Bromley Healthcare Community Interest Company

Bromley Healthcare Community Interest Company (BHC) was established in April 2011 as a social enterprise organisation to provide out of hospital community health services in Bromley. BHC employs more than 1000 staff and over 75% of staff are shareholders in Bromley Healthcare CIC.

BHC provides community health services in four London boroughs. BHC received more than 87,000 referrals in 2020 – 2021 and had nearly 600,00 patient contacts.

BHC provides a rehabilitation/intermediate care ward with 30 inpatient beds at Queen Mary’s Hospital, Sidcup; community health services for adults in the London Borough of Bromley; community health services for children, young people and families including health visiting in Bromley, Bexley, and Greenwich, school nursing services in Bromley and Bexley, and a specialist children’s nursing team in Bromley. BHC took over the provision of health visiting services in Greenwich, at very short notice, eight weeks before the inspection.

In addition, BHC provides specialist dental services from several health centres in Bexley, Bromley and Greenwich. It also provides other services, such as dietetics in Bromley, Bexley and Lewisham, improving access to psychological therapies (IAPT) and sexual health services in Bromley.

BHC has very recently acquired a care agency with 55 staff providing 700 hours of care to people in their homes in Bexley and 200 hours in Bromley.

BHC has eight locations registered with the CQC (as of 6 September 2021). Five of these provide specialist community dental services.

We carried out inspections of three core services provided by BHC and a well-led review as part of our continual checks on the safety and quality of healthcare services. This was the first comprehensive inspection of the three core services and the first well-led review of the provider. The last inspection carried out by CQC was a focused inspection of community health services for children and young people and took place in October 2020 following the death of baby.

We carried out inspections of three core services:

Community health services for adults;

Community health services for children, young people and families; and

Community health services for inpatients.

We did not inspect the provider’s sexual health services on this occasion. CQC carried out a focused inspection of the provider’s dental services in October 2021 as part of a dental services inspection project. This inspection is reported separately and was not rated.

Regarding this inspection report it should be noted that this inspection did not include a Use of Resources rating. Although Bromley Healthcare Community Interest Company is not a NHS trust the word trust is used erroneously in several places in the report as the word cannot be removed from the standardised inspection report template.

We rated Bromley Healthcare CIC as requires improvement because:

• We rated safe, effective, responsive and well-led as requires improvement, and caring as good overall.
• We rated two of the provider’s three core services as requires improvement and one as good.
• The provider had three overarching strategic aims but a lack of clarity and detail regarding how the strategy would be achieved and by when. The provider had begun to refresh the strategy for the next three years.
• Although there was a culture of high-quality care and leaders were clear that quality was not impacted by financial decisions, from our findings in the core service inspections there was some variation in the quality of care across some services. Specialist teams and services were found to have high quality care throughout. However, in district nursing and health visiting teams there was variation in quality.
• Assurance systems in some areas were weak. Although performance data was collected and some of it presented very clearly in the form of dashboards, other key details of service delivery were not routinely analysed leading to gaps in assurance. The provider did not have effective arrangements to ensure that all notifications were submitted to external bodies as required.
• Clinical audits were conducted mostly annually, but in some areas, such as record keeping, this was not frequent enough to drive improvements. The board had identified concerns about the quality of some audit design, which made it difficult to learn anything meaningful from the results. Where gaps had been identified following internal and external audits these were not always addressed effectively to bring about improvements, with the same or similar issues persisting at the time of our core service inspections.
• Focus on the development of black and minority ethnic and other staff groups with protected characteristics, and the equality, diversity and inclusion agenda more generally, was relatively recent and was developing. Indicators across several of the workforce race equality standards highlighted disparities between the experiences of black and minority ethnic (BAME) staff and white staff. Further understanding and strategies were required to improve the experience of BAME staff.
• The provider had arrangements in place for staff to implement the Accessible Information Standard, which applies to people using services (and where appropriate carers and parents) who have information or communication needs relating to a disability, impairment or sensory loss. However, many staff we spoke with did not know what the standard was. The provider did not monitor whether or not staff implemented the standard effectively.
• Arrangements for the Freedom to Speak Up Guardian role had been in place since February 2021 but were yet to be fully established. The service had not been widely advertised or promoted with staff although details about the FTSUGs had been shared with staff via the chief executive’s weekly briefing, and nurses’ forum.
• Patient experience feedback was limited, especially during the pandemic. The provider largely relied on Friends and Family Test feedback and had not fully explored obtaining feedback in other ways. Patient and public engagement was taking place. For example, a children’s community nurse ran a support group for carers and young people with sickle cell disease; the sexual health service was proactive in engaging patients through social media, focus groups and questionnaires; community paediatricians obtained feedback from patients on their experience of virtual consultations; and the COVID monitoring service had used a survey to gain feedback regarding long COVID symptoms from more than 440 patients. However, this work did not sit within an overall patient and public engagement strategy that included how BHC would engage specific patient and public groups who may provide valuable feedback but might not engage through the existing channels.
• The training and delivery of a quality improvement methodology and culture was at an early stage. BHC used a plan, do, study, act (PDSA) approach to quality improvement and a quality improvement lead had been appointed and commenced work with BHC in May 2021. Further work to develop a quality improvement approach and embed a quality improvement culture throughout the organisation was needed.
• Although the provider had carried out fit and proper person checks on directors, they had not made basic criminal record checks with the Disclosure and Barring Service in respect of non-executive directors.

However:

• There was a stable and full leadership team with capability in their roles. Leaders were visible and approachable across the organisation, although some leaders were very operational in their day to day roles and responsibilities. The non-executive directors (NEDs) had a variety of backgrounds with a bias towards commercial skills and expertise. The balance of NEDs on the board was being reviewed at the time of the inspection with consideration being given to the addition of a further NED with a clinical background.
• There was good financial stability and control and a highly skilled team delivering tender bids and winning appropriate contracts. The senior leadership team had a strong commercial skill set and were highly skilled at delivering this for the organisation.
• The provider was very responsive in its approach to health and care delivery as exemplified by the rapid mobilisation of the Greenwich 0-4 service and the setting up of a COVID-19 monitoring service at the height of the pandemic. The provider managed change effectively and minimised disruption when service provision changed.
• The provider had largely effective arrangements for identifying, recording and managing risks, issues and mitigating actions. Risks were recorded at service level and escalated up through clear channels to the corporate risk register where they were discussed and addressed. Risks identified by frontline staff matched those articulated by board members.
• Dashboards were available for teams and used by them to review performance. All staff said they were helpful and easy to use. Bromley Healthcare staff shared their information technology (IT) skills with the local care sector and supported GPs with IT during the pandemic.
• The provider had very positive relationships with external health and social care stakeholders. Senior leaders took an active role in local health care partnerships. Service staff worked effectively with NHS trusts and primary care clinicians to deliver high quality services to adults and children, such as the hospital at home service and rapid response.
• The provider was committed to the development of staff and encouraged staff engagement and an open organisational culture. Senior leaders were very accessible to staff at all levels. A number of new staff well-being initiatives had implemented over the previous year, which were valued by staff.
• Senior leaders had clear oversight of incidents, safeguarding and complaints. Managers investigated incidents and complaints and shared the lessons with staff to minimise the risk of them happening again. Safeguarding procedures were robust throughout the organisation. Staff understood how to protect adults and children from abuse and the services worked well with other agencies to do so.

How we carried out the inspection

Our inspection teams comprised of eight CQC inspectors, one inspection manager, three specialist advisors with expertise in providing community health services and three experts by experience.

The well-led review team comprised an executive reviewer, who was a chief executive from an NHS combined mental health and community health services provider; CQC’s national professional advisor for community health services, who was also a director of nursing in a community NHS trust; three CQC inspectors, an inspection manager and a head of hospital inspection.

During our inspection of the three core services, the inspection teams:

• visited an intermediate care/rehabilitation ward, looked at the quality of the ward environment and observed how staff were caring for patients
• visited six community team bases
• spoke with 21 senior leaders in the services including a matron, associate directors, team leads, and heads of service
• spoke with 56 other members of staff including nurses, nursing rehabilitation assistants, therapy rehabilitation assistants, occupational therapists, administrators, nursing associates, advanced nurse practitioners, district nurses, central coordination centre staff, health visitors, school nurses and nursery nurses
• spoke with 38 patients and six families who were using services or their carers/relatives
• reviewed 82 patient care and treatment records
• reviewed four safeguarding supervision records
• reviewed five patient and carer feedback cards
• observed seven telephone consultations with adult patients and four child clinic appointments with the consent of the parent or carer,
• observed five shift handover meetings, one multidisciplinary team meeting, one child development clinic and one infant feeding clinic
• sent an online survey to Bromley Healthcare staff eliciting more than 200 responses
• looked at a range of policies, procedures and other documents related to the running of the services

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the services say

On the inpatient rehabilitation ward based at Queen Mary’s Hospital, Sidcup, patients and carers told us that staff treated them with compassion, kindness and dignity. Patients and carers said staff were attentive, non-judgmental and were responsive to their needs. Carers told us that they were offered emotional support and advice when needed and that staff were very kind and caring with the patients. One patient commented that the ward felt like a hotel.

We spoke with six families using the community services for children, young people and families. Most people reported a positive experience and said their allocated health visitor had been caring. We heard positive feedback about the infant feeding team and how they supported mothers with breastfeeding. Families were very keen to resume face to face appointments.

Most patients using the district nursing service said that staff treated them well and with kindness, and were friendly, supportive and responsive when other professionals needed to be contacted. However, some patients told us that appointments were rushed, particularly with agency nurses, and sometimes staff would arrive without the correct medical supplies, or knowledge about their care needs. Patients and carers described unpredictable timing as a particular issue, with some experiencing missed or delayed visits. All patients we spoke with who used the specialist nursing teams were satisfied with the care they received and felt involved in making decisions about their care.