family. Patients wereappreciative of the care provided to them and were keen topraise staff. Patients told us the staff were dedicated andone person told us, “Nothings too much trouble for them.”Another patient told us “Staff are very patient – I watchthem with other patients they never get ruffled.”

Patient’s told us they would not hesitate to ask staff for helpif they needed it. One patient told us that they consideredthe staff to be “Kind and compassionate.” Anothercomment was that staff were “Caring and attentive.”Another patient told us, ”I have had very good care andbeen treated with respect.”

We saw that staff provided patient-centred care. Staffencouraged the children and young people to make theirown decisions. They had good knowledge of thebackgrounds and preferences of the children and youngpeople they were caring for. One parent described the staffas “..friendly and patient”. A child that we spoke to told usthat they would recommend the service to their friends andtheir only concern was that “Not all the bits are there in thepeppa pig house.”

Health visitors who we accompanied on visits alldemonstrated a compassionate attitude towards thefamilies and children they were caring for. There was clearunderstanding of people’s individual circumstances andthese staff members showed a skilful and sensitiveapproach to discussing areas such as a baby’s welfare anda mother’s mental health.

We were provided with compliments which had beenreceived by the service. It was clear that many people hadreceived care and treatment which met their expectations.For example, one person wrote “Thank you for doing somuch more than your job. Your advice and kind words willnever be forgotten. Thank you for keeping my spirits highand my smile wide.”

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

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In the community dental service, patients and theirrelatives told us staff were patient and understanding.People spoke positively about the care and treatmentreceived. One patient said, “I was so nervous I washousebound initially but over several appointments I havebeen able to have treatment.’’ Another patient said, ‘’Theyare a very dedicated team.’’

We observed good interactions between staff and patients.For example one dentist put people at their ease andchatted with patients recalling important events in theirlives such as school exams, their favourite sports. Onepatient said, ‘’They talk with you first and chill you out, theygive you time.’’

We spoke with the parent of a child attending a pre-assessment appointment, they said, ‘’My child needs quitea bit of dental work and is terrified of the dentist but theyhave managed to gain her cooperation and been so patientwith her.’’

A relative during a community dentist domiciliary visit said,‘’ We only needed a little bit of help. It’s so difficult for me tohelp my wife even go to the shops. I never expected this, it’swonderful. Look she doesn’t even know the tooth has beenremoved, he (the dentist) is amazing.” One patient who hadexperienced difficulties attending for treatment due toproblems with their wheelchair had written to the staff tothank them for understanding their situation and helpingthem.

We accompanied some community nurses and therapistswhen they visited people in their homes. People were verypleased to see each member of staff who visited them. Oneperson said, “The nurse is very good. I get on well with all ofthem and they get on well with me.”

We contacted patients who used the community service bytelephone and the comments received included thefollowing:

• “I am delighted with the service. I felt very supported. Iwould like to continue with continuity of staff.”

• “Very good service. No concerns.”• “Absolutely fine. No concerns.”• “The staff don’t always turn up on the day they had

planned to visit.”• “Wonderful; a lot of support.”• “Excellent, highly delighted.”• “My only concern is the time; I never know what time

they’re coming, am or pm.”

• A person and their relative expressed they were nothappy when the wound dressings were changed. Theyfelt they had not been consulted.

• “I am very happy with the service; no concerns.”• “The district nurses are very professional.”• “I am quite happy.”

Dignity and respectWe saw staff regarded patients with dignity and respectand spoke to them in a courteous manner.

Where wards were short staffed, staff were observed to becheerful and kindly to patients even though theinteractions were brief and focussed on the care beingprovided. Most but not all staff wore name badges sopatients were not always aware of the name of the staffmember who was providing care to them.

In the inpatient areas we observed that all patients werecared for in same sex accommodation in order to safeguardpatient’s privacy and dignity and, to comply with theGovernment’s requirement to eliminate mixed-sexaccommodation.

We observed some handovers were held in closed roomsor offices, but some handovers and discussions were heldat nurses’ stations which meant patient’s confidentialitycould be breached. We did not see handovers taking placewith the patients. On all wards there were rooms availableto allow for private discussions and meetings.

We observed staff knocking on side rooms doors beforeentering, ensuring that patient’s privacy was respected.

At Ogden Court a privacy film had been applied to somewindows. This had been applied incorrectly meaning thatpatients could no longer see into the garden as themirrored side was facing them. It also meant that peopleoutside could see through the windows onto the wardwithout staff being aware of this. This meant patient’sprivacy was not protected.

We saw staff respected the children, young people andfamilies they were caring for. We saw them give childrentime to answer questions and they all got down to the levelof the child to establish and maintain communication. Allof the communication we witnessed was appropriate andmet the needs of the individual child being cared for. Onechild told us that the doctor they saw was “very nice”.


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We undertook a visit to the home of a family with a childwho had complex needs. We found the staff memberdemonstrated dignified and delicate care. They weresupportive and empowering and able to rapidly build Trustwith the child.

We observed patient interactions on our visits to thechildren’s residential respite units and again noted allinteractions to be positive and appropriate. One parentreported that they felt the staff were “Very attentive.”

Within the dental service, we observed people wereconsulted at each stage of treatment to ensure they hadtheir permission to proceed and that people were givenreassurance before continuing. For example, one personwe spoke with had a phobia of dental treatment and toldus he would gag the moment an examination commenced.

We observed the dentists ensured when discussingtreatment options with people they maintained eyecontact. The staff were familiar with the person’s fears andtook time to reassure and relax the patient without theneed to use medication. People were greeted in a friendlyand courteous manner and reception staff were discreet toensure patient confidentiality when booking appointmentsfor patients in the reception area or by telephone. Duringtreatment doors were kept closed to ensure privacy.

Patients visiting the community outpatient clinics feltrespected and commented staff treated them with dignity.We observed a screen being used before treatment beganfor a person in a leg ulcer clinic. In the IV clinic, we observeda member of staff having a telephone conversation with apatient in a polite and respectful way. We observed twopatients being treated at the leg ulcer clinic in thecommunity outpatients department at Dereham Hospital.One patient commented, “Staff treated me as a humanbeing. Another patient said, “The staff always have a smileon their faces.”

During a musculoskeletal clinic session held in the mainbuilding in the Aylsham clinic we noted that other patientsin the waiting area could hear the interactions betweenother staff and patients who were receiving treatment. Thewaiting area was close to the treatment area and wasseparated by curtains only. This meant there was a risk thatpatients confidentiality or privacy and dignity may becompromised.

In the end of life care service we saw the nurses treated thepatients respectfully and with dignity, they were welcoming

towards the patient and their relatives and supported themin a professional and sensitive manner. At Priscilla BaconLodge we observed staff speaking to patients in a caringand respectful manner during patient contact. Weobserved staff were smiling and positive. Staff took timewith each individual patient and would make equal eyecontact by ensuring they were at the same level as thepatient so as not to stand over them.

The National Bereavement Survey (VOICES) was conductedby the Office for National Statistics on behalf of theDepartment of Health. The aims of the survey were toassess the quality of care delivered in the last three monthsof life for adults who died in England and to assessvariations in the quality of care delivered in different partsof the country and to different groups of patients. Thesurvey results suggest that the Trust was average in termsof dignity and respect

Patient understanding and involvementOn some wards we saw goal setting which took intoaccount what patients wanted to achieve. However, thesewere not always incorporated into the patients care plansand were kept separately. This meant the reviews of careplans did not necessarily take into account the patient’sgoals.

There is no current requirement for community Trusts toadopt the Family and Friends Test (FFT), but Norfolkimplemented the FFT in community services in July 2013.The FTT is a national initiative and aims to ensure patientexperience remains at the heart of the NHS, so members ofthe public can see what patients think of local services, andthat service quality is transparent to all. A simple score isgenerated by taking the proportion of respondents whowould be ‘extremely likely’ to recommend the service,minus the proportion of those who say they are ‘neitherlikely nor unlikely’, ‘unlikely’ or ‘extremely unlikely’ torecommend it. Patients are then encouraged to commenton why they gave that score, enabling services tounderstand what really matters to them.

The national target is for 75% positive response and 15%sample size. The Trust had not yet supplied the samplesize. Between July 2013 and March 2014 the Trust reportedan overall score of 79% positive responses, the lowestresult being 72% in July 2013 and the highest being 86% inMarch 2014.


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We spoke with six relatives and three patients both duringand following our inspection. They all told us they hadbeen fully involved in the care provided and had a clearunderstanding of what was happening at all times.

We observed many patient interactions during ourinspection and noted that the staff were empathetic andthat they listened to what they were being told. We notedappropriate responses and interventions. Treatment goalsand next steps were discussed and agreed with both thechild and their family member or representative.

The Trust has a “Patient Experience and InvolvementStrategy” in place that was developed with staff, patientsand external organisations. There are three strategicthemes in the strategy:

• Ensuring a systematic approach to capturing feedback• Action for improvement• Building meaningful and systematic engagement and

involvement.

Emotional supportThe specialist palliative care team supported peopleemotionally. All the patients and relatives we spoke withvalued the support offered by the nursing teams. The teamhad received training to enable them to support patientsand families; they also delivered training to communitystaff. Bereavement counselling was also available throughthe Trust Psychological service. The service helped patientswho were either living with a life-limiting illness or were atthe end-of-life . Support was also available to patientsfamilies. We noted that this service was available forfamilies for up to a year after bereavement has occurred.

During a home visit with the community nurse, we met aspecialist nurse from the palliative care team who hadbeen asked by a GP to visit the patient to give support totheir partner, who seemed overwhelmed when the patienthad been discharged home a few days earlier. We observedstaff speaking to patients in a kind manner. On Beech wardstaff were aware of how having a stroke impacted onpatients’ emotional well-being. As a ward specialising instroke rehabilitation, groups were held to support patientswith the psychological impact of stroke. The chaplaincystaff visited all wards regularly to offer spiritual support topatients. Staff considered the chaplains to be part of theward team and were positive about their contribution topatient’s care.

Children, young people and their families received supportto cope emotionally with their treatment and care. Wefound all the staff we spoke with were child and familyfocused and they considered the family unit whencompleting their assessments. In most cases it was clearthat staff worked with families as well as the children andyoung people. We noted on numerous occasions staffawareness of the emotional needs of the people they metwith. Advice and guidance was offered and whereappropriate information relating to support services wasoffered.

We also spoke to the parent of one child who had receivedadvice and guidance from the children’s centre to arrangehousing and benefits. This person was grateful for thisservice going “Above and beyond.” This was alsodemonstrated to us with conversations with otherprofessionals who all said they would provide informationand advice about how people could seek support withmatters such as access to mental health services,education or financial support.

We observed the dentists asked patients if they would liketheir relative or carer to accompany them in the treatmentroom. At one clinic the dentist positioned the parent of achild receiving treatment and checked the child was able tosee their parent throughout their treatment. When localanaesthesia was administered the dental nurse heldpatients hand and gave reassurance and praise.

There were pictorial care pathways provided for childrenwho had been assessed as requiring general anaesthetic.This was provided to help them understand what to expectand minimise their fears about planned treatment.Children showed to us they had received stickers aftertreatment as a reward for being a good patient.

Staff showed an understanding of the emotional needs ofpatients living in the community. They were aware ofpeoples home circumstances and the effect that living witha long term condition could have on people. We saw staffwere empathetic in their approach to caring for theirpatients.

Promotion of self-careTherapists generally provided very detailed assessments ofpatient’s abilities to care for themselves. We could see that


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self-care was promoted to improve patient’s independencebut there was a lack of personalisation in care plans. Thismeant staff might not always be clear about what eachpatient could do for themselves.

At Swafham Hospital there was an activities coordinator.Not all wards/hospital had an activities coordinator butthere were some activities were held to promotesocialisation, dexterity and psychological well-being. Therange of activities varied according to staff availability.

One patient told us they were encouraged and supportedby staff to help themselves to dress following a shower.Another patient told us the physiotherapist had taughtthem a way to get themselves out of the chair and they hadstarted to be able to take themselves to the toilet.Following a therapist assessment, a person commented, “Iam so pleased with the way the staff explained things tome. I feel more confident in doing things for myself andhave learnt how to stop myself from falling again. Thetherapist is very good and I am very pleased the therapist iscoming back next week to see me.”

Due to the complex needs of patients receiving end of lifecare services, it was not always possible to promote self-care. However, the patient records we looked at includedperson-centred care plans based on the individual needsand preferences of patients. 92% of patients died in theirpreferred place of care.

Where possible children and their families were supportedto manage their own treatment and care needs.

For example, goals were discussed and agreed and familieswere given advice and guidance about how they couldprogress with treatments alone.

We saw that educational classes were provided for parentsso that they could gain a better understanding of theirchild’s needs. For example, one parent told us that theyhad attended an introduction to autism class and we alsoheard about the Norfolk Steps Programme which wasavailable to parents and which this service promoted. Thistraining programme was in place for parents of childrenaged 4-18 years who have special and additional needsand whose behaviours are physically challenging.

The dental service employed three oral health educators.We saw recent correspondence from children displayed inthe reception area describing what they had learnt aboutcaring for their teeth.

During appointments the dentists asked questions abouteach patient’s current oral hygiene practice and gavesuggestions how this could be improved to preventproblems. Where a patient’s carer attended anappointment with the patient they ensured the carer wasinvolved in the discussion. People who had receivedtreatment were given explanations about what to do tominimise discomfort and prevent problems such as havingsaline mouthwashes following dental extractions. Thedental nurses ensured patients also received writteninformation about how to care for their teeth aftertreatment and between appointments. The staff wentthrough the information to ensure they understood it.


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Summary of findingsWe judged the responsiveness of the services as goodwith the exception of the adult community servicewhich we judged as requiring improvement.

We saw that leaflets on how to make a complaint andcontact PALS were available on wards and in receptionareas. The Trust also kept a record of all complimentsreceived. Over a thousand compliments were recordedduring 2013/14. Staff told us there was active reflectivepractice and learning following complaints.

Aspects of the ward environments were dementiafriendly. Most inpatient wards had garden areas withseating where patients and their relatives could sitoutside. We noted that the wards at NorwichCommunity hospital did not have this space available.

Therapy staff did not work weekends but healthcareassistants had received training to work on exerciseswith patients. Staff told us that some patients wereadmitted to the inpatient wards late at night. Thereasons for late were generally outside the Trust’scontrol but it did affect patient care.

The service planned and delivered care to meet theneeds of children, young people and families. We sawgood examples of how services had developed basedon the feedback of patients which included extendedservice opening times. Health visiting teams did notwork flexibly and this was resulting in resources beingwasted because patients were not attendingappointments.

We were concerned about arrangements in place tosupport children transitioning into adult services. Therewas no pathway in place and some staff were unsure ofwhat services could be accessed when children left theircare.

Staff told us it was more difficult for patients to accessthe stroke pathway if they didn’t start in it and we sawhow this had proved difficult for one patients who hadsuffered a stroke.

The Trust monitored the responsiveness of its servicesand monthly reports were provided to the Trust board.The access to services scores were higher than theTrusts targets. This meant the majority of patients were

getting a responsive service. The Trust achieved the 18week referral to treatment target (RTT) withperformance of 98% in July 2014. Musculo skeletal(MSK) physiotherapy, podiatry surgery and specialistnurses epilepsy management were not meeting the 18week referral to treatment time.

Our findingsService planning and delivery to meet the needs ofdifferent peopleThe Trusts palliative care service provided care for 652patients during 2013/14. We found the service had a goodunderstanding of the different needs of people it served.Services were planned, designed and delivered to meetthose needs. There was evidence that staff activelyengaged with local commissioners of services, the localauthority, other providers, GP’s and patients to co-ordinateand integrate pathways of care that met the health needsof patients. Service specifications were in place whichdetailed the aims, objectives and expected outcomes forpatients nearing the end of their life and were monitoredagainst national and local performance indicators.Outcomes showed patients were receiving a high qualityservice.

There were referral criteria in place and there werediscussions about all patients who were referred to the endof life care service, including those who were waiting for abed.

Staff showed us leaflets about “Preferred priorities for care”that were given to patients. These provided simpleexplanations about advance care planning and thedifferent options available to patients. We visited twopatients in their own home and saw the patients hadreceived this leaflet.

There were identified link nurses who worked with the localprisons to provide end of life care support to the prisonpopulation.

At Priscilla Bacon Lodge we saw complimentary therapiessuch as reflexology and massage were offered.

Are services responsive topeople’s needs?

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

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Car parking was available at all of the hospital sitesincluding designated disabled parking bays. Parking wasfree at all hospitals apart from Norwich CommunityHospital. We saw there was clear signage on all wards tohelp patients orientate themselves around.

Staff knew how to access interpreting services but told usthey could not recall ever having to use them. We did notobserve any patients on the wards at the time of ourinspection that needed an interpreter.

Aspects of the environment in the inpatient wards weredementia friendly, this included having blue toilet seats inplace and we noted there was clear signage. Some wardshad sensor activated lights which came on automatically,limiting the risk of accidents in dark rooms.

Visiting hours were displayed on each ward as well as onthe Trust’s website. Ward managers told us visiting hourswere flexible according to family circumstances and howseriously ill the patient was. Some wards had flowers bypatient’s bedside but others did not. Staff told us it wasdown to the individual wards as to which policy wasadopted. Should a patient have an allergy flowers wouldnot be allowed on wards at any time.

Most wards had garden areas with seating where patientsand their relatives could sit outside. We noted that thewards at Norwich Community hospital did not have thisspace available. Staff told us they had asked if it waspossible to develop a garden area and the possibility of thiswas being explored. At the time of the inspection staff toldus there was no timescale for when this would happen.

We saw evidence that local communities valued their localcommunity hospitals. All the hospitals we visited all hadactive ‘Friends’ organisations which supported them.

During our inspection we saw that translation services wereavailable. We spoke with the parent of a child whose firstlanguage was Lithuanian. They told us that they werealways provided with an interpreter when they came forappointments. We saw and spoke with the interpreter whohad attended for this appointment. During ourobservations and conversations with staff there was a clearunderstanding of the availability of this service and how itcould be accessed although we did speak with some staffwho were less clear about the availability of interpretersand how they would be utilised.

We heard of various initiatives that had been developed inorder to meet the needs of people. This included extendedservice times in child psychology services. We were toldthat this change was based directly on patient feedback.Some services had initiated a text messaging reminderservice for appointments which had received positivefeedback. We noted that not all teams were using theseinitiatives and some services, such as health visiting mighthave benefited from using them.

We found limited flexibility within the health visiting teamsin order to address the current capacity issues. We foundthat out of hours or flexible working was not beingroutinely implemented as way of improving the servicesoutstanding developmental checks. We were told thatsome staff had raised this is a potential way of workinghowever this had not been taken up because there wouldbe no staff member who was office based to offer out ofhours support. We were concerned about how the servicewas being flexible around appointments that had beencancelled. For example, we spent time with a health visitorwho only saw one patient in a day because manyappointments were not attended. This meant valuablehealth visiting time was being wasted. Health visitors wereaware that many patients requested evening or weekendvisits, yet the service was not able to be flexible to meetthose needs.

In one area we saw that as a solution to some of thedifficulties, the children’s centre team had assisted bydeveloping two year developmental review clinics. Theseclinics were designed to free up health visitors time byallocating one health visitor supported by family supportworkers to a three hour clinic to see multiple children. Thiswas a good initiative and the parents we spoke with atthese clinics were supportive of it. But, again, we notedthat many appointments were not attended. This meantthat they would need to be re-allocated. We asked how theeffectiveness of this service was being monitored and wewere told no review had been undertaken.

The clinics we visited were generally well maintained anddecorated in a suitable manner to meet the needs ofchildren. The reception area of Upton Road was fairlybland, however there were a number of posters aimed atparents, containing information about activities happeningin the area, for a range of children. There was access torefreshments and child friendly toilet facilities. We did notethere were no low chairs for children to sit on.



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People were referred to the community dental service whohad been assessed as having complex or special needs,including learning difficulties, where treatment with ageneral dental practitioner was not possible. The servicealso met the needs of children under 16 years of age withbehavioural or management problems which made themunsuitable for treatment within general dental services.Staff reported most patients were seen within six to eightweeks from referral. Staff anticipated this waiting timewould improve when new staff recently recruited hadcommenced.

The service worked collaboratively with other services suchas general dental practitioners, social workers and hospitalteams. Dentists and surgeons worked collaboratively, forexample for those patients whose medical conditionnecessitated dental care being undertaken in a hospitalsetting. This meant patients received care in theenvironment that could safely meet their needs.Appointments were timed to allow people with morecomplex needs the time they needed.

The dental service provided a domiciliary (home visiting)service for people who were not able to attend the clinicdue to illness or disability. The relative of one patient wevisited said, I don’t know how we would have managedwithout this visit it’s so difficult to get out, they (the staff)are wonderful.’'

Access to the right care at the right timeWe saw through advance care planning, patients were ableto dictate both their preferred place of care and preferredplace of death. Information received prior to our inspectionshowed that the Trust monitored the performance of theirend of life treatment and care service.

Data showed that between April and July 2014, there were494 deaths of patients within the care of the communitynursing and therapy teams. Of these 494, 266 had indicatedtheir preferred place of care. Of these, 245 died in theirpreferred place of care which equated to 92%. Staff alsotold us patients were able to change their mind about theirpreferred place of care and preferred place of death andthe electronic care records would be updated to reflect thischange.

Patients were usually admitted to inpatient services fromeither nearby acute hospitals, from their own homes orresidential care settings, usually referred by their GP or acommunity matron. The inpatient services provided by the

Trust were not evenly distributed across the County. Thismeant that hospitals were not always near to patient’shomes but people were given a choice regarding acceptingadmission.

There were Trust staff working in the local acute hospitalswho assessed if patients met the admission criteria for thecommunity hospitals. Relevant information on theircondition as well as medication administration recordsarrived with patients when they were admitted to thecommunity hospital. This meant staff had informationabout patients’ needs on admission.

Ward managers told us they tried to keep a patients bed for24 hours if the patient had to be readmitted back to theacute hospital following deterioration in their condition.Staff told us that some patients were admitted late at night,usually where they were coming from acute hospitals. Thereasons for late admissions were attributed mainly to theavailability of ambulances. Whilst this was outside theTrust’s control, it did affect patient care. One patient told usthey found the journey frightening due to the remote area.Staff told us that late admissions could be disorienting forpatients. Medical staff did not work evenings or nights solate admissions would not see any medical staff to thefollowing day. If a patient was admitted on a Fridayevening they would not see the ward medical staff until thefollowing Monday. The out of hours GP service could berequested to review patients who became unwell andneeded a medical review out of hours. Medical emergencycover was accessed through the 999 emergency service.

Therapy staff did not work weekends. To ensure thatpatient’s rehabilitation continued a number of healthcareassistant had been trained to work on exercises withpatients and promote their recovery

The occupational therapy team raised concerns with uswith regards to the current service specification. We weretold that a historical decision was made to refuse referralsfrom new patients who were aged between 8 and 9. Thishad resulted in 18 patients being refused treatment in thepast 15 months. We were told that this had impacted onpatient complaints and the access to treatment for thesechildren. We were told that this had been raised forcommissioners to review but feedback had not beenforthcoming.

Concerns were raised about the way the service for childrenwith Autistic Spectrum Disorders (ASD) was commissioned.



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Children with a sole diagnosis of ASD did not receive anyfollow up treatment but if the child had an additionaldiagnosed disability as well as ASD they would receiveongoing care and treatment. The commissionersrecognised the pathway for these children was notappropriate and it was currently being reviewed by a rangeof partner organisations.

We were told that the SLT team were not able to seepatients requiring follow up appointments in a timely way.We were told that this was because follow upappointments were often cancelled so that new referralscould be seen in order to meet the services waiting timetargets.

We noted excellent practice within the Starfish Plus service.This service was able to respond to new patient referrals onthe day of receipt and ample time was allocated for visits.The caseload of the practitioner that we met with was 7-8children. This enabled the service to offer 3 to 5 visits perfamily per week.

The community team provided a number of specialistservices to meet the needs of the local community. Theycared for patients suffering from stroke and epilepsy,neurological patients and people with long termconditions, as well as frail elderly people prone to falls andpatients at the end of life.

We observed the community nursing and therapist teamsworking together to ensure all patients on the daily listwere visited as planned. The community staff confirmedpatients were told the day of the visit but were not given atime. One patient felt it would be good if they were toldwhether the visit would be in the morning or the afternoon.Some patients and staff told us they would like morecontinuity of care. We saw the Trust tried to offer continuityas much as possible and there was a commitment to dothis. In Norwich we spoke with three community nursingstaff who expressed concern about the new ways ofworking that had recently been instructed as part of theTrust transformation programme. The nurses wereconcerned that patients were no longer receivingcontinuity of care as different nurses were now visitingpatients all the time. Senior nurses confirmed there hadbeen some issues with continuity when the new model wasintroduced but they working hard to address this. Wespoke with staff who had been using this new model for alonger period of time within the North locality. They told usthat continuity of care was not a problem and the initial

difficulties had been ironed out. Although patients did notget to the see the same nurse for every visit, the aim was toprovide as much continuity for patients as possible. Therewas a recognition that this was in the patients and thestaffs best interest.

We saw a patient who had suffered a stroke whilst out ofthe county. Because the patient did not enter into thestroke pathway at the time of diagnosis they experienceddelays getting rehabilitation following their return home toNorfolk. Staff told us it was more difficult for patients toaccess the stroke pathway if they didn’t start in it. Thismeant services were not equitable because it depended onwhere the patient suffered their stroke. The pathway wasowned by another NHS acute Trust so this was outside ofthe Trusts control. We will raise this with the commissionersof the service.

The Trust monitored the responsiveness of the adultcommunity service and monthly reports were provided tothe Trust board regarding the number of patients withimmediate health care needs seen within 4 hours of referral(category A), the percentage of patients with urgent careneeds seen within 24 hours of referral (category B) and thepercentage of patients with routine care needs seen within10 calendar days of referral (category C). The results for thiswere good with 98% of patients being seen for category A,92.3% for category B and 95.7% for category C. The accessscores were higher than the Trusts targets. This meant thevast majority of patients were getting a responsive service.

In some areas people were able to access care andtreatment promptly once a referral was made. This wasdemonstrated in the Coastal Integrated team (Hersham &Hunstanton area, West locality) where there was no waitinglist. For example, a referral came through on 18 September2014 from a local NHS acute Trust for a home visit. Thepatients required an injection on 14 October 2014. A namednurse was allocated online and scheduled the samemorning. The waiting time for appointments in the LegUlcer clinic (Dereham, South Locality) were between one totwo weeks. There was one patient on the waiting list at thetime of our inspection. However, there were issues withwaiting times for appointments for some outpatients’ andspecialist clinics due to inadequate staffing numbers,unfilled vacancies and increased demands and workloadsas in the following services:

• Community Neurology Service/Clinic, St James Clinic,Kings Lynn (West Locality)



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The neurological team based at St James Clinic, Kings Lynnconsisted of 16 staff of different disciplines, includingspecialist nurses, therapists and psychologists. The staffconducted mainly home visits and some clinics. Due tosickness the team was short of one full timephysiotherapist and bank staff had been deployed but theywere not always available. We were told the waiting timesto see a physiotherapist or an occupational therapist were7 weeks for urgent cases and 17 weeks for non-urgentcases. At the time of our inspection, there were 67 patientson the waiting list.

There was a long waiting list for patients suffering fromstroke to see a therapist in the SALT clinic, namely 8-20weeks, for a swallowing assessment and 30 weeks in thecase of a communication assessment. We were told abusiness case had been submitted recently to the ClinicalCommissioning Group (CCG) for an increase in SALTnumbers to cope with the demand.

• Neurology Service/Clinic (South Locality)

The Neurology Clinic in Wymondham Health Centre (Southlocality) was managed by two specialist neurology nurses,supported by the hospital consultant and four GPs.Patients and GPs were complimentary about the staff andthe service they managed. However, the specialist nurseshad large caseloads totalling 880 patients and the waitingtime had increased from 6 months to 8 months for patientsto be reviewed. The initial referral was 6 to 8 weeks.

• Family Planning Service/Clinic (West Locality)

The family planning service based at St James clinic, KingsLynn, had a two month waiting time for the insertion of acoil and three to four weeks waiting time for an implant.

• Continence Clinics

In the Norwich area the Continence clinic had over60patients on their waiting list.

• Blood Clinic

The Blood Clinic based at Norwich Community Hospitalwas managed by two phlebotomists. We were told thewaiting time for blood tests was around 45 minutes. Twopatients told us they thought the waiting times in the bloodclinic were too long and they felt the opening times werelimited. The clinic was open until 14:00 hours. We observed

three patients arrive at Norwich Hospital shortly after14:00hrs for blood tests and were told the clinic was closed.They said their GP practice had not told them the clinic wasonly available until 14:00hrs.

• Podiatry Service (Norwich and West Locality)

The Podiatry service had been taking referrals from GP’sand other providers as well as from patients themselves.Patients had been complimentary about the Podiatryservice. However we were told the waiting time rangedfrom 5 weeks to 16 weeks, particularly in the Norwichlocality. Recently the waiting time had been over 18 weeksdue to the long term sickness of a senior medical memberof staff. This problem was being addressed by referringsome patients to an orthopaedic surgeon in a nearby Trusthospital. In addition, the Trust had offered clinic staffextended working hours and overtime pay to address thewaiting time problem. There were plans to employ morenurses. This service was subject to a contract query noticeby the Norfolk Clinical Commissioning groups. The Trusthad a remedial action plan in place to address the backlogof patients.

The Trust achieved the 18 week referral to treatment target(RTT) with performance of 98% in July 2014. RTT is aperformance measure used in the NHS to measure the timetaken from when the patient was referred to treatment tothe treatment being commenced. The Trust monitored itsperformance and presented a monthly IntegratedPerformance report to the Trust board. In July, all servicesachieved 100% of RTT times with the exception of thefollowing adult community services:

• Musculoskeletal (MSK) Physiotherapy, 94.7%• Podiatry surgery 80.4%• Specialist nurses epilepsy management 98.4%

The Trust had action plans in place to address thisperformance and these were monitored through the Trustsgovernance arrangements as well as through the clinicalcommissioning group. We did not find evidence that theTrust monitored waiting times for services that were notmonitored through national RTT targets.

Discharge, referral and transition arrangementsThe Trust told us that during 2013/14, there were 21palliative care patients on inpatient units who had adelayed transfer of care to other settings. Of these 21patients, four died on the ward, 4 died on the ward, 2 weretransferred to another NHS provider and the remaining 15



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were transferred to their usual place of residence or a carehome. This meant that 3.2% of patients had some part oftheir care delayed due to waiting to be discharged intoanother setting. The Trust were actively trying to reducethis further. In the inpatient service on the last Thursday ofeach month a snapshot was taken of patients whosetransfer of care had been delayed. Between October 2013 &March 2014 there were 60 delayed transfers of care whichwas an average of 10 per month for non-medical reasons.However the overall trend had been decreasing over theyear with a rate of just 5.0% compared to the upper ceilingof 5.4%.

Since April 2014, there was a single point of referral in placefor the school nursing team. We saw how this systemensured the effective deployment of staff which enabledhigher risk referrals to be fast-tracked so that children andfamilies had access to care in a timely manner. Weconsidered this to be an area of good practice.

Each of the health visiting teams held a weekly allocationmeeting to discuss caseloads and allocate new referrals tothe right staff members. We observed one allocationmeeting and saw how consideration was given to the skillsof each member of staff so they could meet the needs ofthe people accessing the service. Consideration was alsogiven to existing patients and referrals to other serviceswere discussed and agreed upon.

We were not assured there were sufficient pathways inplace to support the transition of the children they caredfor into adult services. We heard on some occasions thatstaff were not aware of adult services which could beaccessed for children who would need on-going supportinto adulthood. The only exception to this was within theresidential respite units where a clear pathway was inplace.

Staff explained patients were reviewed at the end of acourse of treatment before being discharged back togeneral dental services. On completion of treatmentpatients were discharged into the care of general dentistryunless the severity or complexity of their condition requiredtheir on-going care to continue within the specialisedservice. Where patients continued to meet the acceptancecriteria for the specialised service they were advised recallappointments would be offered at appropriate intervals inaccordance with National Institute of Clinical Excellence(NICE) guidelines.

A ‘Silver Call’ daily multi-agency discharge planningtelecom had been introduced in the West Locality. Thispromoted patient discharges at the earliest stage possibleand aimed to alleviate any barriers to discharges takingplace. The manager told us that the length of stay figuresindicated this was being successful in getting patientshome quicker than previously. We considered this to begood practice.

Some wards had discharge coordinators but others did not.Where coordinators were in post staff reported this workedwell and improved the communication and planning withother agencies who were involved in the patients dischargeplan. There were no plans in place to extend the dischargecoordinators role. On Beech Ward there was an EarlySupported Discharge team in place. Staff told us this waseffective in ensuring there was throughput on the ward.

Responding to and learning from complaints andconcernsWe found information about the Trusts complaintsprocedure in all areas that we attended. Staff were clearabout their responsibilities and were able to describe theprocess for escalating concerns internally.

We saw that leaflets on how to make a complaint andcontact PALS were available on inpatient wards and inreception areas. The leaflet included the timescale in whicha response would be given and was available in an easyread version as well as a range of languages. The Trust hada process in place for dealing with complaints whichinvolved the production of a monthly complaints report.The report identified trends in complaints and the learningto come out of them. This was reported every month to theQuality Risk and Assurance Committee and to the Trustboard.

The Trust reported 119 complaints received during thereporting period of December 2013 to May 2014, all ofwhich were acknowledged within 3 days and responded towithin 25 days. There were 19 complaints received aboutcommunity hospital services in 2012 – 2013, this wasexactly the same as the previous year. In some patientrecords, we saw that complaints were positively resolved ata local level at the earliest opportunity. These were notincluded on the complaints log, which meant there was amissed opportunity to learn from issues raised by patients.



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If patients left negative comments on the Trust’s websiteresponses were provided encouraging patients to contactPALS (Patient Advice and Liaison Service). The Trust alsokept a record of all compliments received. Over a thousandcompliments were recorded during 2013/14.

We saw numerous letters and cards expressing positivefeedback from patients and relatives about end of life care.Staff were aware of the Trust’s policy for handlingcomplaints and had received training in this area.Information was given to patients about how to make acomment, compliment or complaint. There were processesin place for dealing with complaints at service level orthrough the Trusts Patient Advice and Liaison Service.

Staff confirmed all investigated complaints and lessonslearnt had been cascaded down and shared at local teammeetings. Staff in the various community teams we visited

said they had not received any formal complaints. Staff haddeveloped a good rapport with people using the serviceand their relatives so that any problems could beaddressed promptly and this had avoided the need forpeople to complain. Practically all the people we spokewith were complimentary about the staff and the careprovided.

We looked at the response to two complainants that werechosen at random. Both the responses were signedpersonally by the Trusts chief executive and contained anapology that they had cause to complain. The responseswere sensitive and answered the questions that were askedwithin the complaint. Where possible the complaints teamwould meet with the complainant. The team would alsoascertain what outcome the complainant was looking for.



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Summary of findingsInstructions

We identified some concerns regarding the leadership inservices but overall we judged this to be good. Theleadership within the adult inpatient areas requiredimprovement.

There was a Trust wide Quality Improvement Strategy inplace which set out the vision and approach to qualityfor 1014-2016. In addition there was also anOrganisational Development Strategy in place that wasdeveloped from engagement of staff. The Trust hadbeen through a transformation programme forcommunity services and staff told us they had beeninvolved in the consultation.

There was an effective governance system in placewhich was made up of a number of committees thatreported through the Trust board.

The Trust board received a monthly IntegratedPerformance Report which rated key risks for theorganisation.

Local risk registers were maintained but we found somerisks were not reviewed in a timely manner and hadbeen on the register for some time. The number of riskson the individual registers varied considerably, with theWest locality having 30 risks and the specialist servicesunit having 258. The Trust took part in a plannedInternal Audit review of the board assurance frameworkand risk management controls during September 2014.The review identified there were no risks in the systemsand processes for risk management, but there wereseven risks relating to the operating effectiveness of thesystems and processes. Of these seven risks, five relatedto the management of the risk registers and two to themanagement of clinical incidents, serious incidentsrequiring investigation and quality issue reports. TheTrust were in the process of addressing the areasidentified by the internal audit.

There were four risks on the board assurance frameworkthat were still rated as high risk after mitigation

measures had been put in place. These related to safestaffing levels, effectively managing staff throughchange, dealing with cost pressures and not being ableto deliver cost improvements.

The Trust was an integrated provider of health andsocial care working with Norfolk County Council.Section 75 agreements were in place and the Trustworked with Norfolk County Council to provide anintegrated learning disability service. Work was underway to create a joint management structure withNorfolk County Council This meant there would be twoexecutive positions, a director of Integrated Care and aDirector of Nursing Quality. The post holders would takeresponsibility for all health and social care (excludingchildren’s services) across the whole of the Norfolk’shealth and social care system. It will see the integrationof community nursing, therapy and social work.

Our findingsInstructions

Vision and strategy for this serviceThere was a Trust wide Quality Improvement Strategy inplace which set out the Trusts vision and approach toquality for 1014-2016. The Trusts vision was to improve thequality of people’s lives, in their homes and community byproviding the best in integrated health and social care.There were a number of strategic objectives in place whichoutlined how the Trust would improve quality, enable itspeople and secure its future. There were business plans inplace for each of the services within the Trust.

There was an Organisational Development Strategy inplace that was developed from engagement of staff acrossthe Trust . As part of this work the Trust values wererefreshed involving 900 staff members. They were formallysigned off at an extraordinary Board on in June 2014. Thevalues were in the process of being rolled out across theTrust through promotion materials, training at Induction,mandatory training and leadership training. We foundsome staff knew about the values but it did vary across theTrust.

There was good leadership and support from localmanagers throughout the Trust and most staff felt engagedwith senior management. Staff felt leadership models

Are services well-led?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.

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encouraged supportive relationships as well ascompassion towards people who used the service. Staffwere encouraged to raise problems and concerns aboutpatient care without fear of being discriminated against.

The children’s community service was about to undergo achange in structure moving to a new integrated health andsocial care model. The changes had recently beenconsulted on and staff had been given opportunities tounderstand the proposed changes and provide feedback.All of the staff we spoke with were familiar with the changesand understood how they affected them.

The Trust had been through a transformation programmefor adult community services and staff told us they hadbeen involved in the consultation. As part of the Trusttransformation programme over 2000 staff werecommunicated with and involved in planning oftransformation, this has been a major change for manystaff. To help support the transformation and the qualityand organisational development work, 40 “ChangeChampions,” have been organised who werecommunicating 3 key messages to staff every 2 weeks.Staff were able to tell us about these messages.

Governance, risk management and qualitymeasurementThere was an effective governance system in place whichwas made up of a number of committees that reportedthrough the Trust board. The Trust Quality and RiskAssurance Committee (QRAC) reported directly to the Trustboard. This committee was chaired by a non-executivedirector who had a good understanding of the Trustsgovernance processes.

There was a Board Assurance Framework in place (BAF).The BAF described how the Trusts governance processesworked and how the Trust board received assurance andidentified key risks and their mitigating actions to managethem. A monthly risk group chaired by the Director ofNursing with representation from all of the business units/directorates was in place. The group reviewed all risks onthe corporate risk register and agreed what needed to beescalated to the executive directors for consideration forthe board assurance framework. Local risk registers weremaintained but we found some risks were not reviewed in atimely manner and had been on the register for some time.There were around 750 risks on Datix in September 2014,these were divided by 14 directorates/business units. Thenumber of risks on the individual registers varied

considerably, with the West locality having 30 risks and thespecialist services unit having 258. We noted the Westlocality had been proactive and had reviewed all of theirrisks.

The Trust took part in a planned Internal Audit review of theboard assurance framework and risk management controlsduring September 2014. The review identified there wereno risks in the systems and processes for risk management,but there were seven risks relating to the operatingeffectiveness of the systems and processes. Of these sevenrisks, five related to the management of the risk registersand two to the management of clinical incidents, seriousincidents requiring investigation and quality issue reports.The Trust were already addressing the areas identified inthe review at the time of our inspection and were makinggood progress against their action plan. This was an areathe Trust would need to continue to strengthen over thecoming months.

There were four risks on the board assurance frameworkthat were still rated as high risk after mitigation measureshad been put in place. These related to safe staffing levels,effectively managing staff through change, dealing withcost pressures and not being able to deliver costimprovements. The latter risk had a RAG rating of “25catastrophic,” and had not been reduced after mitigationmeasures. The risk was cited as “If cost improvementprogramme plans are not delivered over the five yearplanning period then the Trust will be unable to achievethe required surplus and liquidity levels.”

The Trust used an Early Warning Trigger Tool (EWTT) as amethod of identifying risks within teams and services. Thetool assessed metrics such as staffing levels, wait times andmanagement arrangements. The tool should be completedby all teams and when the score reached a definedthreshold, enhanced scrutiny was put into place. Withinthe Trust, any team/service rated as red had to have anaction plan in place of how risks will be mitigated against.In July 2014 there were 85 teams./services who submittedtheir EWTT self-assessment and they all had an action planin place.

The Trust board received a monthly IntegratedPerformance Report which rated key risks regardingperformance for the organisation. This meant the Trustboard were aware of performance across the organisation


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and could scrutinise and challenge action taken inresponse to this. Performance data was collected for eachteam and each locality. This included the use of the NHSSafety Thermometer to support the provision of safe care.

Regular quality monitoring visits were undertaken withinthe service. These visits used the Care QualityCommission’s essential standards of quality and safety as aframework. We noted that both positive feedback andareas for improvement were identified. We saw that localmeetings took place and minutes of these demonstratedthat the findings were discussed and solutions and actionsfor improvement were agreed. The findings from thesemonitoring visits were not always followed up and wefound some areas requiring improvement had beenidentified but not addressed. For example, in the inpatientareas a medication audit had identified areas ofimprovement but we found significant gaps in medicinesmanagement. Trust

As an NHS body, Norfolk Community Health and Care NHSTrust used the Information Governance toolkit. In 2013/14the provider was rated “Satisfactory” against Level 2.

The Trust recorded a compliance score of 87.1% for itsmandatory training programmes in 2013/14 against atarget of 90%. The overall appraisal rate had droppedbelow 90% to 66.6% in May 2014. The North locality hadthe highest level of compliance with a rate of 74.8%, whilstthe South locality had the lowest rate at 51.4%. The Trusthad a plan to improve performance against this. However,the vast majority of staff we spoke with told us they hadreceived an appraisal.

The Trust’s sickness absence rate for January – March 2014was 4.33%, which was slightly lower than the figure of4.57% for Community Health NHS Trusts nationwide forthis period. The May integrated performance report statesthat as at May 2014 staff turnover was at 10.9% .

LeadershipWe found the Trust to have good executive and non-executive leadership. It was evident from the boardminutes that non-executive directors provided challengeand scrutiny. Executive directors reported they feltsupported by the Trust non-executive directors. There hadbeen changes in the chief executive which some staffreported felt was unsettling. A new chief executive was dueto take up post in October 2014.

The Trust Chair provided strong leadership and we notedthe non-executive director who chaired the Assurance andQuality Risk Committee had an excellent understanding ofthe issues the Trust faced. There was good leadership fromthe nursing and medical director but there was arecognition that the portfolio for the director of nursing andoperations was too large although this was beingaddressed as part of the Trusts integration of communityservices.

Executive Directors in the Trust had a good understandingof the challenges and risks the Trust faced. They spokewith compassion and that they aimed to ensure the Trustprovided the best possible care to the communities theyserved. Executive directors were visible and many staffcommented they had seen the Director of Nursing visitwards, departments and community teams.

We spoke with a number of other agencies such as thelocal authority and the commissioners of the services priorto our inspection. We found without exception, all otheragencies felt the Trust had good leadership, were open andtransparent and were committed to providing patients withhigh quality care.

We looked at the NHS staff survey results for 2013 and sawthat the percentage of staff reporting support fromimmediate managers was 3.69 which is average whencompared with other Trusts. Staff reported a positiveculture in the service. They reported good engagement andfelt they were being listened to. Staff spoke positively aboutthe service they provided for patients. The staff surveyreflected this finding with the 73% of staff feeling satisfiedwith the quality of work and patient care they are able todeliver.

Staff told us they were encouraged to raise concerns aboutpatient care and this was acted on. We found all the staffwere dedicated and worked well as a team. Wheremanagers had approached the board with concerns aboutshort staffing levels they told us they had felt supportedand wards had closed to protect patients from thepossibility of poor care or harm.

We saw data that showed staff sickness levels were in lineor lower than expected targets. The majority of staff told usmorale was good but we noted that there were some staffgroups that felt less engaged with the Trust. Managers werepraised as being supportive and approachable.


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We found staff to be positive about their job but they werefeeling the pressures of working in an NHS Trust withstaffing difficulties. Several members of staff commentedthat team working was very good. Several staff told us theywere proud of the service they worked in. One staffmember told us the organisation it was a “Kindlyorganisation, where I can talk to managers, I have raised aconcern with the Chief Executive and as a resultimprovements were made.”

Ward managers told us they attended a monthly meetingwith their peers. This was regarded as a useful andproductive meeting which enabled staff to share ideas andexamples of best practice. Regular team meetings wereheld on wards to allow staff to share their views.

Nursing leadership at ward level was variable. We foundsome ward leaders displayed strong clinical leadershipwhile others did not always display the values andbehaviours that would be expected of a nurse leader. TheTrust did offer a leadership development programme andwere supporting staff to attend this.

Senior nursing leadership, such as that provided by wardmanagers and above was good. Generally we foundtherapy staff to have strong clinical leadership.

Culture across the providerAll the staff we spoke with assured us they understood theTrust whistleblowing policy and told us they would feelcomfortable using it if necessary. This suggested that theTrust had an ‘open culture’ in which staff could raiseconcerns without fear.

We held a focus group for all members of staff within theservice. We noted that staff clearly supported each otherand there was clear sense of team work and pullingtogether. Staff were keen to praise and acknowledge areasof good practice. There was also a demonstrableknowledge with regards to areas which did not work so welland which required improvement.

Staff we spoke with were proud of the service and werecommitted to ensuring patients received compassionateand high quality of care. During our inspection weobserved this passion and commitment translated into theactual delivery of care. Patients we spoke with were keen totell us how impressed they were by the service provided; inparticular they mentioned the understanding and patienceof staff to ensure their needs were met.

Staff told us they had opportunities to meet with theirmanagers and team members. Staff said, they (themanagers) were very supportive and listen to what we haveto say. They described how they felt valued and supportedto develop their skills to enhance the service provided. Staffexplained one to one meetings at regular intervals were tobe introduced and felt this was a useful innovation.

We saw the results of the Trusts staff survey for 2013. Theresults for indicators such as staff motivation, jobsatisfaction and ability to contribute towardsimprovements reflected the findings of our inspection tothis service.

The Trust supported the Nursing Times Speak Out Safelycampaign. The Trust had done this because they wantedevery member of our staff to feel able to raise concernsabout wrong doing or poor practice if they saw it andconfident that their concerns will be addressed in aconstructive way. There was a whistle blowing policy inplace and staff were able to tell us about this.

Public and staff engagementThere were 140 comments on the Trust on the patientopinion website, with 128 of these being positive in nature.Of the negative reports, six were regarding staffing levelsand waiting times, three were around staff attitude andthree regarding poor care. The Trust reported they receivedover 1000 compliments from patients, friends and familyduring 2013/14.

The Trust monitored its performance in the managementof complaints, this included the number of complaints aswell as the trends and themes people complained about.100% of complaints were responded within the Trusts 23day target. We saw evidence of the Trust identifyinglearning points from complaints and cascaded thesethrough to staff through the weekly message, throughnewsletters and to the locality clinical governancemeetings.

Every month the Trust board heard about a patient’sexperience at the start of their board meeting. A patient orcarer was supported by the Patient Experience andInvolvement team to share their experiences of their carefrom the Trust and how this connected with other servicesthey may have experienced. Patients and carers could


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directly tell the board about where care had been good andwhere improvements could be made. Actions arising werefollowed up by the Director of Nursing Quality andOperations.

Generally staff told us staff engagement was good althoughsome staff in different areas felt they were not listened to.Generally, staff spoke positively about being able to raiseconcerns with their immediate managers and to makesuggestions for improvements. The majority of staff feltthere were good lines of communication from the widerTrust, we were told about the “weekly message” which wasdisseminated to staff on a Friday and delivered keymessages such as updates to IT systems, new policies andprocedures, success stories and opportunities for staff tobe involved with.

The Trust held a Recognition of Excellence andAchievement in Community Health (REACH) ceremony onan annual basis. This was an awards ceremony torecognise the contribution of staff. In March 2014 theawards included some for staff working in inpatient areasincluding the specialist neurological rehabilitationinpatient service.

We were told of examples where staff, due to differentreasons, were unable to continue in the role they wereemployed in. The Trust had worked with staff to redeployand support them in new roles, in some circumstancescreating roles which were beneficial to the patients carepathway.

The results of the 2013 NHS Staff Survey showed the Trusthas performed better than the national average against fivequestions and worse than the national average against fivequestions. The Trust performed better against questionsregarding staff feeling their role made a difference topatients, effective team working, staff receiving job-relevanttraining, staff being appraised and staff receiving healthand safety training. The Trust performed worse thanaverage against five questions – the percentage of staffexperiencing physical violence from patients, staffexperiencing harassment from staff, staff feeling underpressure to work when unwell, staff reporting goodcommunication with management and staffrecommending the Trust as a place to work. The Trust’sperformance has deteriorated against the first twoquestions.

Innovation, improvement and sustainabilityThe Trust was an integrated provider of health and socialcare working with Norfolk County Council. Following asection 75 agreement of the National Health Service Act2006, the Trust worked with Norfolk County Council toprovide nurses and therapists to work with social workersin an integrated learning disability service. A furthersection 75 agreement for the provision of a jointmanagement structure was approved on October 1 2014.This meant there would be two executive positions, adirector of Integrated Care and a Director of NursingQuality. The post holders will take responsibility for allhealth and social care (excluding children’s services) acrossthe whole of the Norfolk’s health and social care system. Itwill see the integration of community nursing, therapy andsocial work. The post holders with be employed by theTrust but will report jointly to the Chief Executive as well asthe Director of Community Services at Norfolk CountyCouncil. Health and social care professionals will be co-located in teams and will share access to health and socialcare records as well as sharing referral processes and casemanagement.

Evidence showed staff were encouraged to focus onimprovement and learning. We saw examples of innovationsuch as the development of provision of care andtreatment for people with learning disabilities and ethnicminorities.

This service had been involved in the pilot of a new modelof measuring patient outcomes for those children livingwith ADHD called “Attention Star”. This is an Outcome Starwhich measures and supports progress for service userstowards self-reliance or other goals.

The dental services carried out epidemiological surveysusing national standards and criteria set by theDepartment of Health to provide information to informplanning of dental services regionally and nationally.Screening of local populations was undertaken wherethere was evidence needs were unmet to improve oralhealth and find the most effective way of meeting thoseneeds. We saw evidence of oral health promotion activitiesincluding those at schools and children’s centres andfeedback from children about what they had learnt.

A ‘Silver Call’ daily multi-agency discharge planningtelecom had been introduced in the West locality. Thispromoted patient discharges at the earliest stage possibleand aimed alleviate any barriers to discharges taking place.


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The Trust was involved in initiatives with other providersaimed at maintaining the independence of people at homeand avoiding hospital admission. One of the initiatives wasthe “Hospital Care at Home,” service in the West locality.

On the whole both managers and staff we spoke with werepositive about the reorganisation of the services andmethodology changes taking place within the Trust,through optimisation and transformation. Staff felt thesechanges would help eradicate inconsistencies in practicesthroughout the four localities.

The Trust had been developing a daily capacity reportingtool since early 2013. A project manager was appointed inMarch 2014 to work with operational teams to develop thetool further and create an electronic real time system forlocality teams to report daily capacity, demands and

escalation through the management line. The tool had aGreen, Amber, Red and Black colour coding system (GARB)that was calculated by using a set of agreed operationaltriggers. The information was entered into the electronicGARB (e-GARB) which then automatically calculates the riskfactors and produces the GARB coloured alert score. Eachlocality has a GARB escalation protocol to followdepending on the alert score. This tool has enabled themanagers in the Trust to have an ‘at a glance’ overview ofthe pressures staff were under and it has helped to providemanagers with the information they need to be able todivert resources where they were needed most. The nextphase of the project will see automatic alert emails beinggenerated to senior managers so that they don’t have todeliberately look at the system, they will simply just receivean alert when it is needed.


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Action we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.

Regulated activityTreatment of disease, disorder or injury

Regulation 13 HSCA 2008 (Regulated Activities)Regulations 2010 Management of medicines

Regulation 13

Management of medicines


The registered person was failing to protect peopleagainst the risks associated with the unsafe use andmanagement of medicines.

Regulation 13 HSCA 2008 (Regulated Activities)Regulations 2010


Regulation 18 HSCA 2008 (Regulated Activities)Regulations 2010 Consent to care and treatment

Regulation 18

Consent to care and treatment


The registered person did not have suitablearrangements in place for obtaining and acting inaccordance with, the consent of service users in relationto the care and treatment provided for them.

Regulation 18 of the HSCA 2008 (Regulated Activities)Regulations 2010


Regulation 9 HSCA 2008 (Regulated Activities)Regulations 2010 Care and welfare of people who useservices

Regulation

Regulation

Regulation

Compliance actions


Regulation 9

Care and welfare of people who use services


The provider had not taken proper steps to ensure thatpeople using the service were protected against the risksof receiving unsafe or inappropriate care by means ofthe planning and delivery of care and, whereappropriate, treatment in such a way as to:

• Meet the service users individual needs,• ensure the welfare and safety of the service user..

Regulation 9(1)(b)(i)(ii) of the HSCA 2008 (RegulatedActivities) Regulations 2010

Compliance actions


Documents

Good Norfolk Community Health and Care NHS Trust · improvement. For example medicines management, nursing documentation and care planning. There was a Trust wide Quality Improvement