The clinical lead nurse explained, “We follow the Nursing and Midwifery Council (NMC) guidelines for consent, it covers all forms of consent and different situations that can be encountered.”

A number of risk assessments had been completed covering areas such as moving and handling, health and safety and infection control. A community matron said, “We produce the assessments which are standard but then specific things to each patient and their condition are done as-well, things like peg feeding, warfarin monitoring and COPD (Chronic Obstructive Pulmonary Disease).”

There were effective systems in place to reduce the risk and spread of infection. The provider had a range of infection control policies in place including Infection control for domestic services, decontamination of equipment, specimen handling, isolation guidance and incident outbreak guidance.

We spoke with a community staff nurse who told us, “We work really well as teams; we are always in contact and cover for each other. There is a plan in place to manage winter pressures and we all had to do our bit during the floods but I think we covered things really well.”

Records were kept securely and could be located promptly when needed. The records that we saw were legible and could be located easily.

We saw evidence of consultation with people, to ensure they were actively involved in decisions about their treatment and helped to manage their medical conditions.

We found that clinical staff received a range of training to ensure they were able to safely carry out their roles. Staff also had undertaken regular safeguarding training to ensure they knew how to recognise and report potential issues of abuse.

Members of the nursing staff told us they received “Very good support.” One told us about various courses and further education they had completed, to help them to develop their career.

We saw that administrative systems were in place to ensure risks to people's health; welfare and safety were appropriately monitored and managed and found the provider listened to people and obtained their views about the service. We saw that overall, people were happy with the service provided.

Recent comments from people included:

"The help and care of the nursing staff is invaluable. If I am concerned and ring for advice I get immediate help"

“We feel the care and attention we have received from everyone cannot be bettered”

“I have only the highest praise for the team as they have had to maintain a professional caring attitude”

“All nursing care is excellent and informative”

We found the following areas of good practice:

• Patients were contacted or visited on the day of their referral. Patients and their relatives and carers spoke very appreciatively about the care and treatment they received from staff. Patients were treated kindly and with respect and dignity and their emotional needs were supported.
• Patients with a deteriorating condition received continuity of care. Policies to support the care of patients with deteriorating conditions were followed, including for patients with sepsis.
• The service used telemedicine to support the care of patients with wound care needs with positive outcomes for patients and a reduced number of GP and nurse visits and reduced clinic visits for the patient.
• No never events or serious incidents had been reported in the 12 months prior to our inspection. Learning was shared with teams following the investigation of a serious incident.
• Patients living with dementia and other mental health conditions, patients with a learning disability and bariatric patients were supported and specialist equipment was available.
• Complaints were investigated and the learning was shared, although no recent complaints were reported for the service.
• Staff understood their responsibilities as to safeguarding. Patient records were well maintained and linked electronically with most GP practices. Staff had completed their statutory and mandatory training.
• The service followed nationally recognised clinical guidance to ensure the effectiveness of treatment. The service maintained a library and training facility which staff and students used extensively as a resource to refer to clinical guidance.
• Staff new to the organisation received a comprehensive induction and staff development was supported through preceptorship. Staff had received an appraisal in the previous 12 months which was linked formally to their development programme and a development and education plan for the service.
• The service was located in excellent facilities co-located with GP practices and social services. Facilities were visibly clean and staff followed cleanliness and infection control procedures. Equipment was well maintained.
• The service maintained a strategic risk register which identified the main risks to the service and operational risks were recorded. The risk register was monitored and reviewed to reflect new risks.
• The review and provision of services in conjunction with commissioners took account of quality and sustainability considerations. The quality of care and treatment provided was underpinned by the service’s focus on the learning and development of staff. The service took account of the views of patients and staff in planning services.

However, we also found the following areas that the service needed to improve:

• Not all staff had received training in the requirements of duty of candour.
• In one instance we found staff were using equipment that had not been calibrated. Also, staff sometimes encountered a difficulty in obtaining equipment promptly for patients.
• Triage cover for incoming calls could be intermittent and calls were not always responded to in a timely way. Staff were not always kept informed by the out of hours service about care patients had received, which meant patients may be visited unnecessarily. Managers were already taking steps to address this at our visit.
• Although we confirmed that the service was not unsafe, staff were operating under pressure because of reduced staffing levels and increased caseload commitments.
• One to one training was available for staff to support their use of the iPad but additional training was needed to make the most effective use of the technology.
• Patient outcome information used to demonstrate health care improvements for patients was not routinely monitored.
• A clinical supervision policy was in place and staff received supervision although not all staff received regular one-to-one supervision.
• A draft job description was available for the community mental health care assistant role but competencies for this role needed to be formally agreed.
• Patient information was being used in a way that may not maintain patient confidentiality.
• Liaison within the team between community district nursing staff, community matrons and the mental health support team needed to be developed so that care for patients was consistently supported.
• The service did not have a chief executive in post and the position had been unfilled for most of the year prior to our inspection. We were unclear from our visit how some of the organisation’s leadership and accountability arrangements were covered in the absence of a chief executive.
• Staff morale staff had been affected by recent changes in the service. Some staff did not feel valued or supported by managers and did not appreciate the attitude of managers. The service had not carried out a formal staff survey.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve.