Hillingdon Community Health Services

Hillingdon Community Health Services Services provided and their rating: Service Type Overall Trust Rating Local Hillingdon Provision Inpatient Hawthorne Intermediate Care Unit, Children, young people and families Multiple Hillingdon sites Adults Multiple Hillingdon sites/home care End of life care Multiple Hillingdon sites/home care Community Dental Services Uxbridge and Ickenham Community Sexual Outstanding Uxbridge/Hesa Health Services Acute wards for adults of working age and Psychiatric Intensive Care Units Long stay rehabilitation mental health ward for working age adults Wards for older people with mental health problems Community based for adults of working age Crisis and health based places of safety Inadequate Requires Improvement Requires Improvement Riverside Mental Health Centre 2 Colham Road Oaktree Ward, Pembroke Centre, Mead House, Mill House Riverside Mental Health Centre Community based Areas of good practice: for older people Specialist community for children and young people Community mental health for people with learning disabilities Community substance misuse Not rated Redford Way LBH/Riverside (not inspected) HDAS, Uxbridge The palliative care team worked closely with nursing homes to improve the end of life care, increasing the number of people dying in their homes rather than in hospitals. For the period 2010 to 2014 the number of older people in care and nursing homes dying in hospital had fallen from 31.90% to 22.80%, with numbers of people dying in their preferred place of care increasing from 67.5% to 81.20% and deaths in usual place of residence increasing from 50.5% to 66.80%. partnership working between Hillingdon hospital and the community rehabilitation team had highlighted to commissioners bed days could be reduced by providing intensive seven day a week therapy through evidenced based practice. As a result commissioners invested significantly in the rehabilitation team. Outstanding multi-disciplinary practice between the pharmacist and staff at the Hillingdon Intermediate Care Unit, in both medicines for patients on the unit, and medicines for patients when discharged. Staffing was very stretched especially for health visitors but work was prioritised based on risk. An active programme of recruitment was taking place particularly in Hillingdon. Staff were trained and appraised and there was a positive learning and sharing culture. The children and family provided many examples of good multidisciplinary and multi-agency work. Information was provided in a number of 1

Hillingdon Community Health Services formats to help children and families understand and implement the treatment. Staff understood and applied the principles of consent in their work with the children, young people and families. In Children Health Services risks were monitored at individual service level and across the for children and families. For example Hillingdon had a local service risk register which reflected concerns about staffing levels. This highlighted gaps in that were raised with local commissioners such as the need for specific for children with severe learning difficulties. Clinical audits in the School Nursing Service had looked at the management of asthma and severe allergies in schools. This led to the delivery of more training and care plans for some children. Carried out a mapping exercise using NICE guidance for children with autistic spectrum disorder. This was in collaboration with other partners and agencies across Hillingdon and resulted in a presentation to the joint commissioners highlighting the gaps in provision for children with social and communication disorders and recommendations for service improvements. There is a mind, exercise, nutrition and diet (MEND) programme, which was a 12 week course encouraging children to be more active and eat healthily in order to reduce their obesity. Health visitors were involved in delivering the programme to preschool age children. School nurses helped to identify children who would benefit from the programme and delivered rolling programmes across Hillingdon. Parents were encouraged to participate in the programme as well. processes for the handling of referrals through a single point of access and multi-disciplinary triage. For example a child being referred to the child development centre would be assessed and if they were identified as having a social communications disorder the child would be passed on for a multidisciplinary assessment. Physiotherapists and occupational therapists used visual aids and photo programmes with the parents to help them carry out activities at home. The majority of parents at the child development centre felt they had been involved in the planning and care of their children. The service had set up a local parent s forum which was a meeting for children with complex needs and their parents to discuss their views of the service and how it could be improved as well as providing a support group for parents. School nurses were providing drop in clinics for targeted secondary schools. Complaints were used to make improvements with their such as a complaint about a sight test not being carried out properly which led to more training provided to school nurses and information leaflets changed to reflect better practice. An engagement day which would be held annually, where parents and guardians of children with complex needs would come together to mix and meet other people and share ideas and concerns. Work had been completed to identify and support young carers of primary school age. This resulted in these younger children and their parents receiving more support. The children and families had adapted to make more integrated and accessible. Examples included the school nurse drop in clinics in Hillingdon. Patients were able to access palliative care out of hours. Patients, relatives and cares were able to access out of hour s telephone advice, and there was also a 24 hour consultant on call service for health care professionals to contact. A member of staff who had recently joined the palliative care team in Hillingdon told us that they had regular teaching/clinical sessions and that they had been booked onto further training in palliative care later this year. Palliative care team allocated new referrals on a daily basis and followed up non urgent referrals within 48 hours and urgent referrals within 24 hours. There was no waiting list. In Hillingdon we saw that where complaints had been made that these had been investigated and resolved satisfactorily. The complaints had been discussed in MDT meetings with action points to prevent further reoccurrence. Areas for improvement: No must do s or should do s identified The district nursing teams in Hillingdon should all maintain high standards of infection control practice. Where teams are using electronic and paper patient notes the recording should be more consistent. Assessments and the review of assessments should be completed in line with the agreed procedures for the team. Ensure district nursing staff have access to all essential equipment. Provision of storage for patients self - administered medication on Hawthorn Ward. Room temperature where medicines were stored was too warm (Hawthorn/ Sexual Health Services) 2

Hillingdon Community Health Services This section contains actions that are being taken, or are already in progress, in response to the findings presented in the CQC reports. Our conversations with you will help shape these actions and deliver a robust action plan back to the CQC. The borough continues to review and update the CQC action plan against all the must and should-do s. The Community Health Service has stated that they working towards compliance with the remaining should-dos and will state compliance by the end of March 16. 3

The district nursing teams in Hillingdon should all maintain high standards of infection control practice. The Infection control (IPC) team has worked with district nursing teams and Clinical Locality Leads improving infection control practice. Already in place an audit process to ensure ongoing monitoring of IPC standards and the results are routinely shared with all district nursing teams. The 2010 DH document Uniforms & Work Wear does not evidence outer clothing increasing risk of cross contamination, however we recognise it is best practice to mitigate the risk as far as possible. The CNWL Uniform Policy has been reviewed and now uniforms and dress code policy has been introduced. Where teams are using electronic and paper patient notes the recording should be more consistent. Assessment and the review of assessments should be completed in line with the agreed procedures for the team. Mobile working has long been recognised as a priority for Hillingdon Community teams and specifically District Nursing. The organization is moving forward with a mobile live documentation system which will mitigate this risk. This is due to be rolled out across Hillingdon in the next six months. Ensure district nursing staff have access to all essential equipment. Hillingdon district nurses do not currently have equipment bags; they have small bags first dressing initiative. CQC Inspectors observed that the nursing bag was inadequate. The nurse did not have a sphygmomanometer and told the inspector that it would be useful to have a bag and appropriate equipment to undertake assessments. All teams have sphygmomanometers and other equipment to undertake assessment, however each nurse is not allocated equipment such as thermometer, and sphygmomanometer and bags are not purchased. CQC has recommended that the Hillingdon district nursing service have equipment bags that are similar to the ones used in Milton Keynes. All equipment has been procured and has been distributed to all district nurses. storage of medications in place. Room temperature where medicines were stored was too warm (Hawthorn). The Hawthorn ward has reviewed the pharmacy room and adequate ventilation is in now in place. Room temperatures are being monitored regularly and are being maintained below 25 degrees. Trust wide - cold chain and room temp monitoring to be included in annual safe & secure handling of medicines audit, and risk assess sites/ treatment rooms if too hot. Continued Internal Quality Assurance: As part of the Trust s internal initiatives to monitor and drive continuous improvement across CNWL a quality inspection was undertaken between 23-25 November 2015. This involved volunteer staff from CNWL, commissioners and individuals from patient user/carer groups. The inspections were carried out across a number of. Overall the exercise confirmed that the Trust s other internal assurance processes were working well and no serious safety issues were identified during the course of the inspections. The visits reinforced the positive attributes raised by the CQC visit in February and particularly the caring approach of staff. As well as many positive comments the main continuing issue for community health that arose from the visits were: Care planning: It was found that in most areas the standard of patient engagement with care plans could be improved. Services continue these with spot checks as well as formal audits being carried out each quarter. Additionally, are looking at other ways to increase feedback from patients regarding the involvement they have in their care planning. Provision of storage for patients self-administered medication on Hawthorn Ward. The Hawthorn ward does not have patient self-administration storage. There were arrangements for patients to self-administer their medicines where appropriate. HICU is now compliant to enable patients to self-administer on HICU. All patients who are able to self-administer medication have safe secure Services provided and their rating: 4

Service Type Overall Trust Rating Local Hillingdon Provision Inpatient Hawthorne Intermediate Care Unit, Children, young people and families Multiple Hillingdon sites Adults Multiple Hillingdon sites/home care End of life care Multiple Hillingdon sites/home care Community Dental Services Uxbridge and Ickenham Community Sexual Outstanding Uxbridge/Hesa Health Services Acute wards for adults of working age and Psychiatric Intensive Care Units Long stay rehabilitation mental health ward for working age adults Wards for older people with mental health problems Community based for adults of working age Crisis and health based places of safety Community based for older people Inadequate Requires Improvement Requires Improvement Riverside Mental Health Centre 2 Colham Road Oaktree Ward, Pembroke Centre, Mead House, Mill House Riverside Mental Health Centre Areas of good practice: Specialist community for children and young people Community mental health for people with learning disabilities Community substance misuse Not rated Redford Way LBH/Riverside (not inspected) HDAS, Uxbridge Some positive work took place with the carers of patients and Hillingdon have established a monthly carer s surgery hosted by a senior manager and commencing 5 June 2015. The Occupational Therapy Team at the Riverside Mental Health Unit are demonstrating commitment to quality improvement and innovation, by working collaboratively with a local university (Brunel), on researching peoples experiences of using occupational therapy in. The PICU, acute wards and older adult inpatient wards are individually well led. The Mental Health Act compliance audit result for Crane Ward was 100% for informing patients of their rights within 24 hours. The wards had key performance indicators around admission, physical health care and care planning and these were audited weekly. This ensured that care plans were up to date and individual areas of risk were incorporated into care plans. Patients were positive about the food. Evidence of good practice was found in the implementation of Deprivation of Liberty Safeguards on Oak Tree ward. There were a range of skilled specialists working either on the ward or in the community linking into the ward, including OTs, Clinical Psychologists, pharmacists and activity co coordinators. There was evidence of discussion in the multi -disciplinary team about both physical and needs for all the patients. 5

At Hillingdon CRT most patients were very positive about the staff. However some patients thought some staff were not always caring and compassionate. Peer Support Workers have been recruited to work in the acute wards at Hillingdon. These are people who have had experience of using and they work within the ward based multi-disciplinary teams in a health care support worker role and provide direct support to patients because of their lived experience and provide additional insight to the teams about what it is like to be a patient on an acute ward. The ways in which staff manage relational security on PICU is commendable practice. The CQC inspectors observed positive, kind and caring interactions between staff and patients, including under challenging circumstances. It is worth noting here that there are no seclusion facilities at the Riverside Mental Health Unit. In 2014 the acute care introduced daily whiteboard meetings on each ward. These were attended by a range of disciplines including the Consultant psychiatrist, matron, staff nurse, psychologist, pharmacist, occupational therapist and medical trainees. The meeting provided a delay update on each patient and opportunity for professions to have daily oversight of what was happening with each patient. The support provided by the older persons community teams and the memory was thoughtful, respectful and considered peoples individual needs. The staff were making very good use of the Mental Capacity Act to support people to make complex decisions. The teams had appropriate staffing levels although the recruitment challenges in Hillingdon were noted. The waiting times from referral to assessment were longer than other. Staff spoke highly of their managers and their supportive team. The CQC inspectors spoke to people who use the and they were all positive about the service provided by the community teams. They said that they found the staff to be passionate, caring and respectful. The Hillingdon older adult s home treatment team is due to start a project looking into evidence based practice among crisis teams working with older people, with a view to involvement in research in the future. Changes occurred following serious incidents at Hillingdon CRT and a duty tracker system was developed following an incident. There were many examples of excellent risk assessments in clinical records in the community based. Incident reporting and learning from incidents was apparent across CAMHS teams. Staff had been trained and knew how to make safeguarding alerts. Staff managed medicines well. Young people referred to teams were seen by a CAMHS service that enabled the delivery of effective, accessible and holistic evidence-based care. CAMHS staff demonstrated their commitment to ensuring young people received robust care by being proactive and committed to people using the service, despite the challenges with limited resources. There was strong leadership at a local level and service level across most of CAMHS that promoted a positive culture within teams. There was a commitment to continual improvement across the CAMHS. Young people were used on interview panels and had been involved in developing interview questions. Acute Areas for improvement: 16 must do s 1. Staff working on all acute inpatient, PICU and Older adult wards must be able to articulate how they are assessing and managing the potential risks from ligature points for the patients using these. 2. Safety and suitability of premises: The Trust had not ensured that patients were protected from the risks associated with unsafe or unsuitable premises by means of suitable design and layout: Oaktree was specifically mentioned did not comply with guidance on same sex accommodation and compromised patients safety, privacy and dignity. 3. Patients did not have access to a lockable space to safely store their possessions which should ideally have been provided through a key to their bedroom doors. 4. Patients could not close their observation panel from inside their room to have privacy. 5. On Oak Tree Ward there were not clear lines of sight for observing patients and there was not consistent use of convex mirrors in areas of the ward where you could not clearly see. 6. Staffing: The Trust did not take appropriate steps to ensure there were sufficient 6

numbers of staff. The failure to increase staffing numbers in response to increased numbers of patients on the wards put patients at risk of not having their needs met appropriately. 7. The Trust had not ensured that patients were appropriately assessed and that the welfare and safety of patients was maintained. The reasons for the administration of rapid tranquillisation, and the reviews of patients physical health including vital signs, following rapid tranquillisation were not always demonstrated to ensure patients were not at risk. 8. Safeguarding service users from abuse and patients not being protected against the risk of unsuitable control or restraint. 9. The training of staff in current best practice in terms of prone restraint had not been completed across whole staff teams to ensure that staff had the necessary skills to restrain people safely where this intervention is needed. 10. Bed management: The wards were over-occupied. On admission to the ward, patients did not have a designated bed and often slept on other wards. Patients returning from leave did not have a bed on their return to the ward. 11. Some people in the acute wards experienced several moves between wards for non-clinical reasons during one admission. Of these some people were transferred during the night or went towards where they did not know or were not known by the multidisciplinary tea. 12. The Trust management had not anticipated increases in the demand for acute inpatient beds and put contingency plans in place that preserved the safety and dignity of patients. 13. Further steps must be taken to ensure that the risks to detained patients from being absent without authorised leave are minimised. 14. Complaints: There was a lack of information in the PICUs to inform people how to make a complaint. 15. Patients were not able to make telephone calls in private and there was no payphone for people to use such as on Crane Ward, where patients had to use the office phone and stand in the corridor which meant that calls were not private. 16. Lack of suitable arrangements to ensure that patients could participate in making decisions relating to their care and on Oak Tree ward patients were not always involved in their care planning or have a copy of their care plan where appropriate. community Areas for improvement: 5 must do s 1. Insufficient staff available to work as care coordinators, which meant that duty workers in the Hillingdon CRT were responsible for supporting a number of patients. This meant that the safety and welfare of patients was potentially at risk. 2. The planning and delivery of care did not always protect the welfare and safety of patients. Several patients using Hillingdon CRT had not been referred for regular physical health checks. 3. At Hillingdon CRT the service risk registers were not detailed and did not identify all risks affecting the service. The severity and likelihood of the risks were not measured and Risk Registers were not updated when actions were complete. 4. At Hillingdon CRT there were significant challenges managing a service on two sites. Each site effectively operated as a different team and this affected communication and continuity of care. 5. The provider had not protected service users from the risk of the use of unsafe equipment by ensuring the equipment is properly maintained and suitable for purpose. At the Hillingdon CRT (Pembroke Centre the automated external defibrillator (AED) had not been properly maintained and as a result there was a risk to people from the use unsafe equipment in an emergency situation. CAMHS Areas for improvement: 2 must do s 1. In Hillingdon there were two waiting lists for treatment. At the time of the Hillingdon inspection there were over 100 people on the treatment waiting list and some had been waiting for 12 months or more. 2. CAMHS used a number of measures to monitor the effectiveness of the provided. They conducted a range of audits on a regular basis. For example, in Hillingdon an audit in 2014-15 was completed to look at the dissatisfaction of people using the service with medical student visits and the reasons for the differences. Feedback was used to inform changes. This section contains actions that are being taken, or are already in progress, in response to the findings presented in the CQC reports. 7

Our conversations with you will help shape these actions and deliver a robust action plan back to the CQC. The following actions have already been completed to address the Must do s : Safe environment and safe care: Ligature risks have been identified in each ward and documented in risk registers held in each of these clinical areas. Each of the 4 wards has specific ligature risks identified and documented. There has been a clear drive to ensure that ligatures that are identified as requiring local management ( as reported by the CQC inspector on Oak Tree Ward) are fully understood by staff and included in staff supervision structures and MDT ward rounds. The ligature risk registers are reviewed on a monthly basis via the work place risk assessments. The Ward Managers and local Estates Lead conduct the monthly reviews. The ligature risk assessments are reviewed at the bi monthly estates and facilities meetings, where all four ward managers attend, with the local estates lead and matrons. There is a Trust Wide Ligature removal programme led by one of the corporate Estates Officer s, who oversees the Hillingdon Mental Health Services including the acute wards, Crane and Frays, PICU, Oak Tree and Colham Green. The programme is then reviewed at the local bi monthly estates meeting. The ligature risk audit is completed on an annual basis and this is led by the Trust Health and Safety Department and the Estates Team. The above programme is monitored by the Head of Mental Health Services for Hillingdon. The latest ligature risk audit and identified risks is shared with matron and ward managers and owned locally. Ligature risk competency framework and training programme has been developed. Staff have completed this training and staff are more competent in articulating the way that ligature risks are being managed in their wards. Nursing care plans and shift by shift entries are audited on a regular basis and individual patient care plans being linked to identified ligature risks according to patient and environmental risks are being monitored, and reported at ward level and at the Hillingdon Care Quality Meetings. Datix incident reports are monitored by the Riverside Unit Matron and Head of Mental Health Services. All episodes of self-harm are responded to with the individual team (including Consultant Psychiatrist) providing assurance on care and treatment plans. The Trust Risk Assessment policy includes a review of suicide and self-harm risk and individual patients presenting with ligature tying risks, or general risk of suicide or self-harm are identified and these issues are managed across the Multi- Disciplinary Teams on an ongoing basis. The observation and engagement policy provides the practice framework for managing self-harm risk via therapeutic engagement and enhanced one to one observation for patients identified as presenting significant self-harm risks Statistics on the use of close observation are monitored via the daily Trust wide bed capacity reports. All Estates and Facilities issues raised in the report are in the process of being completed and this is being overseen by the Trust Estates Team and the Head of Mental Health. This programme includes line of sight issues and same sex guidelines breaches. AED equipment has been ordered and is in place in all community sites. A bespoke training package for staff is underway the team managers with support from the Trust resuscitation lead. Rapid tranquillisation Policies are in place and include clear guidance on the safe clinical management of the patient post rapid tranquillisation. An audit programme is in place to monitor adherence to the policy. There is monthly monitoring of the times that rapid tranquilisation is used on the wards and each case is reviewed by the consultant psychiatrist and matron. This is overseen by the Head of Mental Health. All patients who have not been referred for physical health care checks have been identified and have been and referred for physical review. Service risk registers were updated in March 2015 and continually reviewed via the team meetings with oversight via the monthly Hillingdon Senior Management Team meetings. A community redesign programme is underway and the issue of split site issue is central to the proposed model. Staff, partners and service users have been engaged through this process. 8

Staffing Staffing levels have been increased since November 2014. Safer staffing reports are monitored monthly and reported externally via NHS Choices. There has been 100% safer staffing for June and July 2015. This is monitored by the Divisional Director of Nursing. Staff recruitment strategies are in place to ensure that the use of temporary staff is minimised, as continuity of care and treatment and the recruitment of highly skilled staff is a key target. Staffing vacancies are monitored on a regular basis and reported at the local senior management team meetings. All episodes of staffing shortages are escalated to the senior managers with responsibility for the day to day operation of the service. Caseloads held by care coordinators have been reviewed and extra capacity has been achieved through team leaders taking on immediate responsibility for unallocated patients at the CRT. There have not been any unallocated patients since January 2015. Safeguarding service users from abuse and patients not being protected against the risk of unsuitable control or restraint: The Trust now produces monthly reports on the use of restraint including prone restraint incidents. All prone restraint episodes are registered with the Trust serious incident system. A No Force strategy is under development via the Director of Nursing and there was good participation from Hillingdon Staff at a training event in May of this year. Designated key staff have all attended positive behaviour support training. The therapeutic management of violence aggression training is mandatory and all staff working in wards are mandated to attend. Care and welfare of people who use : All patients currently have access to a phone and are able to use personal mobile phones. Patient pay phones will be installed on each acute ward and Oak Tree by the end of June 2015. This programme will be led by the Local Estates Officer and compliance will be achieved by 1 July 2015. The outcome will be that all patients will be able to make personal calls in comfort at any time. Bed management: There have been cases where patients have been slept out since the end of February 2015 in Hillingdon. A breach reporting structure has been set up to monitor bed management. There have been no inappropriate moves of patients to Oaktree Ward. The have maintained wards within their allocated numbers. Extra acute beds are now decommissioned. A transit lounge has been established in Hillingdon since January 2015, with recent commissioning support from Hillingdon CCG. This is now referred to as an assessment lounge and has been fully integrated into the management of patient flow. The overall aim of the Trust s bed management process is to reduce the bed occupancy rate to 95% by 1 June 2016. This is being monitored at a thrice-weekly bed management meeting with director level involvement. community and home treatment team engagement in preventing unnecessary admissions, and Community team provision of support in progressing delayed discharges and work together to resolve unnecessary delays. Escalation process both in and out of hours to manage patient flow put in place. Local ownership: bed occupancy is discussed at least twice daily with Borough and Clinical Directors. Improved information flow: twice daily (morning and evening) bed state disseminated across the Trust. Use of ECR beds: we are using ECR beds as and when necessary with the support of funding from commissioners - these conversations are ongoing. Engagement of stakeholders: Borough Directors are currently working closely with our local authority and commissioner colleagues in managing delayed discharges. This is on-going. 9

Quality of service provision: A bed closure programme is under development for Oak Tree Ward which would ensure compliance with same sex accommodation guidance. Seven beds have now been closed and estates work is underway. All single and dormitory rooms now have access to observation panels that can be locked closed by the patient to ensure privacy. The panels are kept closed and are opened for observation monitoring of patients. An AWOL reporting structure has been put in place from May of this year and is reported monthly to the Divisional Board and to the Trust Quality and Performance Sub Committee. All episodes of detained patients absconding from the unit are reported via the trust serious incident reporting system. An Estates strategy to enhance the security of the Riverside Centre is underway with a completion date of August 2015. partnership arrangements exist between Hillingdon Police and the Mental Health Services to ensure that AWOL processes are safe and responsive to patient need. The waiting times for all community based are subject to a performance review and regular reporting structure. This is overseen by the SMT Significant progress has been made and patients who are on the lists have been reviewed and risk assessed in the memory and older adult CMHTS. been conducted and the Trust-wide audit of care plans includes a section on whether the patient understood the plan and whether a copy was provided. The results of these audits will be reviewed at the Care Quality meetings at Hillingdon from July 2015. CAMHS: Triage system is in place; process in place reiterated to staff which is beginning to address the high demand on the service. There has been additional capacity provided in Hillingdon which has shown a steady progress in meeting this demand. The service has reissued and discussed the Lone Working Policy and Procedures and managers have been asked to review alarm systems. Care and crisis plan - all staff reminded to discuss this with service users and record this is done. Continued Internal Quality Assurance: As part of the Trust s internal initiatives to monitor and drive continuous improvement across CNWL a quality inspection was undertaken between 23-25 November 2015. This involved volunteer staff from CNWL, commissioners and individuals from patient user/carer groups. Complaints: A complaints tracker system has been set up since April 2015 and complaints and response times are monitored via the Senior Management Team meetings. Complaints information for patients on how to complain has been reviewed and provided in all April 2015. A carers surgery hosted by a member of the Senior Management Team has been set up with the first session was held on 5 June 2015. A register for verbal complaints has been operational since end of June 2015. Respecting and involving service users: A review of care plans and the provision of these to patients on Oak Tree Ward has The inspections were carried out across a number of. Overall the exercise confirmed that the Trust s other internal assurance processes were working well and no serious safety issues were identified during the course of the inspections. The visits reinforced the positive attributes raised by the CQC visit in February and particularly the caring approach of staff. As well as many positive comments the main continuing issues that arose from the visits were: Staffing: Issues regarding skill mix on inpatient wards mainly due to high vacancy rates and having to rely on bank and agency staff. This matter continues to be addressed and different recruiting strategies have been implemented to encourage high levels of recruitment and retention. One such method is in a Rotational Programme for Band 5 and 6 nurses which 10

will allow newly appointed staff to work in different environments on a 6- monthly basis for 2 years. Staff will be supported by a mentor and training package. In addition the borough is undergoing an extensive redesign of its community. This, in part, aims to simplify the patient s access and journey through and has considered the skill mix and staffing requirements to manage demand. The implementation of the new is due imminently. Care planning: It was found that in most areas risk assessments were evidenced in care plans. The standard of the care plans were noted to have shown improvement although not perfect everywhere. Services continue these with spot checks as well as formal audits being carried out each quarter. Additionally, are looking at other ways to increase feedback from users regarding the involvement they have in their care planning. The borough continues to review and update the CQC action plan against all the must and should-do s. As of December 2015 the borough has stated it is compliant against all of it must-do s. These will be continued to be monitored along with further work against the remaining should-do s. 11

Hillingdon Community Dental Services Services provided and their rating: Service Type Overall Trust Rating Local Hillingdon Provision Inpatient Hawthorne Intermediate Care Unit, Children, young people and families Multiple Hillingdon sites Adults Multiple Hillingdon sites/home care End of life care Multiple Hillingdon sites/home care Community Dental Services Uxbridge and Ickenham Community Sexual Outstanding Uxbridge/Hesa Health Services Acute wards for adults of working age and Psychiatric Intensive Care Units Long stay rehabilitation mental health ward for working age adults Wards for older people with mental health problems Community based for adults of working age Crisis and health based places Inadequate Requires Improvement Requires Improvement Riverside Mental Health Centre 2 Colham Road Oaktree Ward, Pembroke Centre, Mead House, Mill House Riverside Mental Health Centre Areas of good practice: of safety Community based for older people Specialist community for children and young people Community mental health for people with learning disabilities Community substance misuse Not rated Redford Way LBH/Riverside (not inspected) HDAS, Uxbridge incident reporting system, found appropriate actions had been identified, carried out and learning shared with all staff through regular updates and staff meetings. Patients were told when they were affected by something that had gone wrong, given an apology and informed of any actions taken as a result. Safeguarding champions attended safeguarding meetings, also participated in incident learning groups which brought together within the directorate. Effective system in place for the prescribing, recording, dispensing, use and stock control of medicines used in clinical practice, including medicines for sedation. These medicines were stored safely for the protection of patients. At all the locations clinical patient records were computerised, password protected, and kept securely so that confidential information was protected and could be located promptly. Hard copies of written patient information including consent forms, NHS forms, treatment plans and medical history forms were archived in locked and secured rooms at each site. Decontamination technicians were utilised in all locations which is considered good 12

Hillingdon Community Dental Services practice. Hillingdon PDS had divided dirty and clean decontamination areas into two separate rooms with an instrument track and trace system which demonstrated their commitment to best practice guidance. Segregation and storage of dental waste was in line with current guidelines laid down by the Department of Health. Use of safer sharps and the treatment of sharps waste were in accordance with current guidelines. Daily, weekly, monthly, quarterly, six-monthly and annual checks and servicing and maintenance of decontamination equipment were carried out effectively in line with guidance. There was a range of suitable equipment which included an automated external defibrillator, emergency drugs and oxygen available for dealing with medical emergencies. This was in line with the Resuscitation UK and British National Formulary (BNF) guidelines. The emergency medicines and oxygen were all in date and were securely kept in a central location known to all staff. Expiry dates of medicines and equipment were monitored using a weekly check sheet which enabled staff to replace out of date supplies in a timely manner. This ensured the risk to patients and staff during dental procedures was reduced and patients were treated in a safe and secure way. Services had effective risk assessment systems in place to identify and manage patients who may present with behaviour that challenges. All staff had undertaken training in conflict resolution. The clinical records viewed were well constructed and included evidence of treatment plans discussed. Observed care provided was evidence based and followed recognised and approved national guidance such as the General Dental Council (GDC), National Institute for Health and Care Excellence (NICE), Faculty of General Dental Practice (FGDP), and British Society of Disability and Oral Health (BSDOH) using nationally recognised assessment tools. Care and treatment under sedation was provided by dentists and dental nurses who had all undertaken certificated training with The Society for the Advancement of Anaesthesia in Dentistry (SAAD). Services had developed sedation care pathways which followed evidence based guidance including the Standing Committee for Sedation in Dentistry s Standards for Conscious Sedation in Dentistry: Alternative Techniques and National Institute for Health and Care Excellence (NICE) guidance for Sedation in children and young people. Dental general anaesthesia (GA) and conscious sedation was delivered according to the standards set out by Royal College of Anaesthetists and the Department of Health Standing Committee Guidelines in Conscious Sedation 2007. The GA and sedation care was prescribed using an approved care pathway approach. Patients enter a recognised pathway of: Tender Loving Care (TLC), TLC and inhalation sedation and finally GA. Services had implemented a clinician led system of referral for patients accessing the service. This system had reduced the number of inappropriate referrals to the service and helped to ensure clinic time was allocated to those patients with the greatest need. Services worked with local primary and secondary dental care providers and other providers to ensure smooth discharge and transitional arrangements for on-going care and support. Patients and their families were appropriately involved in and central to making decisions about their care and the support needed. We found planned care was consistent with best practice as set down by national guidelines. Observation of practice and review of patient records evidenced that staff were assessing the patient s capacity to be able to give valid consent using the Mental Capacity Act (MCA). Staff had a good understanding of consent and applied this knowledge when delivering care to patients. This included established processes for gaining consent from children and young people using the test of Gillick competence and following Fraser guidelines. Robust processes in place for obtaining consent for patients undergoing General Anaesthesia and IV sedation. Patients were given explanations about their dental treatment in language that they could understand. They were treated with respect and dignity at all times. Some staff had undertaken additional courses in their own time as well as those supported by the Trust, or were members of specialist societies to help support patients needs. This included training in British Sign Language, autism and dementia care. Planned care was consistent with best practice as set down by national guidelines. Staff were clear on the importance of emotional support needed when delivering care. Staff demonstrated a high degree of empathy in their approach. Staff responsible for providing care and treatment for children under GA or sedation demonstrated compassion and understanding of the level of emotional support required for both patients and their relatives or representatives. This included the 13

Hillingdon Community Dental Services provision of a child friendly environment for treatment recovery areas. collaborative and multidisciplinary team working and effective links between the different clinics. Services worked with the relevant local authorities to develop both the public health and dental public health agenda. Children at high risk of dental decay were offered fluoride varnish as a preventive measure in accordance with the Department of Health publication Delivering Better Oral health; a toolkit for prevention. Locations viewed were fully accessible for people with a physical disability or who required the use of a wheelchair. Oral health improvement teams had considered equality and diversity when planning their service initiatives. This included a programme involving local children s centres. Effective discharge protocols, patients were discharged in an appropriate, safe and timely manner. The use of clinic leads appeared to be a good innovation. The clinic leads were responsible for the day to day running of each clinic. Services had an effective system to regularly assess and monitor the quality of service that patients received. Records of various checks, observation of completed audits and discussion with the senior team management confirmed a strong commitment to quality assurance and maintaining high standards. Services have an open and transparent culture and focused on the needs of patient, many examples of collaborative team working. The culture of the encouraged candour, openness and honesty. Services actively engaged with patients, parents, guardians and carers to seek feedback and used this information to identify any areas for improvement. Culture of the service appeared to be that of continuous learning and improvement. Innovative partnership working enabled oral health to be high on the agenda for the incorporated within a variety of settings. A number of the dentists had additional post graduate degrees and diplomas which enabled the service to provide increasingly complex care to an increasingly complex and diverse patient base. Opportunities and support for staff who wanted to change roles within their service. This encouraged sustainability of the service. Service managers in both Buckinghamshire and Hillingdon had shared ideas in good practice and innovation in order to develop and improve where possible. Areas for improvement: No must do s Discussions from the Quality Summit to be taken forward in partnership with commissioners and other stakeholders: Redesign: All in agreement that bed pressures could not be resolved by expanding bed capacity but needed redesign of community and availability of appropriate admission avoidance. This needed to be done collaboratively and at pace. Discussed regarding Older Adult service redesign as well, including the need to use HTT to support care homes with dementia and for more integrated older adult CMHTs. Actions: MH CRHTT CCG has agreed to consider business case at the CCG governing body without delay, once CNWL submits final business case. Assessment lounge CCG has agreed to consider business case without delay. Dementia: Top priority for CCG looking to invest more resources. Business case put forward by CNWL to increase memory service provision being considered by CCG although a clear timeline in this regard could not be established. Discussed that dementia care homes struggling with managing residents leading to reluctance to accept those with complex needs. MH HTT support in line with physical health rapid response and community matron service considered as a way forward. Action: LA and CCG have agreed to discuss potential BCF business case for integrated older adult CMHT i.e. SW staff within CMHT. Recruitment issues in Hillingdon both within CNWL and the LA. Action: LA (John Higgins) to discuss with Kim Cox (Borough Director CNWL) potential to undertake joint recruitment for MH staff including Care Managers. 14