NorthEastLondonNHSFoundationTrust Communityhealthservices ... · NorthEastLondonNHSFoundationTrust RAT Communityhealthservices forchildren,youngpeople andfamilies QualityReport NorthEastLondonFoundationTrust

North East London NHS Foundation TrustRAT

CommunityCommunity hehealthalth serservicvicesesfforor childrchildren,en, youngyoung peoplepeopleandand ffamiliesamiliesQuality Report

North East London Foundation TrustThe West WingCEME CentreMarsh WayRainhamRM13 8GQTel: 0300 555 1200Website: http://www.nelft.nhs.uk/ Date of inspection visit: 10 to 12 October 2017

Date of publication: 09/01/2018

1 Community health services for children, young people and families Quality Report 09/01/2018

Locations inspected

Location ID Name of CQC registeredlocation

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

Postcodeofservice(ward/unit/team)

Acorn Centre Child Development centre,community medical paediatrics,social communication clinic.

RM7 9NH

Axe Street Child and FamilyCentre

Child and family clinics, BCGimmunisation clinic, Paediatricoccupational therapy

IG11 7LZ

Thames View Health Centre Health visiting, school nursing. IG11 0LG

Harold Wood Clinic Audiology Clinic RM3 0FE

Harold Hill Health Centre Health visiting RM3 9SQ

South Woodford Health Centre Health visiting E18 2QS

Brentwood Community Hospital Paediatric physiotherapy,Paediatric speech and languagetherapy.

CM15 8DR

Grays Health Centre School nursing, 0-19 healthfamilies, health visiting

RM17 5BY

Wood Street Child and FamilyCentre

Physiotherapy, childrenscommunity nursing team, LACteam

E17 3LA

Trinity School Special needs school nursing RM10 7SJ

RATDK Mayflower Community Hospital LAC team, specialist healthvisitors

CM12 9SA

Hainault Health centre Infant feeding team IG7 4DF

The Grove Specialist services for CYP – earlyintervention services, autismdisorders

RM6 4XH

This report describes our judgement of the quality of care provided within this core service by North East London NHSFoundation Trust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘IntelligentMonitoring’ system, and information given to us from people who use services, the public and other organisations.

Summary of findings


Where applicable, we have reported on each core service provided by North East London NHS Foundation Trust andthese are brought together to inform our overall judgement of North East London NHS Foundation Trust

Summary of findings


Ratings

Overall rating for the service Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Summary of findings


Contents

PageSummary of this inspectionOverall summary 6

Background to the service 8

Our inspection team 8

Why we carried out this inspection 8

How we carried out this inspection 8

What people who use the provider say 9

Good practice 9

Areas for improvement 9

Detailed findings from this inspectionThe five questions we ask about core services and what we found 11

Action we have told the provider to take 50

Summary of findings


Overall summaryOverall rating for this core service is good because:

• Following our last inspection in April 2016, we issuedone requirement notice requiring the service to takeaction to remedy breaches to Regulation 17, in relationto good governance and issued 15 actions the providershould take to improve. During this inspection, wefound that the service had dealt with or shownimprovement for most of the previously reportedconcerns.

• Although the trust had addressed the previousinspection’s requirement notice through theimplementation of electronic diaries, the leadershipteam recognised some staff were still using paperdiaries whilst awaiting agile working equipment. Thetrust mitigated risks by completing data managementaudits of these diaries alongside supervision with linemanagers. However, the trust still had to ensure allstaff had access to electronic diaries through theappropriate equipment.

• The trust had been addressing concerns around heavycaseloads through different methods. These includedincreasing staff skill mix, using a new caseloadallocation tool and performance allocation tool,implementing managerial supervision to discusscaseloads, checking staff wellbeing and negotiatedextra funding for staff from commissioners. However,the decommissioning of services, changes to servicecontracts, changing populations needs andrecruitment challenges meant caseloads remainedhigh for some services.

• The trust had implemented a transition policy inAugust 2017 but commissioning issues still affectedthe transition arrangements. Service leadsacknowledged there were some gaps and recognisedthat receiving services had different criteria. Transitionwas recognised as a national commissioning issue.However, where transition arrangements were inplace, the process was effective.

• The trust had recently developed a 10 year vision andstrategy for the service. Senior leads told us the trustmedical director engaged with staff and members ofthe public and patients to develop the strategy.

However, the document was in its infancy and the trustacknowledged that not all staff would be aware of thedocument, and more time was required to embed itfully.

• The trust had demonstrated improvements inreducing staff vacancy rates in some services butrecruitment of specialist therapy roles remained achallenge for the trust. However, the trust managedvacant staff posts effectively by using bank and agencystaff as required.

• Although the trust had made improvements to waitingtimes for some services, further work was still requiredto be compliant with national guidance and maximumwaiting times of 18 weeks. Staff recruitment andcapacity issues affected wait times, but the trust hadconducted data cleansing exercises to ensure onlythose clients who needed assessment andinterventions remained on the waiting list.

• The trust had cleared the initial backlog of transferringscanned consent forms for immunisations by usingadditional administration staff. However, on thisinspection, there was still a backlog due to lack ofappropriate equipment such as scanners. The trustwas addressing this at the time of the inspection andhad developed an action plan to monitor progress.

• The community health services for children, youngpeople and families (CYP) service had systems foridentifying, reporting, and managing safeguardingrisks. The safeguarding team provided good support tostaff across CYP services through supervision, training,monitoring of incidents and advice via the duty desk.

• Staff were encouraged to raise concerns and to reportincidents and near misses. The CYP service effectivelyshared learning from incidents and good practice withstaff through regular meetings, newsletters and acrosslocalities. Staff told us they valued working for the trustand that service leaders were supportive, accessibleand approachable.

• The CYP service demonstrated effective internal andexternal multidisciplinary (MDT) working. Clinical

Summary of findings


practitioners worked with other staff as a team aroundthe child. The co-location of services in health centresand partnership working with other service providersfacilitated MDT working.

• The trust health centres and children centres weinspected were clean, tidy, and clutter free. Waitingrooms and clinic rooms were child friendly with toys,books and other resources appropriate for differentages.

• Staff supported the patients and families they workedwith, and provided patient-centred support in clinicsand in homes. The trust actively sought feedback frompeople using the service and engaged them toimprove services.

• People using the trust’s community CYP services weretreated with dignity and respect. People felt listened toby health professionals, well informed and involved intheir treatment and plans of care.

• The service was responsive to the needs of peopleusing it and had adapted to meet the diverse needs ofthe community it served. Staff, patients and familieswe spoke with told us they had good access totranslation services.

• There was a robust governance framework andreporting structure. Staff had confidence in theirimmediate line managers and leadership at boardlevel.

However:

• We saw inconsistent compliance with controls andstandards for hand hygiene and infection preventionat some of the locations we visited and among staff.

• Compliance targets across localities were notconsistent, with some localities performingsignificantly worse than others in the delivery ofcertain aspects of the health visiting service.

• The trust managed complaints appropriately,completing relevant investigations and respondingwithin the time scales set in the trust policy. However,we found completion of the online recording systemincomplete as risk assessments and lessons learntsections were blank in some cases.

Summary of findings


Background to the serviceNorth East London Foundation Trust (NELFT) provides anextensive range of integrated community and mentalhealth services for people living in the London boroughsof Barking & Dagenham, Havering, Redbridge andWaltham Forest and community health services forpeople living in the south west Essex areas of Basildon,Brentwood and Thurrock. The trust employs around6,000 staff.

The trust managed services for children and youngpeople on a locality basis aligned with the sevenboroughs that the trust works with. Within each locality

children and young people (CYP) services were separatedinto two divisions: targeted services and universalservices. The trust’s universal provision included healthvisiting, school nursing and immunisation. Targetedservices included child development, communitypaediatricians, looked after children, children’scommunity nursing, paediatric physiotherapy,occupational therapy, and speech and language therapy.

Since our last inspection in April 2016, some services hadbeen decommissioned such as Family Nurse Partnership(FNP), and health visiting in Essex.

Our inspection teamOur inspection team was led by:

Inspection manager: Max Geraghty, CQC

The inspection team included two Care QualityCommission (CQC) inspectors and a number of

specialists, including two health visitors, a school nurse,paediatrics service senior manager, a safeguarding nursefor children, a speech and language therapist,community paediatric physiotherapist and an Expert byExperience.

Why we carried out this inspectionWe inspected this provider as part of our comprehensiveinspection programme, and to follow up the progress ofthe service following our previous inspection in April2016.

How we carried out this inspectionTo fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

Is it safe?

Is it effective?

Is it caring?

Is it responsive to people’s needs?

Is it well-led?

Before the inspection visit, we reviewed information thatwe held about these services, asked a range of otherorganisations for information and sought feedback frompatients at nine focus groups.

We inspected a selection of the trust’s services acrosslocalities. During our inspection we visited the trust’shealth and children’s centres such as the Acorn Centre,Axe Street Child and Family Centre, Thames View HealthCentre, Harold Wood Clinic, Harold Hill Health Centre,South Woodford Health Centre, Brentwood CommunityHospital, Mayflower Community Hospital, RedbridgeChild Development Centre and Wood Street Child andFamily Centre.

Summary of findings


We also attended home visits and clinics in localchildren’s centres. We spoke with 45 patients and theirfamily members. We observed care and treatment andlooked at 40 care records, ten administration medicationcharts and 11 looked after children (LAC) records. We alsospoke with 106 staff members, including health visitors,community children’s nurses, consultant communitypaediatricians, physiotherapists, other allied healthprofessionals, administrators and senior managementstaff.

In addition, we reviewed national data and performanceinformation about the trust and read a range of policies,procedures and other documents relating to theoperation of the service. We also looked at looked atpatient feedback about the service over the past year.

What people who use the provider say• We spoke with 45 patients and their families during the

course of the inspection. Although some patientsreported long waiting times, the patients we spokewith talked positively about the care and treatmentthey received once in the system.

• Patients and their families told us they found staff tobe kind, caring, compassionate, informative,

professional and respectful. The following wasrepresentative of the feedback received: “very happywith the care”, “staff do a wonderful job”, “staff havetime to talk to you and encourage children” and “goodemotional support”.

Good practice• The service demonstrated highly effective internal and

external multidisciplinary working, facilitated by co-location of services and partnership working withother service providers.

• The trust had comprehensive safeguardingsupervision processes in place for staff. There was verygood compliance with the trust's child safeguardingtraining and comprehensive safeguarding supervisionprocesses in place.

• The CYP service used a single point of access referralsystem with a single point of contact, such as aspecialist health visitor to simplify the process forpatients.

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

• The trust should consider aligning compliance targetsacross the trust so that there is better uniformity ofapproach to the delivery of health visiting services.

• The trust should ensure all of the trust locations withinall the localities comply with hand hygiene andinfection prevention and control standards.

• The trust should ensure that all equipment iscalibrated regularly including safety testing ofequipment in schools.

• The trust should improve the completion of the onlinerecording system for complaints ensuring riskassessments and the lessons learnt sections werecompleted.

Summary of findings


• The trust should continue taking steps to reduce thebacklog of transferring scanned consent forms forimmunisations onto the trust electronic recordsystems with the provisions of appropriate equipmentsuch as scanners.

• The trust should continue working on reducing waitingtimes for therapy and diagnostic services such asspeech and language therapy, occupational therapyand social communication pathways.

• The trust should continue working withcommissioners to develop consistent transitionarrangements from paediatric to adult services acrossservices and localities.

• The trust should continue taking steps to reducecaseload allocation for therapy staff to ensurecompliance with relevant national guidelines.

Summary of findings


By safe, we mean that people are protected from abuse

Summary

We rated safe as good because:

• The trust had clear and comprehensive policies,processes and training for child safeguarding. Thesafeguarding team and the trust board regularlyreviewed policies ensuring they were up-to-date. Stafftold us they could find policies easily from the trustintranet.

• The trust reviewed mandatory training regularly throughmanagement supervision to ensure compliance ratesacross CYP services were in line with the trust target of85%.

• The service had robust systems for identifying,reporting, and managing safeguarding risks. The childsafeguarding team provided support to staff across CYPservices through supervision, training, monitoring ofincidents and providing advice via the duty desk.

• The service had good processes to report risks andidentify learning from incidents. The service sharedlearning from incidents in team meetings, throughinternal emails and across localities.

However:

• The trust had not ensured all services complied withinfection prevention and control measures to preventthe spread of infection. During this inspection, we foundthat some locations were not compliant with handhygiene standards, for example, the Child and FamilyCentre on Axe Street.

• The trust did not ensure contractors regularlyconducted safety checks on all equipment used acrossthe service. For example, we found checks on most ofthe portable weighing scales were out of date. Wehighlighted this during the inspection. The trust told usthe external contractors subsequently calibrated theportable scales on 17 October 2017.

North East London NHS Foundation Trust

CommunityCommunity hehealthalth serservicvicesesfforor childrchildren,en, youngyoung peoplepeopleandand ffamiliesamiliesDetailed findings from this inspection

ArAree serservicviceses safsafe?e?

Good –––


Mandatory training

• CYP staff compliance rates for mandatory and statutorytraining across the service had improved and generallymet the target of 85%. The mandatory and statutorytraining programme included equality and diversity,health and safety, basic life support (BLS), immediatelife support, infection prevention and control,information governance, adult and child safeguarding,fire safety, prevent levels one and two, manual handlingand conflict resolution. The trust used a mix ofclassroom-based and online training modules.

• However, trust data showed some exceptions wherestaff compliance for mandatory training did not meetthe trust target. For example, in Barking and Dagenhamthe completion of BLS in school nursing special needswas 50%. We raised this with senior managers.Managers told us their report systems for staff on long-term sick leave, maternity leave and new startersdistorted figures for compliance rates.

• Staff received regular clinical and managerialsupervision which focused on development andlearning. On our last inspection, we found thecompletion of mandatory training, requiredimprovement. On this inspection, the trust hadimplemented monthly management supervision, whichincluded discussions on mandatory trainingcompletion. Senior managers also told us theydiscussed mandatory training at monthly performancemeetings and re-checked and challenged compliancerates where necessary, which had improved completionrates for mandatory training. For example, themandatory training compliance scorecard for Thurrockhealth visiting and school nursing team in Grays HealthCentre showed that the service achieved the trust targetof 85% across all of the modules. Some modules suchas safeguarding in children (levels one to three)achieved 100% completion rate.

• Staff told us that they had protected time to completetheir mandatory training and they could easily access e-learning which had become easier with the introductionof agile working. Staff told us they used monthlysupervision meetings to book classroom trainingsessions as needed. Staff and managers told us staff

received a reminder email to update mandatory trainingthat is due to expire. Managers received notificationswhen a staff member’s training was due to expire andraised this in supervision with their staff.

• The service required new staff to complete the trust’scorporate induction and subsequent local induction.The corporate induction included a meet and greet withthe executive team and mandatory training such as firesafety and equality and diversity. The service inductionincluded training on the trust’s policies. Staff told us theinduction also covered the whistleblowing policy tosupport staff to raise concerns at supervision. The localinduction included a walk around to meet the localteam. Staff told us locum staff received the sameinduction as permanent staff.

• The trust had a policy titled Care of the DeterioratingPatient, which included early identification, andtreatment of sepsis using the national sepsis screeningtool. We requested compliance data for staff training onsepsis but did not receive it. However, the trust haddelivered a sepsis training package to medics atWaltham Forest and Redbridge Psychiatry teams lastyear and a similar sepsis package on the non-medicalprescribing (NMP) day over the summer.

Safeguarding

• The trust had clear and comprehensive policies,processes and training for child safeguarding. The trusthad a range of specialist policies, for example, domesticviolence, harmful sexual behaviours and mental healthand substance misuse. Staff told us they could findpolicies easily on the trust intranet.

• There was a high rate of staff compliance with the trust'schild safeguarding training. Staff understood how tokeep children and young people safe from avoidableharm and abuse and to provide them with the care andtreatment they needed.

• The trust’s safeguarding team was available to supportstaff. Staff knew where to get advice about safeguardingconcerns. The trust operated a safeguarding duty deskfor telephone advice during weekday working hoursonly. Staff told us the safeguarding team was responsiveand supportive. Named nurses for both CYP and adultsprovided advice to staff. These named nurses receivedlevel four safeguarding training.

Are services safe?

Good –––


• There was a strong focus on safeguarding childrenamong practitioners through effective safeguardingsupervision processes. This included opportunities tolearn from complex cases, to review safeguardingdecisions and receive guidance and support from thetrust’s safeguarding team. Staff told us the trust had anescalation procedure in place for high-risk children.

• Case holding staff for universal services accessed one toone supervision whilst other CYP staff accessed groupsupervision. Staff identified cases for discussion to bringto these sessions where risks were analysed, decisionsvalidated and peer learning took place. Senior leadstold us the trust also used online video link software tofacilitate remote supervision.

• The service worked effectively with other agencies toprotect children and young people from abuse. Thesafeguarding team had links with local multiagencysafeguarding hub (MASH) teams. Service leads told usMASH practitioners were part of operational teams andthe trust safeguarding team provided safeguardingsupervision for them. In some localities MASH andlooked after children (LAC) were co-located in sharedoffices with social care teams which facilitated effectiveinformation sharing. The trust had PREVENT leads whoengaged with local safeguarding children’s boards(LSCB). Senior managers attended all nine LSCBs.

• The service had effective systems for following upsafeguarding concerns and progress review. The trust’smonthly management supervision includedsafeguarding cases or issues of concern as a specificagenda item. When a CYP risk was identified, staffmembers used a structured assessment and recordkeeping model. This allowed risks to be effectivelyanalysed, appropriate action taken and a suitablerecord made. This helped staff and supervisors to agreeactions and to track the progress at subsequentsessions.

• Managers told us about an approach known as ‘oneplan’ that allowed health and other agency practitionersto provide support to families in a co-ordinated way,using a single plan, under the ‘early help’ processes. Thisapproach was in place in some of the local authorityareas served by the trust but was still evolving in otherareas and so we were not able to assess the impact ofthis approach.

• The trust used two different electronic patient recordsystems across its footprint. The two different systemsused system ‘flags’ to alert staff of children and youngpeople with a child protection plan or for whom therewere safeguarding concerns. This allowed staff to beaware of any safeguarding concerns during theircontacts.

• Staff received dedicated training in safeguarding toensure they understood training on how to recogniseand report potential abuse. Trust records for August2017 indicated that completion across the CYP staffgroups for safeguarding children levels one, two andthree were 93%, 95% and 93% respectively, against atrust target of 85%. Safeguarding adults (enhanced) andsafeguarding adults (recognition and referral)completion rates across the CYP staff groups were 85%and 90% respectively.

• The trust had quality markers in place for safeguardingand monitored them using an electronic datadashboard. Managers were able to review indicators forstaff completion of disclosure and barring service (DBS)applications, management of allegations, supervisionand training provision, female genital mutilation (FGM)cases and safe staffing.

• Staff we spoke with showed thorough awareness andconsideration of FGM. We observed routine questioningon FGM by health visitors during clinics and home visits.This was approached in a sensitive and culturallyappropriate way. Staff could find the FGM identificationprotocol on the trust intranet. There was goodunderstanding of child sexual exploitation (CSE) risks,and this was particularly evident among the trust’slooked after children (LAC) staff. LAC nurses receivedspecific training in child sexual exploitation awareness.The LAC team had a register of their CSE patients.

• The trust had specialist LAC nurses who operated acrosslocalities and named LAC doctors in addition. The LACteam had a close working relationship with child andadolescent mental health services (CAMHS) with a fasttrack system in place for clients to access CAMHSservices.

• The trust had effective formalised processes for staff toreceive regular planned supervision on safeguardingmatters. This included monthly safeguardingsupervision and group supervision sessions to discuss

Are services safe?

Good –––


events and case studies and reflect on learning on athree monthly basis. Data provided by the trust showedthat as of August 2017, the average percentage of staffwho received one to one supervision in the last 3months was 92% trust wide. The average percentage ofstaff who received group supervision in the last threemonths was 87% trust wide. The trust also organised anannual away day for safeguarding to give staff time toreflect and talk about support needed.

• The trust encouraged staff to share lessons with theirteams and the wider service. CYP staff told us there wasgood sharing of learning in a supportive environment.For example, the trust had supervision networks thatmet twice a year in each locality to share learning andthere were monthly safeguarding meetings. Meetingagenda items included new safeguarding risks, casediscussions, other issues related to safeguarding suchas new guidance and lessons learnt. Service leadsdemonstrated good awareness of safeguarding childrenon the team’s caseloads such as LAC, children in need(CIN), early offer of help (EOH) and those with childprotection (CP) plans.

• Managers held regular quality safety meetings to discussserious case reviews across all services. A named nurseor safeguarding advisor completed the individualmanagement reviews before quality assurance tookplace prior to sign off. A team of investigators completedroot cause analyses (RCA) for internal investigationprocesses.

• During our inspection, we saw child and adultsafeguarding awareness and support posters displayedin some of the trust’s health centres and children’scentres. This included posters on female genitalmutilation (FGM) awareness in Thames View HealthCentre and the Expect Respect (an education toolkit forchildren in fear of domestic violence) poster in the AcornCentre. The posters included contact details for thetrust’s safeguarding duty desk and Caldicott Guardian (asenior person responsible for protecting theconfidentiality of patient and patient information andenabling appropriate information sharing).

Cleanliness, infection control and hygiene

• The health and children’s centres we visited were visiblyclean, tidy, well organised and clutter-free. The floors incorridors were clean with no evidence of dust. The toilet

facilities we inspected across sites were clean and tidy.In the 2016 Patient-Led Assessment of the CaringEnvironment (PLACE) assessment, the trust scored99.6% for cleanliness. Most of the health centres wevisited had easily accessible handwashing gel facilitieslocated at the main entrance and throughout publicand clinical areas. For example, we saw a hand sanitiserat the reception desk in Grays Health Centre and AcornCentre. At Hainault Health Centre, the hand gels had asign to notify reception staff when empty. The audiologyclinic in Havering was also hand hygiene compliant.

• The service generally managed infection prevention andcontrol well. The trust’s hand hygiene policy states staffshould follow the World Health Organization (WHO) fivemoments for hand hygiene and six step handdecontamination technique. Staff told us the trustprovided staff with alcohol hand gels and had personalprotective equipment (PPE). For example, we observedclinics in Wood Street Health Centre and saw staff hadaprons and gloves. At Trinity school, in the medicalroom we saw posters on handwashing technique andPPE equipment such as gloves, dressings and wipeswere in date. There was appropriate disposal of clinicalwaste.

• However, there were some exceptions. For example, onour visit to the Child and Family Centre on Axe Street wedid not see any hand hygiene signs and nohandwashing facilities except in the consultation rooms,which had sinks. The consultation rooms did not haveany cleaning materials or replacement sheets forexamination tables or scales. Although scale calibrationwas in date, we found the scales placed on the floorwith no cleaning supplies. We reviewed the March 2017report for the infection control audit for Axe Street. Thereported recorded 81% Hand hygiene compliance. Theaudit highlighted that hand sanitising gel should beavailable in all clinical areas/wherever-clinical activitytakes place and hand cream should be available in wallmounted or pump-operated dispensers in at least onearea. However, we found the action plan incomplete,and evidence of compliance, responsibility and duedates was not included.

• Most of the clinicians and health professionals weobserved cleaned their hands, were bare below elbowsand followed hand hygiene procedures appropriatelywhile in homes and in clinics before and after contact

Are services safe?

Good –––


with clients. For example, we observed home visits withhealth visitors who followed hand hygiene proceduresand disinfected equipment such as the weighing scaleafter use.

• We observed most health visitors and therapists’ cleanequipment before and after use, using disinfectantwipes. For example, at the child development clinic inGrove Health Centre we saw evidence that staff cleanedthe room including toys and surfaces after every usewith updated cleaning records on completion.

• We observed a few isolated occasions where someclinical staff did not adhere to the infection preventionand control guidance and did not follow the handhygiene procedures prior to patient examination. Forexample, during a home visit, we found the healthvisitor did not wash their hands or use hand sanitisinggel. On another occasion, we observed a home visitwhere the staff member had not cleaned the weighingscales before or after use. This was despite the childurinating on the scales. Similarly, at South Woodfordclinic, we observed staff change the disposable paperbetween each patient but we did not see any wipingdown of changing mats or evidence of using hand gel.

• The trust completed quarterly infection prevention andcontrol audits the CYP services and localities to measurequality of practice in health centres and in thecommunity. For example, the clinical audit reportbetween April and June 2017 for audiology (in Havering,Barking and Dagenham and Brentwood) and integratedtargeted services (such as paediatric physiotherapy,occupational therapy) showed 99%, 100% and 100%compliance for hand hygiene, equipment cleaning andPPE respectively.

• The clinical audit report for Waltham Forest, betweenApril and June 2017, showed that school nursing (5-19),community nursing team, CAMHS, child developmentteam, health visiting (0-5), community paediatrics,paediatric occupational therapy and physiotherapy,special schools and looked after children all achieved100% compliance for hand hygiene, equipment cleaningand PPE. The speech and language therapist teamachieved 100% compliance for equipment cleaning andPPE respectively and 98% compliance for hand hygiene.

Environment and equipment

• We visited 13 trust sites, which included health centres,special schools, community hospital and child andfamily centres. The centres were modern, bright andwelcoming with adequate spaces for patients and theirfamilies. For example, the clinical areas in the AcornCentre and Wood Street Health Centre were childfriendly with bright colours, painted murals andchildren’s artwork and staff photos on walls. Thelocations had no trip hazards, as they were clutter free.Each of the locations we visited had accessible facilitiesand baby changing facilities. However, at Grove HealthCentre, we did not see any clear signage to the entrancedespite the premises undergoing building work.

• Children’s centres were secure with locked entrancedoors. Receptionists controlled entry and exit to thecentres and CCTV monitored entrances.

• The equipment we inspected was visibly clean andclinic rooms had sufficient space with which to use it.For example, the gym at the Acorn centre was big,bright, clean, and tidy with lots of space. The gym had afull range of child friendly physiotherapy equipment forassessments such as mats, balls and steps. All of theequipment and toys were visibly clean.

• Fire exits were secure with fire extinguishers ataccessible points.

• Most of the centres managed equipment appropriately.For example, at Havering audiology clinic, we sawevidence of up-to-date safety testing of equipment withvisible stickers on display. We observed clinics wherestaff cleaned equipment before and after patient use. Allof the clinic environments were child friendly withcolourful toys. For example, staff told us the Wood StreetHealth centre had received funding from charities forthe gym, sensory room, soft play and playrooms.

• The trust completed environment audits using the caresetting process improvement tool. Completed auditreports for Langthorne Health Centre (July 2017) andChild Development Centre in Thurrock (July 2017)showed that where they failed in a given area,appropriate actions plans were put in place. However,the report did not include any completion dates.

• An external contractor serviced the trust’s clinical andelectrical equipment on an annual basis However, wefound some equipment had not been safety checked orcalibrated within the one year timeframe. On some

Are services safe?

Good –––


home visits, we found the weighing scales calibrationwas expired, for example in July 2017. We fed this backto the trust. The trust has told us the externalcontractors had calibrated all portable scales by 17October 2017.

• Staff told us their partner schools completed the safetytesting of equipment. However, at Trinity school we sawevidence of safety testing equipment out of date: forexample, weighing scales (2014), sitting scales (2016),kettle and fridge (2015). The clinical fridge that storedmedication did not have any safety testing sticker on it.PPE equipment such as gloves, dressings and wipeswere in date. We fed back the expired safety testing ofthe equipment to the trust. The trust has sincecompleted the outstanding safety testing on 16 October2017.

Assessing and responding to patient risk

• Staff appropriately recorded assessment information,for example in baby record books and in patients’ notes.We saw health visitors record the observations of infantdevelopment indicators such as height, weight,communication and motor skills. Staff assessed infantsfor actual and potential risks related to their health andwell-being.

• The service had mechanisms to identify patients at risk,such as vulnerable women and children and recorddetails in electronic records. The system providedvulnerability alerts. CYP staff told us they would call adoctor if they were immediately concerned about achild or young person’s health or welfare.

• We observed a child in need (CIN) meeting at TrinitySchool. The school nurse, social services, paediatrician,school management, parents, key worker, familysupport worker, senior leads for teaching and learning,attended the meeting. An appropriate risk assessmentand medical review of the child was completed. Parentswere given the opportunity to voice their opinions andgiven information to manage their expectations. Weobserved comprehensive completion of the riskassessment, which included emotional andpsychological needs of the child and family members,an action plan and the transition process. The meetingdiscussion included the voice of the child for example,their hobbies, likes and dislikes. Staff members updatedthe child’s record accordingly.

Staffing

• The trust had improved vacancy rates across CYPservices. At our last inspection, service managersconfirmed substantive staff vacancy rates averaging20% across all services, with between 50-67% vacanciesin some services and localities. At this inspection, theCYP staff vacancy rates showed an improvement sincethe last inspection. The current vacancy rate as ofAugust 2017 was 13%, against a trust target of 10%. Thetrust had secured extra investment with commissionersfor specialist roles such as paediatric occupationaltherapists and physiotherapists; however, senior stafftold us recruitment of some specialist therapy staff hadbeen difficult. This concern was not specific to the trustbut a national issue.

• The trust managed vacant staff posts with the usage ofbank and agency staff. The trust provided data for bankand agency staff used to fill the staffing gaps betweenOctober 2016 and September 2017. Although eachlocality had varied use, the data showed that the trusthad gaps in specialist therapy roles such asphysiotherapy, occupational therapy and speech andlanguage therapy. The highest use of bank and agencystaff was in Redbridge and Havering with 37% and 35%respectively. The community paediatrician service usedlocums, but some consultant community paediatricianstold us they frequently worked longer hours to covergaps out of good will. Staff told us that they could takeback extra hours worked with agreement with theirmanager. However, it was difficult to do so at times ascapacity issues remained.

• The trust provided CYP staff sickness rates betweenSeptember 2016 and August 2017. The data showedimproved rates with the highest sickness rate of 5.36%reported in January 2017 against 3.3% in August 2017,below the trust target of 3.7%.

• However, the CYP staff turnover rates between October2016 and September 2017 had increased from 14.4% inOctober 2016 to 24.8% in September 2017, against thetrust target of 10%. The quality report for September2017 stated the turnover remained high for a number offactors, which included service decommissioning andtermination of a number of fixed term contract workersacross numerous services.

Are services safe?

Good –––


• The trust continued to identify heavy caseloads andstaffing levels as their top risks and was clear that thispresented a challenge to the delivery of CYP services. Atour last inspection, we found extensive recognitionamong all the staff and managers we spoke with ofheavy caseloads for staff across universal and specialistservices. During this inspection, caseloads remainedhigh in some services for a number of reasons. Theseincluded decreased staffing levels, growing populationsand recruitment challenges for specialist therapy staff.

• The trust had mitigated this with regular allocationmeetings with staff and had implemented monthlymanagement supervision, for staff to discuss caseloadsand their wellbeing. Staff and managers told us thecaseload waiting tool and performance allocation toolhelped score the work they had to determine how heavythe caseload was. A performance allocation tool lookedat scoring caseloads and the number of contactsneeded. Staff told us all mandated health visiting checkswere managed in the same way.

• The trust used a new caseload weighting tool on theelectronic recording system, which helped support theallocation of caseloads equitably. We saw minutes forHavering performance reports for July 2017. The reportincluded a comprehensive caseload breakdown data forexample, information on age group, gender, ethnicity,number of children in child protection and safeguardingcases and looked after children (LAC), primary healthcondition/disability and referrals to specialist services.

• The trust had also increased the skill mix of the staff toincrease capacity. For example, the trust was involved ina national pilot for the nursing associate programme,which involved upskilling health care assistants toperform at a more advanced level. The trust was in theprocess of training the staff at the time of the inspection.The trust also had a band six leadership programme tosupport staff to take on the role of caseloadmanagement, and carry the generic caseloads. Moreexperienced and established staff received the complexcases.

• The trust provided data on CYP health visitor caseloadsbetween September 2016 and August 2017. As adultsand children were registered to health visitor’scaseloads, the data was not specific to CYP. The datashowed that staff across all localities had heavy

caseloads, which were above the CommunityPractitioners’ and Health Visitors’ Association (CPHVA)guidelines and the Institute of Health Visiting whoadvised an optimum ratio of 1:250.

• For August 2017, the average caseload for health visitorsranged between 368 (in Barking and Dagenham) to 835(Waltham Forest). However, health visitors in Redbridgehad the highest average caseload at 1294. The trust wasdeveloping a ’skill mix‘ model for the service inRedbridge and had recruited more staff by the end ofSeptember 2017 to support the development of the newmodel. Therefore, we were unable to assess the impactof the new model on this inspection.

• Service leads told us they used the Institute of HealthVisiting (IHV) resilience framework to support staff withchanges to staffing. The framework provided leadersand managers of health visitors and the organisationsthey work within, evidence based information to ensurethat the health visiting workforce was resilient whilstremaining compassionate. In Barking and Dagenham,the family nurse partnership (FNP) service wasdecommissioned in September 2016. Staff told us theFNP cases were allocated into the health visitingcaseload after re-assessments. Staff we spoke withreported that the change did not have any impact onthe workload and service provided.

• Caseloads for occupational therapists (OT) varied bylocality. Havering children’s physiotherapy and OT was63 in August 2017, which was near the guidelines of50-60. However, Redbridge paediatric OT caseload was275 in August 2017, above the guidelines. After ourinspection, the trust clarified that Redbridge OT servicewas integrated with Education, Health and Socialservices. The trust told us the largest proportion of thecaseload was within Education as the children remainedon the caseload for the termly or half year reviews asidentified in their Education Health and Care plans.

• In Thurrock, staff told us they used a clinical activityregulatory system (CARS) which reviewed practitioners’activity daily. Service leads monitored the data monthlyat one to one meetings. Practitioners had to submit thedata within 24 hours and the average for Thurrock was85% completed within 24 hours. Where clinicians werenot meeting the 24 hours competency, managerssupported them informally to review the workload andincluded a discussion on health and wellbeing.

Are services safe?

Good –––


Quality of records

• The CYP service used the trust’s electronic recordsystems (ERS) to input and access patient records. Thetrust used two ERS: one for London boroughs and aseparate system in Essex boroughs. Since the lastinspection, the trust had put in place an ERS championin each locality, for each ERS system to support staffwith agile working. Staff told us ERS user groups tookplace every six weeks. All staff members could attendthe user group forum.

• The ERS systems were available to all staff includingdoctors, health visitors, community nurses andtherapists. All professionals recorded patientinformation from clinics, home visits and therapysessions in chronical order in the notes section. Thisincluded history, consent and referrals. This meantrecording errors from illegible writing were virtuallyeliminated. Staff received prompts to incomplete recordsections through the ERS system alerts. Staff told usonly one of the ERS was linked to the local GPs system,which facilitated timely information sharing. However,staff worked around this by ensuring communicationwas sent in a timely manner. For example, staff in theHavering audiology clinic told us staff members sent outGP letters on the same day the child was in clinic.

• The electronic patient record system required passwordaccess with a smartcard to ensure security. Staffmembers had unique accounts to ensure professionalaccountability. Staff we observed were careful withconfidentiality and locked the computer when not inuse. We observed practitioners and administrators usingthe ERS and saw they were adept at using the system.

• The Trust had implemented electronic clinical records inall the CYP services. At our last inspection, we revieweda sample of paper records in Havering audiology andfound inconsistent notes keeping compliance. On thisinspection, we found Havering audiology usedelectronic records except for audiology test results,which were recorded on paper. However, the ERSshowed other healthcare interventions where anaudiologist had been involved. Staff told us ERS was notcompatible to record the audiology results but the teamhad submitted a business case to request theappropriate software. We reviewed seven audiologyrecords and found all entries were completedcomprehensively with signatures, clearly documented

patient details and consent records. We saw evidence oftimely record completion during our visit. We observedstaff store the paper audiology results in lockedcabinets. We saw evidence in the notes that staffmembers sent out GP letters on the same day the childwas in clinic.

• At our last inspection, we found sensitive personalinformation recorded in paper diaries. This breachedregulation 17 and resulted in a requirement notice. Onthis inspection, we found the trust had addressed therequirement notice by implementing electronic diariesand stopped staff ordering any further paper diaries.Staff and the senior team told us about a seriousincident subsequent to our inspection in February 2017where a paper diary with patient information had beenleft on the roof of a car. The trust had shared thelearning through an infographic and circulated keyguidance to all staff and managers. The leadership teamtold us a small number of staff were still using paperdiaries whilst awaiting for agile working equipment.However, the trust had completed two audits of thesepaper diaries to mitigate any risk and found good datamanagement compliance.

• We reviewed the audits and found appropriate guidancefor staff using paper diaries for example, anonymisingany patient information recorded within paper diaries.The trust mitigated any further data management risksby having line managers review the use of paper diariesand the information contained within, with staff duringsupervision sessions. Line managers would also need toensure that patient information was removed frompaper diaries at the end of the session / day anddestroyed securely after the patient’s clinical record wasupdated with the relevant information. We spoke to staffthat still used paper diaries and found they understoodthe data protection risk and applied the trust policywell.

• We reviewed 40 children’s’ records and care plans andfound notes completed in a logical and comprehensiveway. The notes provided detailed description of careplans, observations, allergies, documentation ofmultidisciplinary (MDT) working, patient history,evidence based practice, risk assessments, action plansand patient progress. Records were consistent with thenursing and midwifery council (NMC) guidelines forrecord keeping. The ERS flagged patients who were atrisk, such as safeguarding concerns. We saw evidence

Are services safe?

Good –––


that the ERS flagging system worked well as the ERSsystem recorded vulnerability alerts. The system alsoprovided an alert for patients with learning disabilitiesor allergies. This meant all staff were aware of a patient’sspecific needs.

• In the Basildon and Brentwood integrated therapiesservice and in the child development unit in Redbridgewe saw records were of a high quality. Staff membersrecorded assessments comprehensively showing goodclinical and social history in a templated format,enabling future users of the record to be clear about thechild’s needs.

• We observed health visitors record information in ‘MyChild’s Health Record’ red books which parents kept. Allcontent was readable and dated. However, on someoccasions the time entry was missing. Before going onhome visits, we observed health visitors findinformation from both the electronic patient recordsystem and the GP system to find the patient’s fullhistory. We observed the immunisation clinic wherestaff members obtained and documented consent bycompleting the red book appropriately.

• We reviewed 11 LAC records and found the notescomprehensive and fully completed. The notes includeddocumented consent, aims and goals for the patient,voice of child, MDT, health education appointment,personal wellbeing, home environment, growth chart,attendance in accident and emergency, annual visiontest, completed care plans, medical history and anyreferrals. LAC staff told us they worked with socialservices to escalate concerns such as 'did not attend'(DNA).

Medicines

• The service had effective policies and procedures tomanage the storage and administration of medicines atthe trust sites and external locations we visited. Staffreceived training in medicines management and coulddemonstrate competency around the safe and effectiveuse of medicines.

• We saw evidence where staff members’ actioned recentMedicines and Healthcare Products Regulatory Agency(MHRA) medical safety alert regarding anti-epilepticmedication. Staff told us all patients who were on thenamed medicines received medication reviews.

• Some health visitors and community children’s nurseswere independent prescribers. They told us thatalthough they did not prescribe many medicines forchildren, they received support in this role from thetrust’s medicines management team. Nurse prescriberstold us that if they did prescribe, they informed therelevant GP appropriately.

• We found prescription pads securely stored in lockedcabinets. Community paediatricians told us they tookone prescription at a time and documented the serialnumber in the log. Staff told us community paediatricclinics did not have any medicines on site. Thecommissioners and trust lead pharmacist monitoredthe prescribing of paediatricians for safe prescribing andconsistency.

• Staff told us that patient information leaflets for somemedicines was available in 12 translated languages. Wesaw evidence of this on the trust’s internet page.

• We observed community children’s nurses provideevidence-based advice to families and patients onstoring medicines at home.

• We visited the immunisation clinic and found the drugfridge locked in the clinical room and temperaturemonitored. We saw evidence of the fridge log completeddaily with no omissions. The trust had a standardoperating procedure (SOP) on the safe handling onvaccines. The SOP included guidance on ordering andreceiving stock, how to manage excess stock, stockrotation, monitoring fridge temperatures, transfer ofvaccines, spillage, incident reporting, disposal ofvaccines and what to do if the fridge temperaturereadings were out of range. The SOP referencedDepartment of Health (DH) guidance called ‘The GreenBook Immunisation Against Infectious Disease’. Thisguidance provided general information on vaccines andimmunisation. We saw staff follow this SOP consistently.

• An external provider managed the trust’s vaccine supply.A staff member would sign for the delivery and placedthe items in the fridge. We observed the clinic stafffollowing Public Health England (PHE) guidance with aPatient specific Directions (PSD) in place and followedthe process consistently. The Bacillus Calmette–Guérin(BCG) vaccine was unlicensed and we saw evidence ofinformation leaflets that explained this to families and

Are services safe?

Good –––


carers. However, the information was only available inEnglish. Clinic staff showed knowledge of the yellowcard scheme and told us they could call the trustpharmacist if they had any queries.

• The immunisation staff used an immunisation impactassessment toolkit. This included Gillick competencyand Fraser guidelines to help assess whether a child hasthe maturity to make their own decisions withoutconsent of a parent or guardian and understand theimplications of those decisions. We saw a sample ofimmunisation records and found them to becomprehensive with consent and allergies recorded.

• At our last inspection, we found there was a backlog ofconsent forms that required uploading onto theelectronic system. Staff told us that although the initialbacklog was cleared through additional administrationstaff, there was still a backlog due to equipment. Theservice reported a backlog of 6634 consent forms, whichrequired uploading onto the ERS from across the fourboroughs (Barking and Dagenham, Havering, Redbridgeand Waltham Forest). However, service managers toldus the team were trialing the use of a portable scannerat Axe Street to upload the consent forms from the clinicas they are received.The support workers planned tofocus on the back log at Bernard House twice a week.The service lead had developed an action plan withweekly updates to demonstrate the backlog was beingresolved.

• At Trinity school, we found staff monitored the fridgeand room temperatures daily and the log had noomissions and temperatures were in range. For childrenwho required emergency medicines, these were storedin a locked cupboard in the school medical room. Thekeys were stored securely and the nursing staffrestocked the medications as needed. We looked at asample of drugs and found them to be within the expirydates. Staff recorded date of opening on liquidmedicines. We reviewed ten administration medicationcharts at Trinity School and found all entries thoroughlycompleted. The medication charts included photoidentification, documentation of allergies and wereappropriately dated and signed. The service sentconsent forms to parents to sign every year. Staff told usthey relied on parents to inform them of any medicationchanges as the neighbouring local hospitals used adifferent electronic record system.

Safety performance

• There was a good overall safety performance and anembedded culture of safety within the children andyoung people (CYP) services at NELFT (the trust).

• The trust reported serious incidents to the StrategicExecutive Information System (STEIS). The CYP servicereported eight serious incidents between September2016 and August 2017. These included an unexpecteddeath of an infant, a safeguarding incident, pressureulcers causing moderate harm (4), potential loss ofpersonal identifiable data and actual or alleged abuse.

• The CYP service reported zero never events for the yearpreceding our inspection. Never events are seriouspatient safety incidents that should not happen ifhealthcare providers follow national guidance on howto prevent them. Each never event type has thepotential to cause serious patient harm or death butneither need have happened for an incident to be anever event.

Incident reporting, learning and improvement

• The trust used an online incident reporting system. Allstaff had access to this system to record incidents. Staffwe spoke with said they felt able and comfortable tosubmit incidents to the system. There was goodawareness among CYP staff across all services andlocalities of processes for incident reporting.

• During our last inspection, we found the trust incidentreporting processes required junior staff at band fiveand below to be accompanied by a band six or above torecord an incident or concern on the reporting system.This resulted in junior staff not receiving direct feedbackon incidents they had reported. On this inspection thetrust policy had changed so that all staff could freelyreport incidents independently of their managers’ andsenior leads informed us all staff had received trainingfor the online reporting system.

• Staff we spoke with said they could obtain support fromthe managers and the safeguarding team easily ifneeded. Staff felt confident to escalate concerns andunderstood how and when to report incidentsappropriately. We spoke with medical, nursing andallied health professionals who told us the trustencouraged them to report incidents.

Are services safe?

Good –––


• Staff felt encouraged to report incidents and nearmisses, concerns, identified risks, and told us theyreceived feedback from reported incidents. The CYPservice shared learning from incidents and serious casereviews effectively in team briefs, in service-wide emails,newsletters or in individual supervision. Service leadstold us they used incidents as case study examples tosupport learning. Staff told us that team meetingsincluded agenda items on learning from incidents, riskmanagement, incidents reports, and action plans,which we saw, recorded in meeting minutes.

• Staff gave us examples of incidents and lessons learnedand actions taken. For example, after the investigationof four serious incidents on pressure ulcers causingmoderate harm, service leads told us there was a rollingaudit for pressure ulcers, which looked at surface, skin,keep moving, incontinence, nutrition (SSKIN). SSKIN is afive step approach to preventing and treating pressureulcers. Staff told us school and health were involved inthe investigation process for the pressure sores andlearning was shared effectively. Staff told us the trusthad provided online training on consequences ofpressure ulcers as a result.

• Staff completed risk assessments comprehensively. Weobserved health visitors and community children’snurses conducting risk assessments while on homevisits and in clinics. Records we reviewed showedevidence that staff members had logged riskassessments appropriately. Speech and languagetherapy (SLT) staff told us of an incident where atherapist had given out thickening powder which hadexpired. The parent complained and staff membersapplied duty of candour. Therapy staff completed therisk assessment with an action plan in place. As a result,the service now had a process in place to check stockexpiry dates. The team shared the learning with theclinical excellence group and now everyone in the trustwas doing the same thing.

• The trust had developed effective team working toreview incidents and improve processes. Senior leadstold us moderate and above incidents were reviewedweekly by an incident review group. Attendees includedhead of risk assurance, representatives from theincident reporting team, a staff member from seriousincidents team, health and safety, safeguarding. Theincidents team worked closely with the safeguarding

team and met monthly. The trust had a patient andsafety group that met monthly and shared learningacross the boroughs. Senior leads told us that theaverage number of reported incidents was between 200and 300 per week. However, there were no identifiedthemes specifically related to the CYP service. The trustrecorded the number of daily incidents live on theintranet and we saw evidence of this.

• There were effective incident investigation proceduresincluding case reviews, root cause analyses anddebriefing meetings, where all involved contributedwhat they had learned and how their service could haveworked better. In some cases, the trust appointedinternal investigators to review incidents and suggestrecommendations for improving processes. Forexample, during this inspection staff told us of an insulinoverdose incident, which had been escalated to thepolice and the safeguarding team. We reviewed the rootcause analysis (RCA) investigation report for this seriousincident and found completion to be comprehensive,with thorough investigation with all actions completed.The report was thorough, for example, the trust hadcompleted a ‘fishbone analysis’ as part of the RCA. Afishbone is a visualisation tool for categorising thepotential causes of a problem in order to identify its rootcauses as part of service evaluation. The case was nowsubject to a serious case review (SCR) for which the trustwas in the process of completing the individualmanagement review (IMR).

• The duty of candour (DoC) is a regulatory duty relatingto openness and transparency and requires providers ofhealth and social care services to notify patients orother relevant persons of ‘certain notifiable incidents’and provide reasonable support to that person.

• The trust had a policy called Duty of Candour and BeingOpen. The trust provided formal DoC training for staffbut this was not mandatory. This was included ininductions for new staff and as standalone training forexisting members of staff. Service leads told us the trustprovided assurance to commissioner monthly for DoCand was currently working on getting a template onERS. All investigating leads received RCA training beforeundertaking an investigation and DoC formed a part ofthis training.

• Most staff we spoke with demonstrated awareness ofDoC and were able to give examples. We found senior

Are services safe?

Good –––


staff within the CYP service understood theirresponsibilities for DoC, and were able to describegiving feedback in an honest and timely way whenthings have gone wrong. Junior staff were aware of theterm duty of candour and when asked were fully able toarticulate how they would respond should a mistakehappen. They appreciated the need for openness andhonesty in the investigation of incidents. Staff told uswhen concerns were raised they reported them tomanagers in the spirit of openness. For example,

following a recent mix up in appointment times, thestaff member documented the mix up in the patient’snotes and apologised to the parent. The staff memberoffered the parent an appointment when suitable forher.

• Senior staff told us the trust’s incident reporting sectionincorporated a section on DoC responsibilities to recordstaff had shared information appropriately with patientsand their family members.

Are services safe?

Good –––


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

Summary

We rated effective as good because:

• The children, young people and families (CYP) servicedemonstrated effective internal and externalmultidisciplinary (MDT) working and practitionersworked with other staff as a team around the childproviding person centred care. The co-location ofservices in health centres facilitated partnership workingwith other service providers, such as GPs and the localborough.

• CYP practitioners provided competent, thorough andevidence based care and treatment in home visits,clinics, development reviews and therapy sessions. Staffdelivered care in line with national guidance. CYP staffdemonstrated awareness of how new clinical guidelineswere identified and disseminated.

• On this inspection, community paediatricians told usthey had adequate time to complete audits to monitorpatient outcomes and clinical performance andprovided examples.

• The trust had single point access systems for mostservices.

• The trust applied comprehensive supervision structuresfor staff, which facilitated reflective practice. There weregood learning and development opportunities for staff.

• Community specialist nurses provided individualisedcare for patients and family members. Children told usstaff make things better for them and take time toexplain things to them

• School nurses used social media to provide advice onhealth promotion.

However:

• Compliance targets across localities were notconsistent, with some localities performing significantlyworse than others in the delivery of certain aspects ofthe health visiting service such as the percentage ofchildren who received a two year to two and a half yearreview.

Evidence based care and treatment

• Staff told us they could easily find corporate informationon the trust’s intranet. Staff showed us how they couldfind protocols, standard operating procedures, policiesand guidance for clinical care and other patientinterventions. Staff told us they found the trust intraneteasy to use.

• The trust policies were clear and easy to follow. Forexample, the policy for care plans for children withadditional needs covered a wide range of conditions.The policy clearly documented that the care plan mustbe completed in partnership and who should beinvolved, what monitoring should take place andcovered consent. Referenced guidance and goodpractice underpinned the policy.

• The trust had a policy on the implementation ofnational regulations and guidance. We reviewed asample of trust policies for CYP services and foundappropriate reference to relevant National Institute forHealth and Care Excellence (NICE) and Royal College ofPaediatrics and Child Health guidelines. For example,the dysphagia guidelines referred to and includedevidence from the Royal College of Speech andLanguage.

• CYP practitioners provided competent and evidencebased care to patients and their families. We observedcompetent, thorough and evidence based care andtreatment by practitioners in home visits, clinics,developmental reviews and therapy sessions. Allpractitioners conducted full assessments as perguidelines and provided up-to-date and evidence-based advice. For example, we observed staff applying‘Conners Clinical Index’, which is a diagnostic tool forassessing attention deficit hyperactivity disorder(ADHD). Therapy staff told us they improved patientoutcomes using the Reason, Observation, Comment,Assessment/Analysis, Intervention, Plan (ROCAIP)evidence based model.

• The trust’s autism pathway and post diagnostic auditswere in line with the NICE Autistic Spectrum Disorder

Are services effective?

Good –––


(ASD) guidelines. Staff told us that audit outcomesimproved the communication following diagnosis andinformation. The trust also implemented training forautism diagnostic observation schedule (ADOS)assessment for practitioners. ADOS is a semi-structuredassessment of communication, social interaction, andplay (or imaginative use of materials) for individualssuspected of having autism or other pervasivedevelopmental disorders. We observed an ADOSassessment video with two practitioners, mother andchild and saw appropriate care and assessments tookplace.

• We observed health visitors in clinics where theyprovided appropriate advice, education, reassurance,and guidance to the mothers. For example, healthvisitors provided advice on weaning and sleep patterns.

• Staff provided patient centred care and treatment,which extended to supporting the family. We observed acontinence assessment at Trinity School and found theconsultation embedded the voice of the child principles.We saw staff compliance with NICE guidance forcontinence. The assessment included discussions onnutrition and allergy, documentation of medical historyand a bowel and continence assessment. Both the childand mother were involved in treatment discussions andthe staff member used the Department of Health (DH)triangle assessment framework. The frameworkincorporated child assessment, parent capacity andfamily environment. The mother received informationon social services support and health promotion. Thestaff member was sensitive to both the child andmother’s needs.

• The CYP audiology service in Havering applied BritishSociety of Audiology standard testing protocols andmoulding protocols.

• The trust had improved the staff intranet to provideinformation on new clinical guidance. During our lastinspection, we found not all senior staff were clear onimplementation and dissemination of new clinicalguidelines. On this inspection, we saw evidence on theintranet where staff received information on newguidance. The intranet had a page called ‘all thingsNICE’ that staff were directed to for clinical guidance.Staff we spoke with were aware of this intranet page.Service leads told us the trust had a central team whowould monitor new NICE guidance. The central

leadership team would then email the integrated servicemanagers who would assign a staff member to reviewthe guidance. New guidance would go through the tiersof governance for approval and for dissemination.Senior leads shared new guidance with staff via emailsand team meetings.

• The trust provided the five mandated checks (antenatal,new birth, six to eight weeks, one year and two year) inthe health visiting healthy child programme.

• School health included reception screening andnational child measurement programme (NCMP),hearing screening, enuresis clinics and drop-in sessionsfor primary and secondary schools.

• The Infant Feeding team (IFT) was an integrated servicedelivered within the 0-19 universal health service. TheIFT complied with UNICEF guidance for Baby friendlyaccreditation. The Baby Friendly Initiative, set up byUNICEF and the World Health Organization, is a globalprogramme, which provides a practical and effectiveway for health services to improve the care provided forall mothers and babies. At our last inspection, theservice was on target to complete full accreditation in2016. On this inspection, the service had achieved fullaccreditation (level three) which was due for review inJune 2018. Achieving stage three of accreditation is thefinal step in becoming ‘Baby Friendly’.

• The Barking and Dagenham health visiting team workedclosely with children centres and local authority to co-deliver the Health, Exercise, Nutrition for the ReallyYoung (HENRY) programme. The HENRY programme wasa national evidence based programme for duration ofeight weeks. The programme covered five themes,which included parenting confidence, physical activityfor little ones, what children and families eat, familylifestyle habits and enjoying life as a family.

• The CYP services had a comprehensive audit plan,which included audits on environment and infectionprevention and control (IPC), medicines managementaudit and equipment in clinic rooms and recordkeeping.

• There were specific clinical audits in individual servicelines. For example, paediatricians in the child


Good –––


development team completed audits on efficiency ofgenetic tests in developmental assessments, epilepsyaudits and attention deficit hyperactivity disorder(ADHD) audits.

• We reviewed a sample of care plans derived fromassessments and found some variability in quality.Some plans were task oriented, as opposed to outcomefocused and were insufficiently time-bound to enableprogress to be measured effectively. For example, oneplan in a patient record in the child development teamat Redbridge noted ‘continue to be supported byspeech and language; continue to be supported byhealth visitor’. These were not helpful in describing whatoutcomes the child was expected to have achieved fromsuch support and by when.

• Some plans however were outcome focused and childcentred and showed good evidence of co-production. Inone case, we looked at in the integrated therapiesservice in Basildon and Brentwood and saw evidence ofthe child’s voice prominently recorded in a structuredcare plan. Sections entitled, ‘my next step’, ‘why this isimportant to me’, ‘I can do’, ‘I will be able’, ‘how I willachieve this’, ‘X can help me by’ demonstrated thechild’s part in constructing the plan and allowed thepractitioner and any other health professionals usingthe record to fully understand the plan form the child’sperspective.

• In one other case in the child development team inRedbridge, we noted one record that contained anexemplar of good practice of an outcome based plan. Inthis case, a practitioner as part of the informationgathering process assessed a child prior to creating aneducation and health care (EHC) plan. The practitioner’sreport to the local authority showed a thoroughconsideration of the child’s clinical and social historyand the outcome of the practitioner’s assessment of thechild. The outcome based plan included what activitiesthe child could achieve in one year’s time and for howlong, what strategies to use to support the child toachieve the goals with the frequency of use, the identityof the person responsible and when to review the plan.

Nutrition and hydration

• Staff provided relevant advice to patients and theirfamilies regarding nutrition and hydration. School

nurses and health visitors discussed children’s food withboth the parents and children. Where necessary, staffmembers would make referrals to the dietitian, speechand language therapists and infant feeding team.

• During our inspection, we saw that staff gave parentsup-to-date and relevant advice about breastfeeding,weaning and nutrition and hydration in children. Forexample, new birth visits included advice for mothers onbreastfeeding. Health visitors checked the baby’s weightto check if the baby was thriving and recorded in the redbook appropriately.

• In clinics, we observed staff supplement advice withinformation from Food Standards Agency, NHS choicesand other NHS websites. Staff provided parents with theopportunity to ask any questions they had. We observedstaff provide leaflets to mothers on breastfeeding cafesas further support. For example, in Redbridge stafforganised baby feeding each weekday at differentchildren centres and health centres. The leaflet includedbreastfeeding contact numbers and the contact numberfor the healthy eating team in the locality.

Patient outcomes

• Staff completed appropriate assessments in line withnational guidance. For example, we observed healthvisitors completing maternal mood assessments usingthe ‘Whooley’ anxiety questions in line with theEdinburgh Postnatal Depression scale. Whooleyquestions are a screening tool, designed to try toidentify two symptoms that may be present indepression. Mothers also received guidance on sleepingarrangements to avoid sudden infant deaths (SID).

• Health visitors used the ‘ages and stages questionnaires’(ASQ) during visits and at clinics. These were evidence-based assessment tools used to highlight areas ofconcern about aspects of a child’s development. Thequestionnaires covered communication and language,fine motor skills, gross motor skills, problem solving andpersonal-social development. Health visitors told usthey used antenatal promotional cards to promote earlyinfant development and early parenting.

• During home visits, we observed health visitors provideevidence based advice to the mother around vitamin Dfor the baby. The mother received thorough


Good –––


information, which included the red book, advice onsafety and hygiene, immunisation appointment,emergency contacts, consent for sharing informationand checked registration status with the GP.

• The trust provided data for Key Performance Indicatorsbetween October 2016 and August 2017 for healthvisitors by locality. The initial data did not includecompliance targets, which we further requested.Although the trust provided compliance targets forsome of the indicators, each locality had differentcompliance targets, which have been included inbrackets. For example, the percentage of new birth visitswithin 14 days by a health visitor between April to June2017 by locality was: Barking and Dagenham 98%(against 95% target), Waltham Forest 97% (against 90%target), Thurrock 98% (against 90% target), Havering99% (against 87% target) and Redbridge 95% (against70% target).

• However not all indicators met the compliance target.For example, between April and June 2017, thepercentage of children who received a two year to twoand a half year review was 44% in Waltham Forest(against 47.5% target). In contrast, the reportedpercentage for the same indicator in Havering was 79%(against 47% target).

• The trust provided data on infants for whombreastfeeding status was recorded at the six to eightweek check. Between April and June 2017, thepercentage of infants being totally breastfed at six toeight weeks in Waltham Forest was only 14% and notarget had been set. For Thurrock, the reported figure forAugust 2017 was 53%, against target 40%. However,data was not available for Barking and Dagenham,Havering and Redbridge as from April 2017, the localauthority obtained data directly from commissioners.

• The trust provided data showing the uptake of BCGimmunisations by locality. For August 2017, thepercentage uptake for Barking and Dagenham,Havering, Redbridge and Waltham Forest was 95%, 92%,91% and 95% respectively. The trust’s compliance targetwas not included in the data submission.

• The trust provided data for the school health service bylocality. The total percentage of NCMP completed inreception year, between June to August 2017: Barkingand Dagenham 99%, Havering 97% and Redbridge 99%.

The total percentage of NCMP completed in Year six,between June to August 2017: Barking and Dagenham99% and Thurrock 94%. The trust’s compliance targetwas not included in the data submission.

• Local monitoring data of patient outcomes againstnational benchmarking data showed the trustperformed better than London and England in NCMPcompletion. The trust provided data for 2015/16, as2016/17 was not available at the time of our inspection.The figures for 2015/16 showed the trust completion forNCMP in reception was 96% for the trust, in comparisonto London (94%) and England (96%). The trustcompletion of NCMP for Year six was 96% in comparisonto London (95%) and England (94%).

• The trust provided data for the Thurrock School HealthService Prevention Programme (Key stages one to four)at academic year end in August 2017. The percentage ofchildren that reduced consumption of fizzy drinks (frombaseline) was 77% and the percentage of children thatincreased the proportions of fruit and vegetables eatenper day (from baseline) was 81%.

• At our last inspection, we found some consultants feltworkload pressures limited opportunities to auditoutcome measures or benchmark against peers andsimilar services. On this inspection, communitypaediatricians told us they had adequate time tocomplete audits to monitor patient outcomes andclinical performance. For example, communitypaediatricians had completed an audit on themonitoring of antipsychotics drugs in child andadolescent mental health services (CAMHS) using NICEguidelines. The audit findings resulted in increasedscreening of glycated haemoglobin (HbA1c) test pre-medication in line with NICE guidance. This wasbecause antipsychotic medication can cause anincrease in blood glucose levels, which increases the riskof diabetes. HbA1c test is used to diagnose diabetes.

• Service leads told us the trust was commissioned foractivity and output, not outcomes. However, serviceleads acknowledged this could be improved with bettercommissioning landscapes.

Competent staff

• The trust had effective induction processes for newlyappointed staff to the organisation. All new staffunderwent a one-day corporate induction, which


Good –––


included sessions on equality and diversity, qualityimprovement and fire safety. Staff told us they wouldthen receive a local induction and orientation to theirservice. New starters had a meet and greet day with thechief executive and the human resources (HR) team.

• Newly qualified health visitors told us they receivedsupport through preceptorship and mentorships. Newstaff received named preceptors with a three monthtraining programme which included a competencybased framework, one to one support and a sign off.

• The trust offered staff a broad range of training,education and development opportunities to supporttheir roles. The trust arranged external training forservices for example parent and child interaction, cleftpalate and neuromuscular courses at a child specialisthospital. Service leads told us approximately 80 staffmembers attended a recent event for therapy staff. Wespoke with a number of administrators during theinspection, who felt they had an opportunity to trainand develop within their roles for example, someadministration staff had applied for college courses. Thetrust had courses to help administrators with their rolesfor example, computer software courses, timemanagement and communication and dealing withdifficult patients.

• The trust applied robust competency frameworks andcomprehensive supervision structures for staff. Staffreceived monthly clinical supervision and safeguardingsupervision. Supervision was in one-to-one sessionsand group sessions with peers. Staff groups such ashealth visitors and school nurses received one to onesupervision on a monthly basis. Other staff groups suchas therapists had monthly group supervision sessions aswell as individual supervision. Staff also receivedmonthly child protection supervision as a group fortherapies. CYP staff told us the supervision wasthorough and constructive and provided good reflectionand learning opportunities.

• Staff told us they received regular one to one meetingswith their line managers and said they felt supported.The trust provided leadership training to staff withmanagement responsibilities. This includedmanagement training, leadership workshops andquality improvement training. The trust offered staff a

rotational programme and apprenticeships to ensurestaff were working at the top of their competencies.Senior leads told us the trust had a training initiative forband five staff moving to band six.

• The trust had good provision of emotional support andwellbeing for staff, particularly in child safeguardingcases. The trust provided support to psychologicalsupport if necessary for health visitors and communitynurses. Staff received debriefing sessions as needed andhad support from the partner Macmillan nurses whenneeded. For example, there were a couple of expectedchild deaths in July 2017 and staff were supportedthrough peer support and a debriefing session. The trusthad identified a specialist practitioner who was keen ondeveloping staff training on mindfulness.

• Some staff told us they received peer support; forexample, physiotherapy staff met every three months.Staff we spoke with gave us examples of joint trainingevents. For example, speech and language therapistsand school staff had joint training on supporting autismwith sensory input.

• Staff told us they had monthly team meetings and theagenda included trust-wide issues, child protectionsupervision, waiting times, service developments,recruitment updates and mandatory training.

• Since the last inspection, the trust had implementedmonthly managerial supervision across localities. Thisincluded review of mandatory training compliance,caseload review, any conduct concerns, annual leaverequests, compliments received and emotionalwellbeing.

• Staff received annual appraisals to review theirperformance. Data provided by the trust showed that asof August 2017, the appraisal completion rate acrossCYP services was 88%, against 85% trust target.Appraisals were used to sign off competencies andidentify training and development needs. Annualappraisals were linked to the trust values andbehaviours.

• Training identified in personal development plans wasdiscussed between staff members and their managers.Where appropriate, staff members could apply for thetrust’s clinical development programme. For example,the programme included sepsis courses and all truststaff could attend the courses free. The trust provided


Good –––


in-house training and resources on conflict resolutionand managing difficult conversations. Staff told usabout a recent external dysphagia training programmethe trust had arranged using continuing professionaldevelopment (CPD) funding.

• Service leads told us the majority of school nurses hadcompleted training and qualifications to becomespecialist community public health nurses (SCPHN).This public health training helped school nurses supportchildren and young people in making healthy lifestylechoices to reach their full potential and enjoy life. Asschool nurses worked across education and health theyprovided a link between school, home and thecommunity to improve the health and wellbeing ofchildren and young people. Staff that had notcompleted the SCPNN training were encouraged toattend courses, although senior leads told us it was acompetitive process.

• The trust encouraged all nursing staff to complete therevalidation requirements set by the Nursing andMidwifery Council (NMC), to improve protection ofchildren and young people who use the service. Stafffelt supported with their revalidation and felt it providedan opportunity for self-reflection on individual practice.Staff told us the trust organised revalidation workshopsand support was readily available on the intranet.Practitioners felt supported and had access to themedical director if needed. Clinicians told us therevalidation process was very smooth and the yearlyappraisals were geared towards meeting revalidationrequirements. Trust doctors took part in the GeneralMedical Council (GMC) revalidation initiative for all UKlicensed doctors to demonstrate they were competentand fit to practice.

• The trust provided a copy of the medical appraisal andrevalidation annual report, which went to the July 2017Board meeting. The report stated that during theappraisal year 2016/17, eight doctors requiredvalidation, four doctors were recommended for renewalof their license, five doctors deferred (although onerevalidated in the same year), six doctors were referredto the GMC Fitness to Practise procedures. Of the six,three were closed without further action, two caseswere longstanding and one case was underinvestigation. The report stated “The 2016/17

revalidation round has very low numbers as mostdoctors has gone through a revalidation process in thefirst three years following the implementation ofrevalidation in 2012.”

Multi-disciplinary working and coordinated carepathways

• The CYP service demonstrated effective internal andexternal multidisciplinary (MDT) working. Clinicalpractitioners worked with other staff as a team aroundthe child. The co-location of services in health centresand partnership working with other service providersfacilitated MDT working. Staff told us this allowed muchcloser joint working and improved access for patients,particularly those with complex needs or those withchallenging behaviours.

• The Acorn Centre was a multi-disciplinary centre withmany services on site including occupational therapy,physiotherapy, speech and language therapy, CAMHS,links to looked after children’s (LAC) nursing, specialistschools and community paediatricians. All the servicesused the same electronic recording system, whichfacilitated timely information sharing. Senior leads toldus they were implementing breakfast clubs to facilitatelocality integration and planned to include further jointstaff training. The breakfast club would take place everythree months.

• At Grove Health Centre, the child development teamand CAMHS shared pathways and had joint single pointof access. MDT meetings included all professionals andpaediatricians and included discussions on pathways.Similarly, the Child and Family Centre on Axe Streetprovided many services, which included occupationaltherapy, physiotherapy, speech and language therapy,CAMHS and immunisations.

• We visited a specialist school and the school staff saidthe links with school nursing worked well. The specialistschool had an integrated team consisting of schoolnurses, dieticians, paediatricians, dentist and therapists.This ensured a comprehensive approach to treatment.For example, at Trinity school, there was effective MDTworking between speech and language therapists andphysiotherapists. Staff told us the speech and languagetherapists were based on the school site.


Good –––


• Coordinated appointments with schools were arrangedwhere the paediatricians and allied health professionalswould go to the school. Staff told us that vulnerablechildren in schools had joint appointments with alliedhealth professionals, district nurses and paediatricians.

• Staff told us there was an increased presence of healthstaff on the Education, Health and Care (EHC) planspanels. EHC plans were for children and young peopleaged up to 25 who needed more support than wasavailable through special educational needs support.EHCplans identified educational, health and socialneeds and set out the additional support to meet thoseneeds but arrangements could differ in different localauthorities. Senior leads told us the service had stronglinks with education.

• The 0-19 Healthy Family School Nursing team was anintegrated health visiting and school nurse function.Theoperational leads for this service met regularly andworked together to ensure the standard operatingprocedures (SOPs) were standardised taking intoaccount the different commissioning arrangements.Nursery nurses had health visitors on site for advice ifneeded.

• Health Visitors shared many locations with GP practicesallowing closer collaborative working. For example,health visitors attended joint GP meetings to discussany concerns regarding patients or vulnerable familiesand newly registered children. Health visitors told usthey worked with other agencies such as childrencentres, nurseries and midwifes.

• During clinics, we observed clinicians sharinginformation received from the other MDT services, suchas occupational therapy, with the patients, providing aholistic approach to patient care.

• Consultant community paediatricians reported goodformal and informal links with paediatric psychiatristsand acute paediatricians in local hospitals. Communitypaediatricians attended joint teaching sessions withtheir acute peers.

• The trust had clinical networks in place, which allowedtherapists in the same field to share good practice. Forexample, just before our inspection, a shared children

event had taken place and included shared learningfrom incidents and good practice. The trust’s educationforum and community of practice (COP) also helpedshare learning.

• The trust had set up clinical excellence groups withinhealth visiting services. The groups were working on ajoint conference with the occupational therapy teamcalled ’inspired to achieve‘. The aim was to help achieveconsistency and help colleagues network across thetrust sharing evidence based practice. Staff told us peersupport and joint training sessions had helped with staffretention.

• Each locality had an integrated children’s servicesmanager or equivalent who met monthly in order tointegrate all the localities as one trust. Services leadstold us they felt “really proud of multidisciplinaryworking with joint goal setting which had a positiveimpact on the child”. Each locality had a link GP withinthe clinical commissioning groups (CCGs). Senior leadstold us they attended GP conferences to promotelearning.

• Each locality held weekly MDT meetings for child andadolescent mental health, local authority, education,therapies and community paediatricians to improveoutcomes for vulnerable children through partnershipworking. We reviewed agendas of these meetings, forexample, the Integrated Targeted Children’s ServicesMDT meeting in Barking and Dagenham for August 2017.The agenda included discussion of new referrals, highrisk children, looked after children (LAC), those in needof internal referral or shared intervention, children whohave not attended for three appointments, attendancerates, pre-discharge planning, agreed actions and actionupdates from previous meeting.

• Staff and service leads told us cross-locality working hadimproved. A conference had been organised forNovember 2017 where representatives from eachlocality would attend. Speech and language therapiststold us they were trying to set up cross-locality workingand practice groups and said they had good supportfrom managers to accomplish this.

Health promotion

• School nurses delivered the healthy schoolsprogramme, which included providing resources andinformation on nutrition, obesity and mental health.


Good –––


Staff told us the early year program included the use ofpuppets for health promotion. School nursing inThurrock helped Year 8 students around smokingthrough peer pressure. Trinity school displayed fluvaccine posters to encourage uptake in pupils and staff.

• The School health national child measurementprogramme (NCMP) for Year six included measurementsof children‘s height and weight to assess overweightand obesity levels. School nurses at Grays Health Centretold us they ran bedwetting clinics. The nurses gaveadvice on what to drink, how much to drink and healthyeating. Staff told us there was a mobile application onthe smart phone for bedwetting.

• We observed home visits with health visitors wherethere was good coverage of health promotioncommunicated to mothers. For example, health visitorsgave advice on exercises such as postnatal pelvic floorexercises. Staff told us health improvement advisorsprovided monthly breastfeeding workshops. Staff in theHainault Health Centre advertised local infant feedingcafes for mothers.

• Health improvement specialists and practitionersprovided health promotion and early intervention forexample: hand hygiene and targeted approach to healthlifestyle using Personal, Social, Health and Economiceducation. Health improvement staff received requestsfrom schools and allocation took place at fortnightlyteam meetings.

• Community specialist nurses such as respiratory nursesworked to empower patients and their families to livewith long-term conditions and completed thorough careplans. We observed a community home visit with aspecialist respiratory nurse. Feedback from the motherand children was extremely positive. The mother said,“Although the staff member may not be the same eachtime, effective handovers took place so she didn’t haveto repeat herself”. The mother felt community nursingspecialist nurses understood the family and was able tosupport their needs. The children told us the nursemade things better for them and explained the plans tothem. We observed appropriate advice and informationprovided during the visit, including support on how touse a peak flow meter. The specialist nurse completedthe asthma plan for the patient to share with the school.

• The trust’s school nurses had produced a ‘10 minute liveshake up broadcast’ to provide online, accessible advice

to school students on exercise and fitness, and this wasshared on social media platforms. It received positivefeedback from Public Health England. School nursestold us they planned to do monthly videos on varioussubjects to support health promotion initiatives.

Consent, Mental Capacity act and Deprivation ofLiberty Safeguards

• The trust had a policy for consent to examination ortreatment. Staff we spoke with were aware of the trustpolicy and told us they could easily find the policy onthe intranet.

• School nurses were knowledgeable about Fraserguidelines and Gillick competencies to help assesswhether a young person of a certain age had thematurity to make their own decisions without consentof a parent or guardian and understand the implicationsof those decisions. Fraser guidelines are usedspecifically to decide if a child can consent tocontraceptive or sexual health advice and treatment.Gillick competence is concerned with determining achild’s capacity to consent. Practitioners showedawareness of situations where these principles wouldbe applied.

• We observed practitioners request consent forinformation sharing and consent to treatment duringclinics and home visits. If parents wanted to requestinformation from the records, the trust policy stated thatrequest must be made in writing.

• Staff clearly recorded consent in the patient notes onthe electronic record system for example the LACrecords we reviewed all had documented consent.However, we found some isolated instances whereconsent was not recorded. Some staff told us they tookpatient attendance as implied consent for theassessment or intervention.

• Patients and their family members told us that in mostcases, health visitors, community nurses and therapistshad explained the purpose and evidence for differentclinical assessments and interventions and confirmedtheir consent before proceeding with any actions. Forexample, health visitors told us about a case where theprinciples of “voice of the child” was applied in practicewhere the child wanted independence but hadprotective parents. The health visitor specialistsupported the family with the child’s medical condition


Good –––


and the nursery nurses focussed on what was importantto the child, such as likes, dislikes, thoughts andfeelings. The child named the care plan, which helped,put the child at the centre of care.

• We observed homes visits where the health visitorsintroduced themselves, explained their role, soughtconsent appropriately and documented the electronicrecord appropriately.

• The trust provided the statutory and mandatory trainingmatrix, which showed all clinical staff received training

in the Mental Capacity Act (MCA) and Deprivation ofLiberty Safeguards (DoLS) as part of mandatory training.The trust delivered the training either through e-learning or through a classroom session. Recordsshowed varied compliance across the localities. Forexample, staff in Havering and Thurrock across allservices had met the trust target of 85%. However, inRedbridge, all services met the trust target exceptpaediatric occupational therapy and the school healthservice which reported 75% and 60% respectively.


Good –––


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

Summary

We rated caring as good because:

• Most of the patients and families we spoke with saidthey were happy with the care and treatment receivedand would recommend the service to others.

• Children, young people and their carers told us that stafftreated them with compassion, dignity and respect. Wesaw staff communicating with patient and families withempathy and in a polite and caring way.

• During our inspection, we observed children, youngpeople and their families receive treatment withkindness and compassion. Staff supported patients andfamilies they worked with, and provided patient-centredsupport in clinics and in homes.

• Patients and their families felt listened to and involvedwith their care and treatment.

• The children and young people (CYP) serviceencouraged patients and their families to providefeedback on the care and service they received.

• Parents told us that although they do not see the samestaff in clinics, this did not cause any problems aseffective handovers took place so parents did not haveto repeat themselves.

Compassionate care

• Patients told us they would recommend children, youngpeople and families (CYP) services to their families andfriends. Most patients we spoke with said they were veryhappy with the care and treatment they had received.They told us staff treated them with dignity and respect.The following was representative of the feedbackreceived: “does not feel rushed”, “staff do a wonderfuljob”, “treated with dignity and respect”, “the support isbrilliant”, “good emotional support” and “staff wereprofessional, organised and gave clear and conciseinformation”.

• The specialist community children’s nursing teamdisplayed a compliments poster for the public to view.The compliments were received between June andSeptember 2017. Comments included “thank you forlooking after us, you’re wonderful”, “thanks for the

support you give not only to me but my family”,“community nurses were kind, caring and patient andput my child at ease”, “information was explained clearlyand helped me understand a lot” and “thank you somuch for your fantastic service”.

• Parent feedback from children and families usingservices in Axe Street was generally positive. Onemother told us staff members had offered her emotionalsupport. Other parents also said “although thephysiotherapist changed regularly, the general supportprovided by staff was good as effective handovers tookplace”. Patients and family members were pleasedoverall with the service as staff were helpful andwelcoming, the location was accessible and their childwas happy.

• Patients and family members feedback on theaudiology service was staff were brilliant and theenvironment was calm and relaxed. Comments alsoincluded “the service was quick and efficient” and “itwas always easy to get through on the phone”.

• Health visitors created a friendly and child-focusedatmosphere during activities and assessments such asweighing and height measurement. We observed healthvisiting staff introduce themselves and demonstratedsupportive care to mothers they visited, and providedperson-centred support in both clinics and in homes.We observed good interactions between health visitorsand babies. For example, health visitors praised childrenand babies when they cooperated with activities andassessments such as weighing and heightmeasurement. Mothers’ felt listened to and said the“health visiting staff were incredibly caring andsupportive”.

• We observed positive rapport between the practitionerand the child. We also observed school nurses at a dropin session where age appropriate explanation wasprovided. The staff member listened, showed concern,and was caring and aware of the emotional needs of thechildren.

• Staff clearly explained what was going to happen duringan appointment and gave parents the opportunity toask questions and raise concerns. Parents we spoke

Are services caring?

Good –––


with said clinicians and therapy staff engaged with thepatient during consultations. Staff took the time toexplain the findings of assessments to the parents. Weobserved speech and language therapists provide veryclear and informative advice on exercises and other tipsat home. The staff member handed out feedback formsto parents and family members. Parents were “verypleased” with the session the outcomes.

• The trust’s overall score for privacy, dignity andwellbeing in the 2016 PLACE score was 82%. This haddecreased from 2015 PLACE score which was 86%.

• Each of the locations we visited had information boardsfor patients, information leaflets and posters such asfamily support for health care, emotional support,childcare placements and signposting to free localcourses. Toys and children’s books were available inwaiting areas at health and children’s centres. Weobserved welcoming staff speak with patients andfamily members and found they spoke clearly andpolitely.

• All the staff we spoke with showed passion for their rolesand dedication to making sure that the children andyoung people they cared for received the best carepossible. Senior leads told us the trust used the ‘voice ofthe child’, and friends and family test results forunderstanding patient experience.

• The Friends and Family Test (FFT) was launched in April2013. It asks people who use services whether theywould recommend the services they have used; givingthe opportunity to feed back on their experiences ofcare and treatment.

• The trust provided the friends and family test data forchildren community services between September 2016and August 2017. The trust divided the data into threeservices, health visiting, school nursing and specialistpaediatric services. The percentage of patients whowere extremely likely to recommend health visiting,school nursing and specialist paediatric services for thetrust was 64%, 46% and 65% respectively. Service leadsdiscussed friends and family test results with staff inteam meetings.

• The trust also provided patient experience data forchildren community services between September 2016and August 2017 and divided the data into threeservices: health visiting, school nursing and specialist

paediatric services. From the 3080 responses, thepercentage of patients who found it easy to get care,treatment and support from health visiting, schoolnursing and specialist paediatric services was 98%,100% and 90% respectively. When asked if patients feltinvolved in their care as much as they would have liked,the percentage of patients who said yes for healthvisiting, school nursing and specialist paediatric serviceswas 93%, 91% and 92% respectively.

• Each location we visited had locality specific FTT. Forexample, Grays Health Centre displayed the results as“your views count” for July 2017. From 833 responses,94% would recommend the service.

Emotional support

• CYP practitioners across universal and specialistservices could refer patients to the trust’s psychologyand emotional and wellbeing service. Practitionersacross services and localities told us listening, managingexpectations and emotional support for families ofchildren with disabilities was a core part of their role.

• Staff provided emotional support to the patients andtheir families. We observed health visitors sensitivelydiscuss mothers’ feelings and emotional wellbeingduring home visits. We observed health visitors create asafe atmosphere allowing mothers to talk openly aboutdifficult matters. However, staff offering emotionalsupport to parents was inconsistent as some parentstold us staff did not offer them emotional support.

• We saw evidence of emotional health leaflets for thepublic. For example, at the Acorn centre, we saw aSamaritans leaflet, which included telephone numbersfor ChildLine, parent surgery (free advice service forparents and carers), Young Minds (CYP wellbeing andmental health) and Harmless (a self-harm supportorganisation). The leaflet included a free telephonenumber, mobile number to send a text and emailaddress for the Samaritans.

• Staff told us they had good access to the emotionalwellbeing service. School nurses provided emotionalsupport to children and families through drop insessions. School nurses told us they had access tocounsellors in secondary school and sometimes inprimary school. One parent voluntarily told us she feltwell supported, especially at the nursery school.


Good –––


• The trust worked in partnership with independentorganisations and charities to provide emotional andpractical support to patients such as counselling andfamily activities. The CYP services in Essex boroughsworked with local charities including SNAP (SpecialNeeds and Parents) and the Sycamore Trust, whichhelped local families with children and young, peoplewith special needs or disabilities. SNAP offered differentparent training which included large specialist talks forparents and professionals. The charity had produced aleaflet, which included their services, and we saw theleaflet displayed in some of the children’s centres wevisited.

• Sycamore Trust had set up an autism hub in Havering tosupport families and individuals affected by autism,putting them in control of the delivery and accessibilityof local services and opportunities. The hub worked inpartnership with local hospitals, GP surgeries, dentistsand other health service providers to achieve betterhealth outcomes focused on resilience, supportnetworks and coping strategies. The leaflet includeddifferent services such as family support, parent supportgroups, befriender project, autism ambassadors,signposting and advice and youth clubs.

• A charity called Open door in Thurrock providedcognitive behavioural therapy (CBT), a mental healthprogramme and a self-esteem programme. Staff told usthis service had supported children and familiesexperiencing domestic violence.

Understanding and involvement of patients andthose close to them

• Staff across the different services worked together inpartnership with the patients and their families.Practitioners demonstrated a patient-centred approachand encouraged family members to take an active rolein their child’s healthcare. Parents’ feedback included“positive experience, we were always aware of nextstep”. This included adapting the style and approach tomeet the needs of the individual children and involvingtheir relatives appropriately.

• We observed therapists and clinicians involve the childin assessments to ensure that everyone took part

equally. Practitioners explained the Education, Healthand Care (EHC) plan to parents in jargon free language.The clinics we observed were child-led and involved thechild for the whole session.

• Health centres we visited displayed information leafletsand the reception staff were welcoming and polite.These included advice and guidance on victim support,financial support and breast-feeding. We found ageappropriate books, games and toys across most of thehealth and community centres we visited.

• We witnessed age appropriate instructions with clearexplanations, encouragement and feedback given in allCYP staff interactions with children. One mother told usthe “staff member was professional, honest and good atlistening. She even researched information to supportadvice given”.

• The trust worked with local independent communitygroups. For example, Havering and Barking andDagenham had a local support and action group called‘add+up’ which helped unite parents who had childrenwith attention deficit disorders. The group taughtparents/carers new skills to manage ADHD in theireveryday lives to help reduce the risk of familybreakdowns. The children would learn how to managetheir ADHD and were encouraged to remain ineducation to achieve their true potential.

• Staff showed good cultural understanding of their localpopulation. For example, therapy staff in the childdevelopment centre had supported a child undergoingassessment for social communication disorder andnoticed the identified ethnic minority group did notdiscuss the disorder freely. Therapy staff noticed thefather was showing signs of social communicationdifficulties and supported the father by referring him tohis GP. The father was now accessing mental healthsupport. The overall outcome for the family had beenpositive, staff told us the mother, and father’srelationship had improved since the father hadaccessed appropriate support. This created a betterenvironment for the child to manage his recentdiagnosis with family support.


Good –––


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

Summary

We rated responsive as good because:

• The trust planned and delivered services in line withlocal needs and in partnership with localcommissioners.

• The trust had worked to make services as accessible aspossible facilitated by co-location of multiple services inhealth centres. This included flexibility in the timings ofappointments, where the clinics took place and how theservice was organised.

• Waiting rooms and clinic rooms were child friendly withtoys, books and other resources appropriate fordifferent ages. Staff communicated with children andyoung people in an age appropriate way and involvedthem as decision makers in their care.

• The trust had redeveloped the referrals standardoperating procedure to make the process morestreamlined for patients.

• The trust followed up patients who did not attend theirappointments to ensure they were safe and well.

• Staff had a good understanding of the different culturalneeds and backgrounds of patients.

• Staff and families we spoke with told us there was goodaccess to translation and advocacy services.

• The trust offered good provision of services and supportfor vulnerable client groups.

However:

• The trust had improved the waiting times and referral totreatment times for some services but still facedchallenges from commissioning, staffing capacity andrecruitment of specialist therapy staff.

• Although the trust responded to complaints within thetrust time scales, we found completion of the onlinerecording system incomplete as risk assessments andlessons learnt sections were blank.

• Although some services managed the arrangements fortransition from paediatric to adult services well in someservices, service leads acknowledged there were a gapand admitted that receiving services had differentcriteria.

Planning and delivering services which meetpeople’s needs

• The trust worked collaboratively with commissionersand other NHS trusts in East London and Essex to planand meet the needs of local populations. Seniorpractitioners and service leads told us they had regularcommunications and, for the most part, constructiveworking relationships with commissioning bodies. All ofthe staff we spoke with recognised the differentpopulation demographics, socio-economics andhealthcare needs of the diverse communities in thelocal area.

• Service leads were concerned about their ability toprovide services to rapidly growing and changingpopulations. However, where the trust had felt serviceswere not safe to run, discussions had taken place aboutgiving notice to the commissioners.

• Local authorities and commissioners haddecommissioned a number of CYP services in the yearbefore our inspection. Although this had created someuncertainty for staff, the staff we spoke with said theyfelt the trust and service leads had kept them informedaccordingly. For example, the Thurrock Health Visitorsmeeting minutes for September 2017 included anagenda item on tendering and staffing updates forBrighter Future and Healthy Family Service.

• Patients and their families also noticed the changes tocommissioning arrangements, which meant they didnot see the same staff member at each visit. However,parents told us that “this didn’t matter too much aseffective handovers took place between staffbeforehand, with no read to repeat myself”.

• The trust had a robust policy for interpreting andtranslation for use when English was not the firstlanguage to help patients and families make informeddecisions. The policy included legislation, national

Are services responsive to people’s needs?

Good –––


guidance and referred to the NHS constitution. Thepolicy gave clear guidance on consent and safeguardingand details expectations of the service. The trust had aninterpreter service and telephone translation serviceand staff in the CYP service used the servicesappropriately. Staff told us they recorded translationrequirements for patients in the electronic recordssystems.

• The trust’s partner interpreting service providedtranslation for 36 different languages. Staff and patientsreported good links to interpreter services. However, weobserved a session where the quality of interpretationwas poor as there were missed opportunities totranslate. The trust was in the process of rolling outdevices to staff to facilitate the use of an immediateonline translation tool.

• The Havering audiology clinic displayed a wide varietyof leaflets, mostly from the National Society of DeafPeople, which were available in different languages. Thetrust had a leaflet on compliments, comments, concernsand complaints available in different languages. Theseincluded Turkish, Albanian, Portuguese, Bengali, Farsi,Polish, French, Tamil, Arabic and Russian. We saw thisleaflet at most of the locations we visited.

• Staff at Grove Health Centre told us that they ensuredtwo staff members were available to give feedback toparents after a confirmed diagnosis of an autismdisorder. The rationale for this was to enable staff tosupport the family as well as acknowledge the child whowas present. This also increased peer support amongstaff. Staff requested translation services where neededespecially for feedback sessions where parents receivedthe diagnosis.

• The locations we visited had age appropriate spacesand environment for children, which included toys forthem to play with and children’s drawings on display.The service displayed patient information boards inreception areas of health centres, which providedinformation about local children’s centres, baby groupsand other activities and free courses available in thelocal area.

• Staff in some services ran different sessions in a numberof locations and on different days of the week with a

mixture of both morning and afternoon sessions tooptimise attendance. For example antenatalbreastfeeding workshops were available in six healthcentres across Redbridge.

• We observed home visits with health visitors wheremothers were signposted to services and givensupporting information leaflets. The trust’sbreastfeeding leaflet included telephone numbers forthe national breastfeeding helpline, national childbirthtrust and breastfeeding line and Bengali/Sylhetibreastfeeding helpline.

• The trust offered a wide range of services to supportpatients and their families. For example, local residentsin Barking, Dagenham, and Havering were offered freeEnglish classes to help with employment through aregistered charity called Lifeline. The classes not onlyhelped individuals with learning English and makingfriends but also helped with job applications. However,as this service was advertised in English, access wouldhave been limited to those who had English as their firstlanguage.

• Service leads told us that although it was not possible toproduce material in all the languages, patients and theirfamilies could request translation of leaflets into therequired language. However, we did not see any signagesaying this service was available either.

• Staff told us they adopted a targeted approach toparental involvement for CYP patients. They told usbeing honest and open was a key focus when dealingwith parents and they said this had resulted in muchimproved relationships. However, some staff reporteddifficulties managing the expectations of some parentswhich contributed to increased workloads.

• Health visiting and school nursing teams applied a dutysystem from Monday to Friday 9-5pm to enable timelyaccess to other services. Staff had a duty folder withrelevant contact details for the different teams. The dutyfolder included contact details antenatal pathway,prevent escalation process, guidance on concerns withpatient/carers, information for other health centres,safeguarding contact details, brief intervention forsmoking, domestic abuse forms, accident andemergency forms, responsibilities for duty health visitorand weekly duty rota.


Good –––


• The nursery nurses offered a range of interventions tosupport parents and children, which included toilettraining, sleep, eating, education preparation, behaviourmanagement, early support process and observationwith children undergoing investigation for autism.

Meeting the needs of people in vulnerablecircumstances

• Staff directed patients to relevant support groups.Health visitors’ directed patients to local supportgroups, charity groups and religious groups for example,funding and social services support. Health visitors usedantenatal and postnatal guides to target young teenagemums, looked after children and other vulnerablegroups.

• The trust provided a number of resources for autismsupport, which included parenting groups, support andhome visits, play and development support andmultidisciplinary coffee mornings.

• We observed therapists using pictorial timetables andcare plans for children living with a learning disability.We found therapists used appropriate language andbody gestures to help communication with patients, forexample clapping to say “well done”.

• The service offered appointment times to suit the needsof individuals. We observed several interactionsbetween staff and patients and their families todemonstrate flexibility with appointments. Staff told usif patients were running very late and missed theappointment every effort would be made to rescheduleanother appointment where possible.

• The trust used an appointment reminder systemthrough text messages to inform patients and theirfamilies of their appointment details. For example, thesupport worker at the immunisation clinic sent textmessages the day before or on the morning forappointment reminders in addition to postalappointment letters. This had resulted in fewer missedappointments and patients and their families fed backthat the system worked well. Practitioners told uscontinually missed appointments were referred tohealth visitors and schools to identify actions andwhether a safeguarding referral was needed.

• The trust used a single point of access referral system tosimplify access to child development and paediatric

therapy services such as physiotherapy, autism andsocial communication assessment and speech andlanguage therapy. Patients could access these systemsthrough a single point of contact, such as a specialisthealth visitor. Staff told us clinical leads triaged referrals.Paediatric therapy practitioners told us that the singlepoint of access had rationalised referrals fromstakeholders.

• At the last inspection, we found inconsistentcompliance with the trust’s referrals standard operatingprocedures (SOP). The trust’s community of practice(COP) for CYP had reviewed the SOP and implemented arevised version across all localities in the summer of2017. The trust completed an audit to check complianceand the trust found the SOP was fully embedded whichmeant patients were not referred too frequently orunnecessarily.

• Staff told us that once a referral was received, a MDTreferral meeting took place. Various health careprofessionals attended for example, speech andlanguage therapists, occupational therapists,physiotherapists, child and adolescent mental healthservices (CAMHS) and paediatricians.

• Staff gave us examples of where the service was findingnew ways of working. For example, the north localityproject was a pilot extended support scheme, whichaimed to work with five to six families that do not meetthe referral threshold, for one year. Staff told us this hadimproved joint working and information sharing. Theservice included PREVENT escalation, intervening earlierfrom health, social care and the local authority.

• The trust had a vulnerable children initiative in placesince May 2017 aimed at children who do not meet thethreshold for referral to social services. This couldinclude children who were on a child protection plan orlooked after children (LAC). The trust had received goodfeedback from parents on this initiative. We sawevidence that local social services had provided positivefeedback on joint working with the trust. The trust’sCAMHS transformation project funded the initiative,which improved joint working with CAMHS. The initiativeimproved parent resilience and helped improvecommunication with children and schools.

• Each locality had a youth offending team, whichconsisted of a clinical psychologist and a specialised


Good –––


nurse. The team received referrals from youth offendingservices and the team provided support around mentalhealth, physical health and health promotion untilpatients needed transition to adult services. Althoughyoung people accessed the service on a voluntary basis,consent was obtained and the young person receivedan appointment within a month of referral. There wasno set limit on visits and contacts as the service was ledby the young person’s needs. Practitioners soughtfeedback at each session using a questionnaire.

• During our review of records, we saw comprehensivecare plans for patients with appropriate referrals made.Staff we spoke with told us patients would not bedischarged until the outcome was received. Serviceleads told us there was a local and national strategy forchildren with disabilities to be within young peopleservices until the age of 25 years and be offered servicesbased on their needs. The trust had a clinical interfacegroup in place to review the most vulnerable, high-riskpatients with complex needs.

• Although the trust had produced a transition policy,some local commissioning arrangements still impactedon effective transition arrangements. Senior staff told ustransition was a national commissioning matter and notwithin the trust’s control but service leadsacknowledged there was a gap and admitted thatreceiving services had different criteria. At the lastinspection, we found inconsistent transitionarrangements from paediatric to adult services acrossservices and localities. The trust had since implementeda transition policy in August 2017 and had appointed atransition lead. The policy was robust and based onrelevant child and adult guidance and legislation andreferred to Fraser guidelines and the Mental CapacityAct. The policy clearly outlined the expectations onchildren’s and adult practitioners to work jointly toensure transition was seamless.

• However, not all services had transition arrangements inplace because of commissioning arrangements.Therefore, it was not always clear where the child wouldbe transferring to. For example, service leads advised usthat therapies services were only commissioned forchildren and young people up to the age of 16, or up to19 for those who had an education and health care plan.Generally, young people with a learning difficulty wouldbe transitioned into the adult learning disability service.

However, this offer might be different across thedifferent local authorities. Therefore, it was not clearwhich service young people would go to if they requiredspecialist therapeutic intervention such as speech andlanguage or occupational therapy up to the age of 25 asrequired by the Children and Families Act 2014.

• Where the trust had transition arrangements in place,for example the learning disabilities team for adults,transition arrangements were effective. Staff told usthere were good transition arrangements for patientswith epilepsy. Transition included multi-agency teammeetings with all the necessary health professionalswho would also visit the patient’s school. This involvedworking with specialist education needs and disability(SEND) staff from primary to secondary school. Thecommunity nurses continued to provide support for thefamilies. Both parents and patients would also beinvolved.

• The trust told us there was no pathway for children inspecial schools to transition to adult services. The trustoffered early support to children with special needs withjoint working with education and health to supporttransition into school. Currently, when children wereleaving special schools, aged 16-19 they weretransferred back to the care of the GP by the schoolnurse. The school nurses wrote to the GP and copied inthe parents to advise them that care was transferring tothem. School nurses reviewed children with morecomplex health needs in school clinics before they leftschool, to ensure referrals were made to adult services.The school nurse referred children with a learningdisability to adult learning disability team if appropriate,but the adult team did not accept referrals until 18 yearsand above so this was not always appropriate. The trusttold us there was no capacity to see all the children whowere leaving for a transition medical. There were a fewchildren for example who had life limiting conditions,who were referred back to a child development centre(CDC) when they left school if there was still a clinicalneed and transfer to adult services were still ongoing.

• The trust told us children community nursing teamwould refer the transitioning child to district nurses andcarry out a joint home visit to transfer care to them.

Access to the right care at the right time


Good –––


• Patients had good access to multiple CYP servicesacross the trust. The co-location of services such astherapies in one location, as well as shared premiseswith general practices, facilitated good access forpatients (see multi-disciplinary working andcoordinated care pathways section for more detail).Theservice displayed posters throughout CYP premises tosignpost patients to other services. Staff told us therewas effective communication between departmentswithin the organisation.

• CYP services followed the trust’s 'did not attend' (DNA)policy. Staff told us letters were sent out to parents andif they did not respond, then the child was discharged. Ifthe child was vulnerable or there were safeguardingconcerns, and they did not attend a communitypaediatric clinic, staff members would then contact theGP, health visitor, social worker to make them aware.However, staff told us that where parents did not attendand still wanted another appointment, the serviceremained flexible and would always try to slot them intoa clinic. We observed a member of staff being sensitiveto the needs of patients and family members whilstoffering a physiotherapy appointment.

• Community paediatricians told us that if a patient didnot attend a clinic, the doctor would try to call them andsend a text message. Additional appointments would beoffered where contact was made. However, if no contactwas made, the doctor would inform the crisis team andsocial services.

• The physiotherapy team had a 48-hour cancellationpolicy. Where a patient did not attend, the staff memberwould make contact within the hour. If contact wasmade, appointments would be rescheduled. However, ifthere was no contact, a written letter would be sent.After three DNAs, the patient would be discharged. Stafftold us DNA rates were low due to appointmentreminders by text message.

• The service managed DNAs through electronicreminders for patients in addition to an appointmentletters. The trust provided DNA data for CYP services.The DNA rate for the CYP service had increased for July2017 and August 2017 at 9.13% and 9.67% respectively.However, prior to that, DNA data for June 2017 was7.73%. The trust’s compliance target was not includedand the data provided was not broken down by services.

• Clinic appointments ran on time with minimal waitingtime for patients and their families. During ourinspection, we observed children and families did notwait long for their appointments. Most of the parentstold us clinic appointments ran efficiently with nocancellations from the service. However, whereappointments were cancelled, alternative appointmentswere booked promptly.

• Trust administrators worked closely with practitioners toensure that multiple sessions were combined in oneappointment to reduce the impact of multiple visits onpatients and their families. Although the trust healthcentres we visited were well located for local publictransport with accessibility across localities,administrators alerted patients to factors such aslimited parking or public transport in appointmentletters to ensure they attend on time. However, someparents told us parking was an issue and found itfrustrating at some centres, for example Wood StreetHealth Centre.

• Community paediatricians, dieticians, continence andfeeding and swallowing teams all held clinics at specialschools so children did not miss out on learning or haveto be taken out of school for appointments. Schoolnurses worked across a number of schools and haddrop-in sessions for parents in primary schools everyterm to maximise opportunities with parents.

• The trust provided waiting times data by core service ina ‘Clock Stop Report’. The data was representative of theCYP service across all services. The percentage of CYPpatients seen within 18 weeks was 93%. The percentageof CYP patients seen within 19 to 37 weeks and 38 to 56weeks was 6.5% and 0.5% respectively.

• The trust continued to face the challenges of breachedwaiting times due to recruitment difficulty of specialisttherapy posts. At the last inspection, we found evidenceof long waiting lists and waiting list breaches inpaediatric therapies across localities, particularly inoccupational therapy, speech and language therapyand dietetics. Senior managers told us this was due toreported staffing pressures and lack of commissionedresources. During this inspection, service leads told usthat although commissioners had granted furtherinvestment, recruitment for some posts remained achallenge. For example, funding had been approved foradditional occupational therapy posts but there was a


Good –––


national shortage, which has affected recruitment.Therefore, on this inspection, we found that waitingtimes remained high for some services. Staffing levelsaffected waiting times for example physiotherapists toldus that patients had to wait between 8 to 12 months.Service leads told us the trust monitored waiting times,waiting lists, and said all patients on the waiting listsreceived clinical harm reviews to maintain safety.

• The trust also provided data on the first treatment tofollow up. The percentage of CYP patients who receivedtheir follow up appointment within 18 weeks of the firstappointment was 84%. The percentage of CYP patientswho received their follow up appointment within 19 to37 weeks and 38 to 56 weeks of the first appointmentwas 14% and 2% respectively.

• Some parents told us they had noticed changes to someservices, which they perceived was a result of changesto funding arrangements. For example, the autism clinicused to be a drop-in clinic but now was appointmentonly. However, patients and their family members toldus services had improved communication. For example,previously parents told us they did not always receiveappointment letters in a timely way. However, they feltthat the system of text messaging reminders forappointments worked well for them.

• Parents we spoke with said they always receivedappointment letters and the service rescheduled anycancelled appointments promptly, offering flexibilitywhere possible. However, some parents told us it wasdifficult to get a physiotherapy appointment and theyfelt they waited “months and months” but the servicewas “much better now”. Although parents commentedon the long waiting times, they also said, “Once theywere in the system, the care received was supportive,caring and amazing.”

• There was recognition that staffing and resourceallocation differed between localities because ofcommissioning arrangements. However, CYP staffworked through the challenges adapting new ways ofworking to manage waiting times. For example, therapystaff told us they completed data cleansing to checkwith parents if the referral for physio or OT was stillrequired.

• Although, the trust had shown some improvement inwaiting times for some services, further work was still

required to be compliant with national guidance withmaximum waiting times of 18 weeks. At the lastinspection, community paediatricians and therapistsreported long waiting lists for the autism and socialcommunication pathway. The referral pathway forautism began with a referral into the service, anassessment by a paediatrician followed by an AutismDiagnostic Observation Schedule (ADOS) assessment.On this inspection, staff told us the trust hadimplemented a quality improvement programme. Thiswas an initiative to manage waiting lists for servicessuch as community paediatrics and autism diagnosis.Staff told us the waiting times had improved. Forexample, the waiting time for autism diagnosis waspreviously 24 months and now was 8-12 months. Theservice had also made sustainable changes to tacklewaiting times and facilitated improvements. Forexample, staff reported increased speech and languagetherapy sessions from two per month to eight permonth.

• The physiotherapy department within Brentwoodhospital had a MDT triage system in place with singlepoint of access, which included speech and language,occupational therapy, physiotherapy and paediatrics.The MDT meetings took place weekly and on occasions,used skype meetings to facilitate attendance.

• The audiology service provided a daily drop-in clinic forpatients with hearing aids and after schoolappointments. The clinic provided same day service forbattery replacement, new moulds and replacementhearing aids. We observed that patients did not wait toolong to be seen. Parents told us appointments could bechanged to suit the patient needs. Staff told us theHarold wood clinic would see children within four to sixweeks from referral.

• Parents we spoke with commented on the waitingtimes. For example, at Wood Street Health Centre, oneparent said, “six months wait was far too long andupsetting”.

• Service leads told us that although staffing levelsaffected waiting times: they were confident that staffinglevels did not affect the quality of care.

Learning from complaints and concerns

• The trust provided feedback forms and submissionboxes in health and community centres where CYP


Good –––


services were delivered. The locations we visiteddisplayed leaflets on the trust complaints process andguidance on complaints, concerns and compliments.Most of the families we spoke with told us they hadreceived information on how to make a complaint.However, they told us they had no concerns orcomplaints about the service but felt the waiting timeswere long.

• Between 1 September 2016 and 31 August 2017, thetrust received 19 complaints related to children andyoung people services. Of these, 16 were closed andthree remained open. One of these was fully upheld, fivewere partially upheld and 10 were not upheld. Nocomplaints were referred to the Ombudsmen. Serviceleads told us there were no particular themes fromrecent complaints and most complaints were aboutstaff attitude, communication and clinical care involvingthe diagnostic assessment.

• The Trust recorded 393 compliments from CYP patientsin same 12 month period. The service recordedcompliments by location on the online reportingsystem. We reviewed 12 compliments for the Acorn

Centre in the last six months and comments included: “Iam grateful for all you have done for me”, “as a first timemum I really appreciate knowing someone caresenough to help us after being passed around so much”and “we really appreciate you being here”. On someoccasions, children submitted drawings as part of theircompliments with comments such as “I miss you”.

• We reviewed two CYP service complaints on the onlinereporting system, from two different localities and foundrisk assessments and lessons learnt were notcompleted. We fed this back to the senior managers,including the complaints manager, during theinspection. However, the two reviewed records showedcomprehensive responses, compliance to the trusttimelines and application of duty of candour in bothcases.

• Service leads told us that learning from complaints andincidents was shared using the community of practice(COP) structure and ‘our sharing learning strategy’.Service leads presented cases at COP meetings forlearning and in team meetings.


Good –––


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

Summary

We rated well-led as good because:

• The trust had robust governance structures and systemsfor the review of performance and risk managementinformation.

• The service had a strategy that reflected the needs ofpeople using the service and the changes happening inlocal health and social care services. This reflectedcurrent best practice in providing services for children,young people and families.

• The service consulted and worked in partnership withthe local community, other commissioners andstakeholders to improve services and health outcomes.

• The trust had published the vision and strategy for theentire CYP service in July 2017 having engaged withboth the staff and the public.

• The trust managed risks effectively. For example, staffhad a good awareness of lone working arrangements.

• Despite some areas of high workload andcommissioning challenges, there was good moraleamong CYP staff and practitioners across all services.

• Staff demonstrated innovative working usingtechnology.

• Staff told us that service leads were supportive,accessible and approachable and they articulated howthey would escalate any concerns beyond theirimmediate line manager.

• The staff we met reflected the trust values and vision.Staff valued working for the trust and told us that thetrust involved staff in different ways; for example, duringthe development of the trust vision and strategy.

Leadership of this service

• The trust had an established and stable leadership teamin the CYP service. Allied health professionals such ashealth visitors, community nurses and therapists told usservice leads were visible, accessible and receptive tostaff feedback and evaluation. Staff viewed the CYP

leadership team as supportive and encouraging. Staffdescribed service leads as compassionate andknowledgeable. Practitioners told us their managerslistened to needs of the service and provided support.

• The trust’s leadership team for the CYP serviceacknowledged that with the different commissioningarrangements and individual localities each locality hadlocalised working practices to deliver services based ontheir local populations’ needs. However, the trust hadembedded robust governance and safeguardingstructures to facilitate a cooperative and consistentapproach. Opportunities for staff interaction or sharedlearning across localities were in place and supportedby service leads.

• The trust adopted a ‘communities of practice’ (COP)model to provide trust wide multidisciplinary strategicleadership to CYP services. The COP included a clinicallead, operational lead and nursing lead. The COPscoordinated development of corporate strategies,developed new pathways and led on audit andevaluation. Staff told us the COP met every eight weeksacross the organisation and helped integration oflocalities into the trust ensuring consistency withprocesses such as standard operating procedures(SOPs). Senior leads in the CYP COP told us there was nosingle lead for CYP as a whole as the COP was based ona partnership model.

• At the last inspection, we found clarity was neededaround the representation of CYP services at trust Boardlevel. The trust had recently appointed a non-executivedirector (NED) on the Board with responsibility for CYPservices. The NED told us there was representation ofthe CYP voice at Board; for example, the trust invited apatient to each board meeting to share their experienceand give their opinion of possible improvements.

• The trust leadership team explained their services werenot organised through service lines but through locality.Therefore, staff would have an awareness of how to

Are services well-led?

Good –––


escalate any concerns to their line manager, and thenext line of management, their named nurses andprofessional leads but would be unlikely to know theirassigned NED.

• Staff we spoke with told us they felt confident to raiseany concerns and demonstrated awareness of themanagement line in order to do this. Staff told us theyknew the names of their immediate team lead,operational lead and assistant director. Staff couldaccess the organisation chart to identify other seniorteam leaders.

• The trust organised leadership listening events for staff.We saw posters advertising these events in some of thelocations we visited. Practitioners told us about thedrop in surgery for staff members to raise and discussany issues or concerns with senior management. Stafftold us they felt listened to by managers but alsounderstood the financial restrictions on the service,which limited what managers could do.

• Managers supported staff in their roles. Staff withmanagement responsibilities had access to leadershipand management training funded by the trust.Operational staff such as health visitors, school nurses,therapists and community nurses told us they felt wellsupported by service managers. Staff told us that sinceour last inspection the visibility of senior managementhad increased. For example, the non-executive chairvisited some of the locality teams. Staff also told usabout the breakfast with the chief executive, which tookplace every month in different localities. For example,there was one in Thurrock a few weeks prior to ourinspection.

• Several staff told us: “my manager is fantastic”, “I admiremy manager”, “we have a good supportive team”, and“we are like family”. Staff told us that one to onemeetings had increased and were more regular. Seniormanagement rescheduled any cancelled one to onespromptly. Administrative staff told us they felt wellsupported. Staff told us team meetings were notcancelled and said “there is always someone you can goto”.

• Staff received regular information from the senior teamthrough staff engagement meetings and team meetings.Staff told us they received the trust newsletter weekly,which included information on what was happening

across the trust, training information, positive storieswithin the trust and nominations for staff awards. Stafftold us that the director of the CYP service wasaccessible and visible and attended team meetings tonotify staff of any changes or when requested to attend.

• The trust involved staff during the tendering of services.Several staff told us managers kept them informed ofany updates. Service managers supported staff tomanage their anxieties and concerns. For example, staffat South Woodford Health Centre told us about a staffaway day arranged to discuss new ways of working andtransition. Staff also told us the links to the trust’shuman resources team had improved and they haddirect contact details for their named human resourcespartner.

Vision and strategy

• Staff we spoke with understood the trust’s values. Mostof the staff, including practitioners that we spoke withcould tell us about the trust’s values. All of the staff werecommitted to delivering excellent care in line with thetrust’s strategy. Staff told us about their passion forproviding high quality care for their patients during ourconversations with them, which we further observed inclinics and home visits.

• Staff demonstrated effective patient-centred, internaland external multi-disciplinary team (MDT) working andthey were “proud of the integration”. Staff providedexamples of integrated working such as allied healthprofessionals and paediatricians working morecohesively and linking in with school nursing.

• The staff we spoke with were aware of local challengesand continually worked on engaging with hard to reachgroups. For example, on many occasions, we observedstaff provide holistic care for patients and extend thiscare to other siblings in a family.

• Some of the locations we visited displayed the trust’svisions and values on the public notice board, forexample, we saw the information displayed at GroveHealth Centre. The display also included key qualityoutcomes, aims and benefits of the targeted service,team purpose and team feedback.

• The trust had produced a Best Care Clinical StrategySummary in July 2017. At our last inspection, the trustdid not have a formal documented vision and strategyfor community health service for CYP as a whole. On this


Good –––


inspection, the trust had developed a 10 year vision andstrategy for the service. Senior leads told us the medicaldirector who engaged with staff and members of thepublic and patients, led on the document. The trust hadrecently cascaded the document through variouschannels such as the intranet, the three tiers ofgovernance, in the weekly newsletter and at teammeetings. However, the document was in its infancy andthe trust acknowledged that not all staff would be awareof the document, as more time would be required toembed it fully. However, the trust had started to developthe implementation approach for the Best Care strategyand had recognised that staff and services will needsupport to take these principles and understand whatthey might mean for their services and how to makechanges. Service leads told us the trust hadincorporated use of technology into the trust’s visionand strategy.

• Although corporately the CYP service was one trust, theleadership team acknowledged that the CYP servicespresented as separate entities and individual localitiesrather than one trust. Different commissioningarrangements had resulted in localised workingpractices to meet the needs of the local population.However, the trust had embedded robust foundationsacross the localities, which included governance andsafeguarding structures to ensure there was consistencyacross the trust. Staff and service leads told us the CYPcommunity of practice (COP) worked on developingstandard operating procedures and care pathways tostandardise the services and delivery.

Culture

• The service had an inclusive and constructive workingculture. We found highly dedicated and passionate staffwho were committed to providing a good service forchildren and young people, often working in challengingcircumstances. However, some staff felt that there werefewer opportunities to be proactive due tocommissioning challenges and changes to roles.

• Practitioners across services were very positive,knowledgeable and passionate about their work. Thestaff we met understood their local challenges anddemonstrated a desire to improve services for the

benefit of patients. Team working was positive as staffsupported each other through effective communicationand ensured allocation was equitable to alleviatepressure on colleagues.

• Staff we spoke with said the working culture was openand honest which enhanced communication. Seniorleads recognised that staff valued honesty from leaders.Senior leads acknowledged the challenges aroundworkload and capacity remained as extra staffingresources were not always possible. However, seniorleads said the priority was to look after the staff withregular engagement, supervision and the trust’sfreedom to speak up guardians. Staff with personalcircumstances received support through referral tooccupational health.

• Staff told us they felt cared for, respected and listened toby their peers. Health visitors, school nurses, communitynurses and therapists reported approachable andsupportive colleagues. Staff told us they receivedcounselling and debriefs when needed. Staff we spokewith valued peer support and joint training sessions.Staff said they were able to ask questions and receivedresponses quickly from service leads.

• Staff told us the trust was an enjoyable and rewardingworkplace. Staff highlighted the supportive environmentand appreciated the training provisions. Several stafftravelled long distances to commute to work and hadcontinued to do so for several years.

• Senior leads referred to the staff as their “biggest asset”.Senior leads of the service felt proud of their teams andtold us staff were committed, respectful to patients andcolleagues and made a positive difference to their localcommunities. Staff and senior leads were proud of thehigh retention of staff. Staff felt communication withtheir managers and team was effective. Staff were awareof the trust’s award system and felt valued at a locallevel by their peers and managers.

• The trust had different diversity network groups in placefor staff such as the Black and Minority Ethnic (BME)network, disabilities network and the lesbian, gay,bisexual, and transgender (LGBT) network. The trustoffered LGBT awareness training, which although notmandatory, was readily available. Although the trust didnot mandate unconscious bias training as part of therecruitment process, the trust’s clinical development


Good –––


programme included an ‘understanding unconsciousbias‘ workshop. However, staff we spoke with did notmention this to us, which may suggest staff were notaware. BME staff we spoke with said they had receivedopportunities for career progression but they wereaware of less BME representation at senior levels withinthe trust.

• The trust had improved processes for staff to sharelearning and good practice effectively across localitieswith their colleagues. At the last inspection, we foundthere were limited opportunities for shared learning ofdifferent practices across localities. On this inspection,staff told us that communication around sharinglearning had improved. For example, the medicaldirector met monthly with clinicians across the localitiesto share learning and best practice. Each locality hadan integrated children’s services manager or equivalentwho met regularly to facilitate cross-locality sharedlearning.

Governance

• The trust had governance structures across the CYPservices and localities and staff felt they were effective.The trust had established patient safety andperformance governance arrangements which wereordered into three tiers of reporting, each meetingmonthly. The tiers included trust board, quality andsafety committee and locality performance and qualitysafety groups (LPQSG) and departmental performanceand quality safety groups (DPQSG).

• Assistant directors for children’s services attendedmonthly quality and safety group meetings with setagendas to discuss performance data, finances, seriouscase reviews, new guidance, and operational reportsfrom each service.

• Each CYP service held regular planned governance andteam meetings. Monthly governance meetings wereheld to review performance against key performanceindicators, incidents, risks, complaints and staffingmatters. Monthly departmental performance andquality safety groups fed into monthly LPQSG, whichthen reported up to the trust board.

• We reviewed minutes for the quality board report forSeptember 2017. The agenda included discussions onstaffing trust-wide (including vacancy, turnover,

sickness), financial performance, risk registers, qualitydashboard and exceptions, equality impact and actionsrequired. The dashboards were ‘live’ and allowed fordirect scrutiny of present performance.

• The trust had forums and meetings for CYP staff tomonitor quality, review performance information and tohold service managers and leaders to account. Wereviewed minutes for monthly performance reports. Forexample, the Havering monthly performance report forJuly 2017 included discussion on key performanceindicators for school nursing and health visiting,caseloads, do not attends (DNA), referrals received,discharges and staffing capacity.

Management of risk, issues and performance

• The trust had a major incident plan, policy andprotocols in place for the CYP service. The staff we spokewith demonstrated awareness of the trust’s majorincident plan and told us they could find emergencycontact telephone numbers easily.

• The trust provided alerts to staff on major incidents onthe trust intranet pages. This included alerts for trafficand road works, adverse weather and infectionoutbreaks. We reviewed the July 2017 monthlysafeguarding summary report for shared learning andoperational action for Barking and Dagenham,Redbridge and Thurrock. The minutes included aheadline message on terror threat with advice to stayvigilant and provided the anti-terrorism hotline numberto staff.

• CYP staff cited recent examples where businesscontinuity plans had been implemented. For example,staff told us about the cyber-attack in July 2017. Serviceleads told us business continuity plans were in place.We reviewed the minutes for September 2017 qualityboard report where an update regarding the cyber-attacks had been included. The trust had plans, whichinvolved using the leading next generation antivirussolutions, after a trial use. The trust had selected anexternal company to help them with their cyber securityessential accreditation planned for October 2017. Thisaccreditation would allow the trust to inform staff aboutfake emails and increase cyber awareness. Staff told usthey could access the business continuity plan readilyon the intranet and found it easy to follow using theflowchart.


Good –––


• The trust had fully embedded agile working since thelast inspection. Staff told us they used a buddy systemand kept in touch with colleagues using a mobilemessaging application. We reviewed the agile workingpolicy and found it thorough covering equipment andtechnology. Staff told us they used the alert system onthe electronic recording system to highlight any safetyissues and notified the duty desk. Some localities had acode word in place for staff to use.

• Senior leads told us they reviewed risks weekly, allowingactions to be completed on a local level.

• The trust still reported staffing levels as a risk on the riskregister for all of the services in each locality. At the lastinspection, across all services, workforce vacancies,staffing levels and heavy caseloads were reported asrisks, with vacancies in paediatric therapies. On thisinspection, identified risks on the register includedinsufficient capacity either due to increasing demandsor staffing levels, heavy caseloads and vacancy gaps inpaediatric therapies such as speech and languageaffecting waiting times. The trust managed staffing andcapacity risks by increasing skill mix, using the caseloadwaiting tool and routinely employing locum and agencystaff but the recruitment challenges remained in someservices. Other identified risks included retendering anddecommissioning of services and changes to ChildHealth functions. The CYP service rated risks accordingto impact and likelihood and serious risks wereaddressed with an action plan and a named lead.

• Staff told us new services where contracts had changedrecently, such as health visiting and school nursing inThurrock, had been added to the risk register. Serviceleads reviewed new services monthly at the DataPerformance Quality Safety Group (DPQSG) meetings.

• The CYP service adhered to the trust’s lone workingpolicy, which staff could find on the trust intranet. Thepolicy was based on NHS Protect, Health, and the SafetyExecutive guidance. The policy stated there were healthand safety advisors available for staff and managers.Staff we spoke with demonstrated good awareness ofthe lone working arrangements. Staff told us they used acode word, which differed, in each locality. Healthvisitors and children’s community nurses conductinghome visits used text messaging through phoneapplications, to inform other staff of their location. Staffrecorded visit details in their electronic diaries. The

service had a buddy system in place and shared diaryaccess to ensure that staff were aware of theircolleagues’ whereabouts. A duty staff member ensuredthat all staff had responded to text messages daily.

• The trust provided information to staff via a trustbulletin, emails and staff meetings. Service managerscascaded information about complaints and incidentsto staff via team meetings. We saw the minutes forAugust 2017 Waltham forest monthly children’sintegrated services meeting. The agenda includeddiscussion on safeguarding, performance dashboard formandatory training and supervision, quality and patientsafety (which included complaints, compliments, riskregister, serious incidents, high risk reporting, patientfeedback and service development.

Information Management

• The trust had fully embedded the agile working policy,which included guidance on laptops and otherequipment. The trust supplied staff with encryptedphones and laptops to ensure security in line with thetrust’s data management policy. The service had adedicated IT team, which staff said were responsive andefficient. Staff told us the agile working team attendedstaff away days to support and speak to staff about anyconcerns. Staff we spoke with told us they called theduty desk when they had a home visit or if they weregoing home post visit. Staff told us the trust intranet wasbetter than before.

• Practitioners across universal and therapy services hadlaptops, secure mobile internet connections and mobilephones to support remote and mobile working. We sawpractitioners using laptops to complete forms withpatients and record notes simultaneously during clinicsand home visits. Practitioners were responsible forupdating the shared drive documenting children withchild protection plans, looked after children andchildren in need. Staff told us they could find the shareddrive easily. The shared drive held information onspecific service pathways and care plans. Staff did notmention any delays with test results.

• At our last inspection, service leads within the servicerecognised the need for remote working champions andfurther training to help staff understand the time savingbenefits of this technology. During this inspection, stafftold us that the trust had agile working champions inplace.


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• The trust used two electronic record systems (ERS) toinput and access patients records. Since the lastinspection, the trust had put in place a champion ineach locality for each ERS system, which supported staffwith agile working. Staff were encouraged to attend theERS user group forum, which took place every six weeks.Patient notes were available electronically which meantthey were easy to access with no issues with legibility.

• Regular updates to templates on the electronicrecording system took place to facilitate agile working.Staff told us the trust involved them in the developmentof templates or forms for the ERS systems.

• Some staff felt positive about agile working as itimproved their work life balance and reduced traveltime. Although most staff told us agile working wasgood for record keeping, some staff felt that agileworking made it difficult to connect with the patient.

• Although staff told us flexible working was effective as ithelped them to make better use of their time, staff alsotold us that some equipment such as old laptopsrequired updating.

• At our last inspection, some practitioners told us thatremote connections to the ERS were not always reliableand contemporaneous recording of notes was notalways possible. However, on this inspection, most stafftold us the connectivity had improved. The trustaddressed the remote connectivity issues by usingdifferent network providers in different localities, basedon the strongest signal. Staff told us connectivity onhome visits was facilitated using 4G sim cards in thelaptops and we saw evidence of this working well.

• Although staff said that some of the equipment was old,staff we spoke with told us IT support was effective andresponsive. Staff told us the current model of trustphones took time to send text messages on. Some staffwould send a text from their personal smartphone andthen to the work phone before sending the message tothe patient. Some staff told us that smart phones wouldbe useful to show patients and families the relevantmobile applications during consultations. Staffmembers received requests from families and carers tohave information via emails.

• Further to staff feedback, the trust had recently pilotedthe use of smartphones to work out which phone was fitfor purpose and to support the use of smartphones

replacing the paper dairies. However, staff awareness ofthis pilot varied and so the details of the pilot were notclear. Some therapy staff told us they did not have atrust phone and used their personal phones.

Engagement

• The CYP service obtained feedback from patients. Theservice carried out ‘five by five’ telephone surveys wherea member from each team called five patients andasked five questions each month to discuss theirexperience of the service. This allowed the clinicalteams to respond to any concerns at source. The trustprovided summary data from five by five reports on aquarterly basis to the commissioner. Staff told us thetrust made service improvements further to feedbackfor example, the implementation of the duty desk forhealth visiting and school nursing services.

• Similarly, staff at Hainault Health Centre also gave us anexample of how the service made improvements furtherto patient feedback. Patients had commented on theempty reception desk since the implementation of agileworking. The service now had a clinical assistant basedon reception who was able to direct patients to theirclinics. Staff told us that some health centres had familycommunity days.

• The service used social media to get information to thepublic and this had proved popular. For example, thehealth visiting team had a Facebook page, whichreceived the most ‘likes’ across the trust. School nurseshad a Facebook and Twitter page.

• Senior leads told us the trust invited patients and theirfamilies to attend the trust board meeting to share theirexperience of the service and suggest improvements.Service leads told us that patient representatives andyoung people took part in interview panels. Staff told usabout the production of a CYP leaflet on health careassessments included young people in thedevelopment process.

• The Acorn Centre had a parent forum in place. Parentshad provided feedback on the language used inEducation Health and Care (EHC) plans. Parents foundthe language too complicated and could not determinethe responsibilities of all the stakeholders. EHC plansinvolved health, education and local authority. Serviceleads had discussed this feedback with the borough andplanned to work on a flowchart with the integrated


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team explaining the process and stakeholderresponsibilities. The service leads planned to presentthe draft flowchart to the parent forum to checkunderstanding of the language and clarity of processbefore implementing.

• Staff at Grove Health Centre held a parent engagementgroup, which had been in place since March 2017 andmembership was increasing. Further to parent feedback,staff told us the service was implementing a newquestionnaire as part of the pre-assessments forms. Thequestionnaire would allow the parents to submit threekey questions ahead of the appointment to maximisethe use and value of the available time.

• Service leads told us patient’s family members hadprovided feedback on the Ages and Stages letters torequest the information in different languages. Theservice was currently working on translating thecovering letter as a result.

• Further to the Francis Inquiry report, the trust published’you said we did‘ reports every quarter on the trustwebsite to demonstrate areas where they hadresponded to feedback to improve services. Serviceleads provided an example of change to the servicefurther to a patient complaint. For example, if staffmembers could not make contact with a patient or theirfamily by phone, a written letter followed upcommunication.

• The trust had completed the NHS staff survey andprovided data for the staff survey from September 2015to September 2016. However, the trust told us theresults excluded teams with 11 staff or less and couldinclude data for decommissioned services. Howeverfrom the staff survey 2016 report, the trust wasdeveloping locality based action plans through activestaff engagement. Each locality would choose the areasthey wished to concentrate on, in addition to the threeworst scored areas chosen by the trust. These threeareas included 92% of staff reported feeling underpressure from self to come back to work when feelingunwell, 25% of staff reported that they felt there areenough staff available to meet patient needs and 26% ofstaff agreed that there are enough staff in thisorganisation to do their job properly. Each locality had

different review dates for the locality plan. The aim ofthe locality plans was to collate and combine the topicsto form an overall trust wide action plan, designed bythe staff and delivered in partnership.

• Staff acknowledged communication within communityservices was good. Staff told us they felt listened to bytheir managers and well supported. For example, staff atSouth Woodford Health Centre gave us an examplewhere staff reported concerns for their health andwellbeing. This resulted in the development of abusiness case which secured funding for staff to accessfitness sessions. Senior leads told us stressmanagement training was planned to help staff improvetheir wellbeing.

• Staff told us they received frequent and effectivecommunication via emails and bulletins, and thatmanagers kept them updated accordingly. Staff told usthey had opportunities to provide input into thedevelopment of standard operating procedures as therewere working groups specifically tasked with this.

Learning, continuous improvement and innovation

• Staff felt encouraged by their line managers to putforward new ideas and make improvements. Forexample in Barking and Dagenham, staff memberscompleted a piece of work on the costings of healthvisiting leaflets compared to printing of paper leaflets.As a result, the team had implemented a dedicatedsocial media page to improve public access toinformation.

• Staff demonstrated innovation using technology. Forexample, in Havering, the physiotherapy team hadfilmed their consultations to provide all the exercises forparents from start to finish.

• In Thurrock, staff told us they were using technologymore innovatively to improve service uptake andprovision. For example, health visitors and schoolnurses planned to start remote consultations usinginternet video links. Staff used technology to provide ‘e-drop in sessions’ so that patients could access servicesremotely and minimise any disruption to the children’seducation. The staff made it clear to young people thatthis was not an emergency service.

• The school nursing service was piloting a new textingsystem called ‘Chat health’ to provide confidential andanonymous health advice. The pupils could text the


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school nurses about their concerns and would receive aresponse within 24 hours. Staff told us they wereplanning to introduce this service by October 2017 andpromote the service using social media and adverts inschools.

• The service was organising a ‘Healthy Halloween’ eventto include oral hygiene, smoking cessation andprovision of food for attendees.

• The trust had a new programme called ‘Assist’ forsecondary school students. The programme discussedthe dangers of smoking and smoking cessation.

• We saw examples of innovative models of multi-agencyworking for example, joint commissioning to support

vulnerable families across many agencies. The servicedeveloped pathways through experience and measuredusing individual led outcomes. Similarly, speech andlanguage team were commissioned to work in youthoffending teams.

• Staff told us about their plan to integrate earlyintervention services for autism disorders with CAMHSwith implementation of a joint single point of access.

• The trust’s medical Education team won first prize inJanuary 2017 at the National Association of ClinicalTutors (NACT) UK for the team’s work on sepsis training.


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Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

This section is primarily information for the provider

Requirement notices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

This section is primarily information for the provider

Enforcement actions


Documents

NorthEastLondonNHSFoundationTrust Communityhealthservices ... · NorthEastLondonNHSFoundationTrust RAT Communityhealthservices forchildren,youngpeople andfamilies QualityReport NorthEastLondonFoundationTrust