Quality Account 2025 - 2026

Our vision is: To work in partnership with people living and working in our community to deliver outstanding lifelong local NHS healthcare, supporting everyone to achieve their potential.

Our values are: First-rate care, by First-rate people at First-rate value.

First Community is part of the NHS family and provides community healthcare services to people in east Surrey and the surrounding area. We offer a friendly face with highly rated, well-run services, delivered by our skilled people.

We provide high-quality care through our nursing and therapy teams, specialist care teams and support, as well as a rehabilitation ward, and minor injury unit at Caterham Dene Hospital.

We are a not-for-profit organisation and, as such, any surplus we make is reinvested into our community services. We are constantly striving to improve services for our community, and our passion is to deliver the highest quality of care for our patients, service users and carers.

Our staff are co-owners of our organisation and become shareholders when they join. It is a symbol of their commitment to patient services, giving them a voice to help make decisions on how money is reinvested and to develop existing services with our commissioners for the good of the community.

As an employee-owned organisation, we have created an organisational and governance structure that turns the traditional organisational hierarchy on its head. The managers and board are there to support the function of clinical services and their interface with patients and the public. The inverted triangle (shown here) is stabilised by two smaller triangles: the Council of Governors and Community Forum.

Working in partnership

Find out more here: https://www.firstcommunityhealthcare.co.uk/about-us

Our services

To see the full list of First Community services please visit our website: www.firstcommunityhealthcare.co.uk/services

First Community is committed to ensuring and improving the quality and safety of the care we provide. We recognise there is always more we can do, which is why we continue to pursue improvements.

Looking back - Reporting on our 2025/26 priorities for improvement

In 2025/26 we progressed seven priorities for improvement - one priority carried forward from 2024/25, one new priority and five Patient Safety Incident Response Framework (PSIRF) priorities included within our Patient Safety Incident Response Plan (PSIRF Plan). The tables below provide a quick overview of these priorities with further details provided later in the report.

Improve the management of pressure ulcers

Partly achieved

What we said we would do: Improve the way we risk assess and manage people at risk of developing pressure ulcers.

Why we chose this: Managing a pressure ulcer costs the NHS [1] £8.3 billion annually . There is variation in care across healthcare systems which deviate from evidence-based research (National Wound Care Strategy Programme, 2024).

Within First Community, the number of pressure ulcers reported each year has significantly increased, in 2023/24 accounting for 15% of all incidents being reported across the organisation.

What we have done: Training has been rolled out and continues with a deadline for all relevant staff to complete. The training is an e-learning module on ESR and is a one off training with no refresher required. Going forward, new starters will access the pressure ulcer training which will include PURPOSE T.

[1] British Journal of Nursing - Wound care in the UK: addressing variations in practice, cost, outcomes, and the data deficit - British Journal of Nursing

Outcome Measures: How will we know if we are successful?

Number of pressure ulcers reported that occur whilst someone is receiving care from one of First Community services- to remain constant or decrease. The SPC charts show this has remained constant with one variation in December 2025 in Caterham Dene Ward where numbers increased, this has not continued

Caterham Dene pressure ulcers acquired whilst an inpatient: 

Primary Care Networks:

Number of staff trained to use PURPOSE T - 27 out of 35 clinical staff in two teams (community nursing and the ward) have completed the training trained.

The teams are one community nursing neighbourhood plus the dietitian that covers this neighborhood and the ward and these teams are piloting Purpose T.

Staff feedback: a pre training questionnaire has been sent to clinicians and the same questionnaire has been sent post implementation to measure knowledge gain.

• 90% report they have a good or very good understanding of the PURPOSE-T
• 90% report that have good or very good confidence in their ability to use it (compared to 43.75% before training)
• 82% report that they have very good or excellent confidence that the PURPOSE-T will support holistic care (compared to 53% before training)
• 72% report that they feel that this is very good or excellent compared to the Waterlow (compared to 43% beforehand)
• Staff report that it is more comprehensive, they don't have to fully complete it for all patients, it's straightforward/easy and they like that there is a clearly defined pathway to follow and that it's a more holistic approach to pressure area care
• There have been some challenges identified and additional support which would have been useful. This is being utilised to improve future roll-outs and we plan to continue to gather this data at each stage to continue to learn and improve as we do.

Percentage of patients identified at risk compared to the number of assessments completed (to enable us to measure productivity saving)

Data for one team:

• December (last full month Waterlow) - Total pressure ulcers 13 (7 on admission, 6 developed in First Community care)
• February (first full month PURPOSE-T) - Total pressure ulcers 11 (5 on admission, 6 developed in First Community care)

Next steps:

All community nursing teams, pro-active care teams and two further services will have received their training and will be using PURPOSE-T by June 2026.

This is a significant change to the way we assess the risk of people developing pressure ulcers so the approach is to do this as a phased roll out so as to implement this safely.

MSK waiting times

Partly achieved

What we said we would do: Reduce waiting times in the Musculoskeletal (MSK) service to within 19 weeks over the next 12 months.

Why we chose this:

• High waiting times potentially leads to more complex and chronic MSK conditions which require more urgent attention;
• Impacts on staff morale and organisational reputation;
• Increases inappropriate referrals to our First Contact Physiotherapists (FCPs) for 'in house' physiotherapy.

What we have done:

What we said we would do and other actions	What we have done
Deliver an assessment day for an identified patient cohort to quickly and efficiently assess and signpost and speed up the patient journey	Waiting list initiative clinics have been held with the aim to assess and discharge where appropriate or signpost. There is additional funding for initiative clinics. 120 patients have been seen between February and June 2025, 92 were discharged, 23 went to follow up and 5 were offered a class. In Q3 21 patients were seen across five clinics, 13 were discharged, 7 went to a follow up appointment and one went to a class. In Q4 there were two clinics with nine patients seen. Seven of whom were discharged and two went on to have follow up appointments.
Deliver a signposting day to ensure that other identified needs such as social isolation are met	The Moving Together Group have held two events in different neighbourhoods with very low attendance. This will not be continued due to the lack of up take.
Send text messages to everyone on the waiting list to ask if they want to remain on the waiting list.	This continues and is business as usual.
Send text reminders with the aim of being able to fill vacant slots if people cannot attend.	This continues and is now business as usual.
Caseload reviews	All clinicians can now run a report and discuss any patients that they have seen four or more times. This is business as usual.

Staffing changes throughout the year have impacted the ability to run clinics. Vacancies are continually being recruited to.

Getting it right first time (GIRFT) funding from the ICB was confirmed in December 2025 which means the offer an additional band 3 fixed term contract to help free up qualified physiotherapists to undertake clinical work from March 2026. This funding is also for overtime so staff can run additional clinics which is dependent on staff working additional hours. There will also be work to set up ESCAPE classes at local gyms with the ambition of the gyms taking this on with support from First Community physiotherapy. There is no ongoing funding to support this so after 6 months continuation will be dependent on the added value for the gyms. This has been delayed because of availability of ESCAPE training courses.

Sessions for people with hip and knee osteoarthritis have been set up and are now running, see table below. People attend and get given exercises and a limited assessment. People may also go onto ESCAPE classes or an appointment with the ICATS service. Consideration is now being given to other cohorts that can be managed in this way.

Table Caption

Date	Number of patients attended	Discharge to self management	Referred into Escape	Remain on waiting list	Did not attend	Triaged to another service	Required redirection to another service
24/09/2025	9	5	2	0	0	0	2
08/10/2025	8	6	0	0	1	0	1
22/10/2025	6	5	1	0	4	0	0
05/11/2025	7	6	1	0	3	0	0
19/11/2025	8	7	1	0	2	0	0
03/12/2025	9	6	1	1	0	0	1
17/12/2025	9	7	0	1	0	0	1
28/01/2026	9	6	2	0	1	1	0
11/02/2026	7	5	0	1	0	0	1
25/02/2026	4	3	0	0	1	0	1
25/03/2026	10	9	0	0	0	0	1
	86	65	8	3	12	1	8

Outcome measures: How will we know if we are successful?

Complaints and feedback: There have been two formal complaints, one informal complaint regarding waiting times and two Friends and Family Test (FFT) feedback that mention waiting times. FFT is a short survey where patients can quickly share their experience of our service. This means waiting times continue to impact on people's experience.

Reducing waiting times and reach the desired target of within 19 weeks:

Work in Q1 and Q2 has seen significant improvements. The team continue to be pro active and innovative to drive down waiting times, numbers have risen in Q3 and 4 however there has been recruitment and additional funding as described.

This will continue to be a priority for improvement as part of our Quality Account as we continue with our activity and ambition to reduce waiting times.

Patient Safety Incident Response Plan (PSIRP) priorities

In order to evidence that improvements have been sustained, a process for closing priorities which fall under PSIRP has been developed and has been implemented in 2025/26.

Improvement priorities which have achieved their aim are approved for closure at our Clinical Quality and Effectiveness Group. Data is then reviewed at three and nine months to provide assurance that improvements have been maintained before final priority closure.

In 2024/25 we achieved our aim to improve the post falls management of patients under the care of the Intermediate Care team (ICT) who fall in their own home.

This year we were able to demonstrate that the improvements we had made have been sustained (see table below).

Measure name	Target measurement	Measurement when improvement group closed	Measurement at 3-month review	Measurement at 9-month review
Number of falls	No increase	Average 1.8 per month	Reduced number of falls. No falls meeting criteria for radar (incident reporting system) across 3 months.	Reduced number of falls. One fall met criteria for radar across 3 months.
Percentage of post-falls assessments completed	100% over 3-month period	100% of all falls	100% of all falls	100% of all appropriate falls
Percentage of post-falls assessments completed within 24 hours	90% over 3-month period	100% for falls reported on radar 99% for falls not meeting criteria for radar	100% of all falls	100% of all appropriate falls
Percentage of post-falls debrief forms completed	100% over 3-month period	100% of all falls	100% of all falls	100% of all appropriate falls

This year we have also closed:

• The safer administration of insulin priority and demonstrated that improvements have been maintained at 3 months;
• The falls group and demonstrated that most improvements have been maintained at 3 months;
• The administration of PRN (as required) controlled drugs priority and demonstrated that improvements have been maintained at 3 and 9 months.

Further data collection is planned for 2026/27 to evidence ongoing maintenance. See the sections below for further information on each of these three priorities.

Safer administration of insulin

Achieved

What we said we would do: Safer administration of insulin for people living in their own homes.

Why we chose this: This is a Patient Safety Incident Response Framework (PSIRF) priority and is included in our PSIRP (our PSIRF plan).

What we have done:

• We have held monthly meetings to identify learning and review actions;
• We routinely undertake after action reviews for all insulin administration incidents, and the learning is discussed at the monthly meetings and improvements that have been identified are being tracked via an action plan;
• We have improved how information is communicated to the evening shift staff following holidays and annual leave by implementing a MS teams call for updates to be shared;
• We have made improvements around the delegation of work to Healthcare Assistants (HCAs) when dose changes are made and it may potentially no longer be appropriate to delegate to an HCA, supported by the Practice Development Nurse (PDN);
• We have improved how we share learning across the District Nursing teams, including timely reporting of incidents;
• We invited staff to provide feedback on the impact of this improvement priority;
• This priority was approved for closure in October as it had achieved its aim. Data was reviewed at 3 months to ensure improvements had been maintained and there is a plan to review this again at 9 months (June 2026).

How we have measured this:

• Number of insulin medication errors: This priority was initiated in response to staff feedback and professional concern, rather than an elevated number of reported incidents. Review of the data over time shows no significant increase or worsening trend in insulin related administration incidents. At the three month review point, four of the six incidents reported were identified as near misses, indicating that potential harm was recognised and mitigated before reaching the patient. Reporting of near misses is widely accepted as a positive indicator of an open safety culture and a key mechanism for preventing patient harm. Overall, the current data provides reassurance that there is no cause for concern, and that the focus on insulin safety is supporting learning, early risk identification, and continuous improvement, in line with national patient safety expectations
• Increase in confidence of staff across community nursing: The staff questionnaire results show that teams feel there has been an improvement in safety, and increased awareness and confidence when managing patients requiring insulin. This confidence was sustained at 3-months, evidenced by continued engagement and information feedback.

What next:

• As this priority was initiated in response to staff feedback and professional concern, rather than a high number of reported incidents, this review will predominantly focus on qualitative data from clinical staff to ensure staff continue to feel that the improvements made and their increased confidence have been maintained. We will also review the number of incidents and near misses to ensure there are not any significant changes which may indicate a cause for concern and a requirement for further action.

Falls group

Achieved

Reduce the risk of falls and associated harm on Caterham Dene Hospital Ward.

Why we chose this: This is a Patient Safety Incident Response Framework (PSIRF) priority and is included in our PSIRP (our PSIRF plan).

What we have done:

• We have held monthly meetings with the multidisciplinary team to identify learning and review actions;
• We have continued completing After Action Reviews (AARs) for falls occurring on the ward. Patients and staff have been involved in the AARs, to identify further learning and improvements;
• We have now trained ten staff on the ward to be able to conduct AARs;
• We have reviewed our falls guidelines to ensure they capture learning from the falls group and align with the updated NICE falls guidance;
• We have provided lying standing blood pressure refresher training sessions;
• This priority was approved for closure in October as it had achieved its aim. Data was reviewed at 3 months to ensure improvements had been maintained and there is a plan to review this again at 9 months (June 2026).

How we have measured our success:

• We have measured the number of falls and have seen a sustained and meaningful reduction in the falls that have occurred on the ward;
• There has been no Patient Safety Incident Investigations (PSIIs) commissioned for people who have fallen on Caterham Dene Ward;
• We monitor the number of completed learning responses: After Action Reviews have been completed following 100% of falls since January 2025;
• Our records show improvements in completion of lying standing blood pressure (LSBP) assessments were maintained between July 2023 and November 2025. There was a small drop to 72% when data was reviewed at 3 months, although this remains above the national target of 60%. Data was therefore captured again at 6 months where this had increased again to 96%, indicating that the slight drop was likely due to normal variation in practice;
• The group recognised that it would also be useful to capture more meaningful data relating to the completion of LSBP assessments and therefore began to capture data regarding the percentage of LSBP assessments completed within the recommended 72 hours and the percentage of identified postural drops for which action was taken. We have demonstrated significant improvements in both of these measures, achieving 73% and 100% respectively, compared to 39% and 0% in April 2024.

What next:

• We have achieved our aim but will continue with our multidisciplinary falls prevention group to allow us to identify and respond dynamically and quickly to changes in factors contributing to inpatient falls;
• Data will be reviewed in June 2026 to ensure that improvements have been maintained before final closure of this priority.

Administration of PRN (as required) controlled drugs

Achieved

What we said we would do: Improve the process of administering controlled drugs for people staying at Caterham Dene Hospital as required, increasing the timeliness for patients.

Why we chose this: This is a Patient Safety Incident Response Framework (PSIRF) priority and is included in our PSIRP (our PSIRF plan).

What we have done:

• We have held monthly meetings to understand the problem/learning and identify and implement improvement actions;
• We have embedded and continue to conduct After Action Reviews (AARs) with patient involvement, and have ensured additional staff have attended the training to support with this process;
• We captured patient's pain experience through their involvement in AARs;
• Learning with the team regarding informing the patient that there might be a delay due to getting a second nurse. This learning was obtained through patient involvement in an AAR;
• This priority was approved for closure in July as it had achieved its aim. Data was reviewed at 3 months to ensure improvements had been maintained.

How we have measured our success:

The table below details the measures we collected for this priority both before we started the improvement work, when we closed the improvement group, and at 3 and 9 months after closure, as well as the initial targets we set out to achieve.

Measure name	Target measurement	Measurement before improvement work	Measurement when improvement group closed	Measurement at 3-month review. Date: September 2025	Measurement at 9-month review. Date: March 2026
Time from need identified to CD given	10 minutes	Mean 18.4 Longest 38	Mean 7.6 Longest 21	Mean 8 Longest 12	Mean 4.75 Longest 10
Number of disruptions within the process	No change	Average 1 per event	Average 0.3 per event	No disruptions documented	Average 0.16 per event
Patient pain level at time of administration	Positive qualitative feedback		AARs capture that PRN pain relief was effective.	94% completed patients pain chart	Data collected for 66% of events, all of which note pain chart was checked. Staff also report this is done consistently.
Quantity of CDs in medicines cupboard	Qualitative feedback	Too many in cupboard to find correct items	Process in place for CD destruction. Staff feedback this is much better.	Staff feedback With monthly destroying it's much better it's not overloading these days.	Destruction continues to be scheduled monthly.   Unable to obtain comparative feedback as staff are currently using a temporary space for medicines whilst improvements are made to the medicines room, including the cupboard.
Percentage meeting target timeframe	80% within 10 minutes	30%	Over 80% for last 6 months	82%	100%

What next:

• There is ongoing space utilisation work to improve access to medicines on the ward;
• We will continue to use AARs as required on the ward.

Violence, aggression and abuse: Keeping staff safe

Achieved

What we said we would do: We will encourage and help staff understand the process of reporting an incident of verbal/ physical aggression and unacceptable behaviour and empower them to deal with incidents of unacceptable behaviour.

Why we chose this: This is a Patient Safety Incident Response Framework (PSIRF) priority and is included in our PSIRP (our PSIRF plan).

What we have done:

• We have fed back on the Violence, Aggression and Disruptive Behaviour Policy and an updated version has now been published;
• The Communications team have promoted reporting of incidents and support available;
• We have reviewed reported incidents, discussing outcomes, causes, courses of action and sharing learning;
• The Learning and Development, Health & Safety and People Team representatives have researched training needs, comparisons with other organisations and availability;
• We have developed a training pack for use in team meetings which we have promoted in our internal newsletter;
• We have learnt from what neighbouring organisations are doing;
• We have reviewed our 'It's Not Ok' poster and support leaflet for staff;
• We have developed a screensaver, directing staff to the dedicated intranet page;
• Personal alarms have been made available for all staff;
• We have carried out After Action Reviews following relevant incidents to identify learning opportunities and support staff.

How we have measured our success:

• Number of incidents: There were 29 incidents reported in the 9 months prior to the start of this improvement work compared to 42 incidents reported in the 9 months since it began. This demonstrates that promotion and discussions around this type of incident have increased reporting
• How staff feel about how they are supported: Feedback from staff who have joined the priority group has indicated that staff feel more supported by teams and managers
• Staff survey: 97% of staff reported that they had not experienced physical violence from patients/service users, their relatives or members of the public, compared to 98% last year
• Despite this remaining stable the number of staff who reported their last experience of physical violence has significantly increased from 60% last year to 80% this year
• This year, fewer staff report that they have not experienced harassment, bullying or abuse from patients/service users, their relatives or members of the public (79% compared to 86% last year). Despite an increase in experiencing this type of behaviour, reporting has remained stable at 58% (compared to 59% last year).

What next: We will continue to promote the resources and support available to staff as part of business as usual.

Communication with relatives and carers on Caterham Dene Ward

Partly achieved

What we said we would do: We will ensure relatives, carers, patients and staff know how to raise concerns about a patient's clinical condition, that these concerns are listened to and acted on, and that there are clear steps of communication when people raise concerns.

Why we chose this: We undertook a Patient Safety Incident Investigation, and a key piece of learning was around communication. This learning aligned with Martha's Rule which is about empowering patients, families and staff to be able to raise urgent worries about a patient's condition. This has been called call for concern and has been implemented in acute hospital settings to enable a second opinion by a critical care outreach team. Caterham Dene does not have on site critical care teams so we wanted to implement a process for people to able to raise concerns proactively. 

What have we done: To ensure people feel listened to and supported tor raise concerns, we have created Don't take your worries home . This is designed specifically for a First Community's ward and provides a clear way for concerns to be escalated to a senior clinician, so action can be taken quickly if a patient's condition changes or if there are concerns.

• We have completed two reviews using the Systems Initiative for Patient Safety. This is a way of looking at healthcare as a whole system-people, tasks, equipment and environment-to make care safer and easier for patients and staff.
• Embedded a process to make sure we always have correct next of kin details.
• A member of the public undertook a walkaround of the ward to help us understand where and what communication was needed. This has enabled us to update our notice boards to ensure information is adequate and clear and create a poster telling people how to raise concerns.  
• We have developed a patient survey to understand the effectiveness of the welcome meetings where we tell patients and their loved ones how to raise concerns . Six responses have been obtained to date and all are positive including that the information received on how to raise concerns was adequate and clear.
• Data has been collected on GP requests where concerns have been raised, see below:

GP requests: 

	No of requests to speak to patient	Number of requests to speak to relatives	Number of requests marked as actioned in GP book	Number of requests where follow up is recorded on EMIS
April 2025	3	9	12 (100%)	8
September 2025	19	4	23 (100%)	16
December 2025	17	6	20 (87%)	18
March 2026	11	8	18 (95%)	15

What next: We will continue to embed this process and monitoring of its effectiveness.

How we identified our priorities

Our priorities for improvement and patient safety for the period 1 April 2026 to 31 March 2027 have been developed through engagement with and learning from stakeholders including patients, carers and our staff. We have looked at feedback we receive and learning we have identified throughout the year to understand where we need to focus our improvement activity. We have used the CQC assessment framework and our strategic direction of people, planet, performance and partnership in our thinking and planning.

People - Recruitment and retention and living and working in our community.

Performance - Financial viability, data collection and monitoring and quality and safety impacts, outcomes and impacts.

Partnerships - Importance of internal relationships and partnerships and external partnerships, use our scope of influence working to tackle priorities across partnerships to improve services for local people.

Planet - Delivering our sustainability plan.

This is how we have developed our priorities for quality improvement:

• We asked our staff through our Quality Group, our Council of Govenors, and our Community Forum what we should consider and for feedback on the priorities we have identified. Additionally, each service is invited to review their data to develop Patient Safety Improvement Priorities
• We considered how to measure these possible priorities including measurements and data collection already in place
• We further developed these priorities and agreed which to take forward
• Further engagement to develop measurements and process
• We looked at our achievements, risks, performance and national / regional priorities.

What? What are we going to do	PSIRP or Quality Account Priority	Why? Why have we chosen this	Strategic theme	CQC statement	How? How are we going to do it	Outcome measures? How will we know if we are successful
Improve how we put shared decision-making into practice.	Quality Account	When making decisions in healthcare, it is essential that each patient's choices are taken into account in order to achieve the best possible outcome for them. We have conducted a Shared-Decision Making audit across the organisation which identified many strengths, but also some areas for improvement. This improvement work will also support our compliance with associated NICE guidance (NG197, 2021).	Performance	Caring - supporting patients independence, choice and control.	Utilise existing good practice where shared decision-making processes are already taking place. Share and spread good practice, and support services to build on their strengths and make improvements in relevant areas. Track improvements against the action plan.	Number of services writing clinic letters directly to patients Number of services using a decision support aid, including our ask 3 questions leaflet Number of decision support tools identified and implemented within relevant services Number of services who have a process in place to arrange additional support for those who find it difficult to share in decision making.
Improve record keeping around wound photography		High quality photographs of wounds photos create a consistent visual baseline, allowing clinicians to compare the wound over time and evaluate whether it is progressing or deteriorating. This supports more accurate assessment than written descriptions alone. There are standards on how to take photographs of wounds and information that must be included such as date and time.	Performance	Effective - Monitoring outcomes, assessment of needs and information sharing.	Review guidance and undertake training needs analysis	Review of record keeping that include would photography

First Community will also work on the priorities set out in its Patient Safety Incident Response Plan, to view these please visit: Patient Safety Incident Response Plan 2026-2027 | First Community Health & Care

The statutory statements in this part of our Quality Account relate to the quality of the service we provided in the period 1 April 2025 to 31 March 2026. The content is common to all providers, allowing comparison across organisations.

Review of service

During the period 1 April 2025 to 31 March 2026, First Community provided NHS services. First Community has reviewed all the data available to it on the quality of care in all of these NHS services.

The income generated by the relevant health services reviewed in the reporting period (1 April 2025 to 31 March 2026) represents 100% of the total income generated from the provision of relevant health services by First Community for the reporting period.

Participation in national clinical audit and confidential enquiries

During the period 1 April 2025 to 31 March 2026, seven national clinical audits and zero national confidential enquiries covered relevant health services that First Community provides.

During that period First Community participated in 100% (seven out of seven) of the national clinical audits and national confidential enquiries it was eligible to participate in.

The national clinical audits and national confidential enquiries that First Community participated in during 1 April 2025 to 31 March 2026 are as follows:

1. National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme
2. National Audit of Cardiac Rehabilitation
3. National Audit of Care at the End of Life
4. National Audit of Inpatient Falls
5. National Diabetes Foot Care Audit
6. Sentinel Stroke National Audit Programme (SSNAP)
7. UK Parkinson's Audit.

The national clinical audits and national confidential enquiries that First Community participated in, and for which data collection was completed during 1 April 2025 - 31 March 2026 are listed below, alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

National clinical audits and national confidential enquiries	Number of cases submitted as a percentage of the number of cases required
National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme	All appropriate patients were asked to participate (110 in total), 13 did not consent. In total, 88% consented and all of those were included in the audit.
National Audit of Cardiac Rehabilitation	100%
National Audit of Care at the End of Life	100%
National Audit of Inpatient Falls	100%
National Diabetes Foot Care Audit	100%
Sentinel Stroke National Audit Programme (SSNAP)	99.5% (one record was not submitted as the patient had their initial stroke abroad and it was not possible to gather all the required data for the record)
UK Parkinson's Audit	100%
	100%

The reports of seven national clinical audits were reviewed by the provider between 1 April 2025 and 31 March 2026, and First Community intends to take the following actions to improve the quality of healthcare provided:

National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme

This year the Pulmonary Rehabilitation team has successfully achieved accreditation under the Pulmonary Rehabilitation Services Accreditation Scheme (PRSAS). Following a rigorous assessment visit on 29 April 2025 and provision of further evidence, the Pulmonary Rehabilitation service was recognised on 15th December 2025 for meeting nationally recognised standards of excellence in the care and support of people living with long-term respiratory conditions. We are scheduled for an annual review assessment on 29 April 2026. To achieve this accreditation, we have:

• Reviewed our risk assessments and developed a standard operating procedure, which we are now reviewing again following First Community's relocation to Consort House;
• Embedded staff training, competencies and collection of feedback;
• Completed quality improvement following feedback obtained from patient focus groups;
• Implemented annual collection of service specific patient feedback to support identification of potential areas for improvement;
• Embedded annual feedback questionnaires for referrers, from which we receive largely positive responses;
• Developed strong links with Senior Leadership. We demonstrate good engagement with referrers, acting on their feedback, and have delivered well received talks to the acute team.

In addition to this, we have also developed and implemented a strict protocol, allowing us to identify patients with hypertension and blood pressure readings above the safe limits for exercise prescription at triage. This ensures that resource is optimised, in addition to avoiding unnecessary appointments for patients who are inappropriate for the service.

We have created a hybrid pulmonary rehabilitation option for patients who are unable to attend the research recommended two sessions a week, and next year we plan to explore the outcomes and effectiveness of this offer.

Following feedback from the patient focus groups we are continuing to create video options for all of our education sessions, for patients to access if they are unable to attend face-to-face or for those who would like a reminder of the information included.

National Audit of Cardiac Rehabilitation

The cardiac rehabilitation team have made a number of improvements across 2025/26 and have used data and patient feedback to identify further areas for improvement in 2026/27.

We have improved the way we collect data for the National Audit of Cardiac Rehabilitation. We have moved from adding this manually to working with the Business Intelligence (BI) team to extract this directly from the electronic patient record. We are continuing to work with the BI team to ensure the dataset is complete before transitioning fully to this approach, which we expect to do early next year.

Following patient feedback on the cardiac rehabilitation education sessions we started offering a face-to-face option in 2024. In 2025/26 we have seen an increase in face-to-face attendance compared to the previous year, exceeding the number who attend virtually and demonstrating the positive impact of its implementation. Graph 1 demonstrates the difference in uptake between the two offers. This year we also implemented a one year follow up call to better evidence the impact of the cardiac rehabilitation service.

Graph 1

In 2025/26 we started offering virtual classes, which patients can access after attending face to face classes. We have developed a questionnaire to gather patient feedback on this virtual offer and next year we intend to review the responses to identify further areas for improvement.

Following introduction of the virtual classes, patients have told us they would also like videos, in addition to the home exercise programme sheets already available, that they can follow if they are unable to attend a session or want more sessions. We are therefore planning to create some videos next year.

Additionally, for those who may be unable to access the virtual class option we plan to explore the feasibility of offering a walking group for those who have completed the face-to-face classes.

This year we also recognised that some patients achieve all of their goals before the end of their cardiac rehabilitation classes. We therefore now recognise this as completion of the cardiac rehabilitation programme and discharge these patients early, ensuring resource is used in the most optimal way.

Lastly, we also identified that a number of patients who are referred to our service then decline the offer of cardiac rehabilitation. We have captured data to identify at what stage patients declined, highlighting that the majority of these (63%) are at telephone triage, and their reason for doing so, with the aim to identify and implement potential improvements in this area.

National Audit of Care at the End of Life

There was one inpatient death in January 2025 that was included in the data that was submitted during the quality account reporting period.

End of life training has been refreshed and is now fully in place, with accessible booking for all relevant staff groups, including nurses, healthcare assistants, allied health professionals (AHPs) and rehabilitation assistants.

The End of Life Nurse Advisor continues to provide regular ward presence and ongoing support to staff caring for patients at the end of life when required.

National Audit of Inpatient Falls

The ward at Caterham Dene Hospital has taken part in this year's National Audit of Inpatient Falls (NAIF). All falls were reviewed and in 2025-2026, there was one relevant case where a reportable injury was sustained on the ward. This related to a wrist fracture, evidencing that we are identifying relevant falls appropriately within the expanded NAIF criteria which from January 2025 includes patients who sustain any fracture, spinal or head injury.

The NAIF 2025 report makes 3 suggestions for local improvements.

1. Aim for 60% completion rate for lying standing blood pressure - this has been a focus of our falls group with regular auditing demonstrating that we are now consistently achieving above this target.
2. Aim for 65% delirium screening rates (4AT) - 100% of patients are screened using the 6CIT (Six Item Cognitive Impairment Test) on admission and a 4AT (Rapid Clinical test for Delerium detection) is then completed as required..
3. Hasten the time to administration of analgesia - in 2024/25 the ward identified that improvements could be made within this area and subsequently undertook an improvement priority focused on the administration of PRN (as required) controlled drugs.

Over the past year, we have continued to conduct After Actions Reviews (AARs) to identify learning following a fall. We have reviewed and updated our post-falls pack to ensure consistent data collection and a streamlined post-fall process. We are also updating our falls guideline to ensure this aligns with the updated NICE guidance and learning which has been identified as part of our falls improvement work. To ensure our compliance with this updated guidance, we have also embedded a validated home hazard assessment tool, which now forms part of our electronic record keeping template, to reduce the risk of falls on discharge.

In the next reporting period, we aim to prioritise improvements to ensure all staff within the multidisciplinary team feel confident providing appropriate walking aids on admission, as per the referral. We also plan to continue utilising mobility status wristbands as well as continue with our multidisciplinary falls prevention group to allow us to identify and respond dynamically and quickly to changes in factors contributing to inpatient falls.

Please see the Quality Account falls group priority for further information. 

National Diabetes Foot Care Audit (NDFA)

As NHS England are currently reviewing the routine production of National Diabetes Audit State of the Nations report there has not been a report during this time period to review. However, we continue to monitor the dashboard and once updated data has been released, we plan to review this to identify potential areas for improvement. Additionally, we have reviewed the data quality report which confirmed that all patients who meet the criteria have been included in the audit submission up to 2024/25.

Due to upcoming planned changes to estates and where the podiatry services are provided, we plan to focus on how we can keep the multidisciplinary team (MDT) work running effectively, working with the acute hospital to ensure that patients continue to be seen in the right place at the right time.

We also plan to explore independent prescriber training, to support the development of a more streamlined process for antibiotic provision, which does not need to be returned to the patient's GP. Additionally, we are exploring how we can increase the total contact casting for appropriate patients, which aligns with NICE guidance, to improve wound healing. We are exploring the feasibility of training a podiatrist in casting so that this can be initiated earlier. We are also considering succession planning to ensure a robust offer.

Lastly, we are working with consultants at the acute hospital to support their introduction of a tissue loss clinic, which can see any foot wounds with a vascular deficiency. We have ensured that the podiatry scheduling allows availability of a podiatrist to support at the clinic if their input is needed. We hope that this collaborative working will free up urgent slots in the MDT podiatry clinic and increase capacity.

Sentinel Stroke National Audit Programme (SSNAP)

The SSNAP data from 1 April 2025 until 31 March 2026 was reported through the standard web tool and did not identify any issues with service delivery. The improvement in the transfer of records between partner agencies on our local stroke pathway has been maintained after continued focus on this in the previous financial year. This is reflected in the high percentage of eligible records included in our SSNAP database. We continue to work with our partners in the acute hospital and our subacute rehabilitation site to ensure ongoing timely transfer of patient records. During this financial year, our provider for inpatient neurorehabilitation changed from Queen Elizabeth Foundation, which went into administration, to Dorking Hospital.  This has required new pathways and working groups to be established.  Further work is required to address the transfer of records for patients referred from outside of our standard stroke pathway, including those that are referred from out-of-area acute hospitals and local GP services.

Following significant changes to the SSNAP data set in October 2024, with an increase from six weeks to 24 weeks for the length of time that data is required to be submitted for each patient on the stroke caseload and a re-categorisation of therapeutic input based upon the impairments addressed, the team have worked hard to embed these changes.   These changes have required several team meetings, training, and review of all documentation tools to enable the team to fully embed new practices. Results from the SSNAP team indicate strong levels of audit compliance and consistent inclusion of outcome measures and data required.  Results regarding active therapy input demonstrate that we are delivering comparable input to the national average across all disciplines. It is recognised that we are not delivering the 3 hours of motor therapy daily that was recommended in the updated Royal College of Physicians Stroke Guidelines in 2024, however we have not received an uplift of staffing to enable delivery at this level.  This challenge is a national issue with recent national data showing an average of 50 minutes of motor input per day, which compares closely to our result of 51.8 minutes per day. 

Several team members attended an Integrated Stroke Delivery Network (ISDN) meeting in September 2025 where data trends and analysis were discussed.  As an outcome of the meeting, the team planned an audit of the prioritisation system for patients on the Stroke Early Support Discharge (ESD) Pathway to confirm whether rehabilitation intensity reflected the category assigned to each patient.  The team audited patients on ESD for a 3-month period from 1st October - 31st December 2025.  They gathered data on the priority rating each patient received (red, amber, green), whether their priority rating was changed during their time on the pathway, the number of days they received input during their 6-week intensive period on ESD and the number of minutes of therapy input received during their 6-week intensive period across each SSNAP domain.  Results indicated that patients assigned a 'red' rating, indicating highest priority, consistently received higher input from the therapists across all domains.  The team have concluded that patients are correctly categorised on the priority system and that input reflects the level of need.

UK Parkinson's Audit

The results and report for the UK Parkinson's Audit had not yet been released at the time of writing. Once released this will be reviewed and an action plan developed. In the meantime we have created Parkinson's templates to improve data quality at assessments.

Reviewing reports of national and local clinical audits

Our clinical audit priorities are selected based on national requirements, commissioning requirements and local evidence that has emerged from themes, risks, incidents and/or complaints.

The reports of 217 local clinical audits and quality improvement projects were reviewed by the provider between 1 April 2025 and 31 March 2026, and First Community intends to take the following actions to improve the quality of healthcare provided:

• The digital audit was conducted to review how digital images are being taken, stored and transferred by Responsive Services and to measure compliance with First Community's updated guidelines. It highlighted some key areas of success, including consent, use of First Community devices to take images and timeliness of uploads. It also identified opportunities for learning, with training provided to staff on the correct way to share images and standardisation of the labelling of images;
• The National Audit of Intermediate Care is an opportunity for First Community's Urgent Community Response Services (UCR)  Intermediate Care Team (ICT) and Caterham Dene Rehabilitation Ward to benchmark against other services nationally and gives insight into the work that we do whilst identifying any learning opportunities. A number of positives were identified when benchmarking against similar services, in addition to some areas for improvement and we plan to raise awareness of the reasonable adjustment flag for people with a learning disability, review the use of the Comprehensive Geriatric Assessment and the benefit to the role of the team and review skill mix as part of work force planning;
• Following the DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) audit we aim to strengthen the process for reviewing DNACPR decisions on transfer from the acute hospital, ensuring patient wishes, clinical reasoning and escalation preferences are clearly revisited and documented. We plan to discuss the findings with Caterham Dene Ward to gain a better understanding of the current processes and identify potential ways to further drive improvement, in addition to arranging a multidisciplinary team (MDT) review to explore current pathways clarify roles and identify barriers to completing DNACPR documentation. We then plan to utilise the PDSA (Plan, Do, Study, Act) model to test and implement any identified changes;
• Annual environmental audits conducted by the Infection Prevention and Control team have identified actions across various teams to support the ongoing safety of patients and staff. This year this has included:
  • Replacing chairs and sinks;
  • Purchasing new clinical waste bins;
  • Decluttering;
  • Repairing flooring; 
  • Replacing out of date and expired products e.g. spill kits 
  • Relocating items e.g. patient towels.

Read later in the report for further actions we have taken related to Infection Prevention and Control.

Research

The number of patients receiving NHS services provided or sub-contracted by First Community from 1 April 2025 to 31 March 2026, that were recruited during that period to participate in research approved by a research ethics committee within the National Research Ethics Service was 37.

Goals agreed with commissioners: Local Quality Requirements (LQR)

First Community's income in 2025/26 was not conditional on achieving quality improvement and innovation goals. First Community did work on the following local quality requirements:

LQR	Description	Update
Flu vaccinations for frontline healthcare workers.	Achieving 80% uptake of flu vaccinations by frontline staff with patient contact.	Not achieved. This year, 44% of First Community's frontline healthcare workers were vaccinated against the flu virus, an increase from 41% in the previous year. As part of our 2025/26 approach, we introduced a voucher only scheme, enabling staff to receive their vaccination at a community pharmacy at a time and place convenient to them. Although uptake has improved, it remains below what we would like to see. We recognise that flu vaccination rates have declined nationally across most age groups and this remains an ongoing challenge. To support higher uptake, we will review our delivery models for 2026 to ensure they reflect staff preferences and make accessing the vaccine as easy and flexible as possible
Healing rates for lower leg wounds as a clinical outcome.	Venous leg ulcers to be healed within 12 weeks.	Achieved, please read in the 'are we effective' section.

CQC

First Community is required to register with the Care Quality Commission (CQC) and is currently registered with no conditions. The CQC has not taken enforcement action against First Community.

The CQC undertook an unannounced inspection of First Community in March and April 2022. The CQCs overall rating for community health services provided by First Community was 'Good' across each of the five CQC domains; safe, effective, caring, responsive and well-led with an overall outstanding rating for their Community Urgent Care Service.

Data quality

Data quality has remained a key focus for us at First Community and top priority to ensure that our data is reflective of the fantastic work that we do. We are continuing to ensure we get things done right the first time by ensuring that we have the right systems and templates in place to help colleagues capture required data. We also ensure that colleagues have adequate training and tools required to support them. We continue to look at more efficient ways to improve our data quality while broadening our Data Quality Improvement Plan (DQIP) which is focused around four distinct data quality pillars which are EMIS (Electronic Patient Record) system optimization, user optimisation training, data quality and reporting to cover any new areas of improvement identified. As part of our commitment to smarter decision-making and data-driven growth, we continue to develop and enhance our Power BI reports and its capabilities across our teams with a 2025 focus of getting commissioner reports on Power BI and onboarding some corporate services.

This allows for data ownership and accountability, reduces duplication while improving patient outcomes.

By using integrated, secure and high-quality data, we aim to deliver proactive, patient-centered care, improve community outcomes and drive efficient, evidence-based decision making. Bringing to life our data strategy of using data to tell our story, drive insight and deliver patient-centered care.

We are strengthening our digital maturity at First Community to deliver smarter insights, better outcomes, more efficient services and act on the stories our data tells us. With a focus of implementing our Patient Engagement Portal (PEP) which would allow patients to have more control over their appointments and enable self referral, reschedule appointments and improve DNA's

Ensuring a solid infrastructure is also key and this year we aim to embed and optimise the use of MS Teams across the organisation focusing on working with our workforce to support capability and identify tools and functionality that will support daily work processes.

NHS number and general medical practice code validity

First Community did not submit records during the reporting period to the Secondary Uses Service (SUS) for inclusion in the hospital episode statistics which are included in the latest published data.

Clinical coding error rate

First Community was not subject to any payment as a result of a clinical coding audit during the period 1 April 2025 to 31 March 2026 by the Audit Commission.

Data security and protection toolkit

The Data Security and Protection Toolkit (DSPT) assessment for 1 July 2024 to 30 June 2025 was submitted in line with the national timeline and First Community exceeded standards on 30 June 2025. First Community is on target to meet or exceed the standards and our submission is due on 30 June 2026.

Investigations and learning from deaths

Infection Prevention and Control (IPC)

We have continued to strengthen IPC across our services through a range of targeted improvements that enhance safety, reduce transmission risks and support best IPC practice. We have achieved a number of key improvements by

Increasing the number of infection control support visits we carry out and now include places like joint injection and leg ulcer clinics. These visits give staff hands on IPC advice in real time, helping them to follow good infection control practices and making sure that higher risk procedures are carried out as safely as possible.

Introducing After Action Reviews following infection control incidents such as an outbreak situation. These are team discussions that look at what went well, what didn't go so well and how we can respond better next time. Because of what we have learnt from these reviews, we have improved the way we manage situations such as infection outbreaks on Caterham Dene Ward including improving team communication and helping patients continue with their rehabilitation when there are outbreaks whenever it has been safe to do so.

Introducing uniform clips for clinical staff and replacing lanyards. This change reduces the risk of lanyards becoming contaminated during patient care. Uniform clips are easier to clean, reduce contact with clinical environments and enable staff to follow safer infection prevention and control practices.

Creating a simple infection risk checklist for all patients before they arrive on the ward. This helps staff quickly spot any signs that a patient may have an infection so they can put the right precautions in place straight away. By identifying risks earlier, staff can make quicker decisions about whether someone needs to be cared for in a separate area, keep the ward running more smoothly, and reduce the chances of infections spreading.

Maintaining our Aseptic Non Touch Technique training levels high at 90%, meaning that staff have the underlying understanding they need to use this technique confidently and safely during clinical procedures. We have also improved how we identify new staff who need to complete the training, making sure they develop these skills as soon as possible when they start in post.

Introducing a new system for safely collecting clinical waste generated during care in patients homes. This ensures waste is disposed of appropriately, protects both staff and patients and creates a consistent approach across all teams. It also supports environmental sustainability by improving how waste is managed.

Reviewing the use of couch roll in some clinical areas and removed it unless it is needed for infection control reasons. This not only reduces unnecessary surface contamination and makes cleaning easier and more effective but also supports sustainability by cutting down on single use materials and reducing waste.

Improving how we manage issues that could affect infection control, not just in the buildings themselves but also in the equipment and facilities such as hand washing basins and other items that may need repair or replacement. We now have a better system for identifying these problems early, keeping track of them and making sure they are escalated appropriately. This stronger process means infection related risks linked to our environments and equipment are monitored more effectively, prioritised appropriately and given the attention needed so they can be resolved as quickly as possible.

Infection control on Caterham Dene Ward within the reporting period

Two infection outbreaks occurred during 2025/26 on Caterham Dene ward and both were managed safely and efficiently with quick escalation, good teamwork and clear learning captured through After-Action Reviews.

• Influenza outbreak (6 January 2026 - 29 January 2026):
  Five patients on Caterham Dene Ward were affected during a time when flu rates were already high in the community and in nearby hospitals. Staff acted quickly by isolating patients where needed, increasing monitoring and escalating concerns through the proper organisational routes.
• COVID 19 outbreak (20 October 2025 - 18 November 2025):
  Four patients on Caterham Dene ward were linked to this outbreak. Control measures were put in place promptly, with strong teamwork across different clinical roles throughout the incident.

As the outbreaks occurred at the time of year when these infections are more common, we introduced universal mask wearing on the ward for staff and visitors. This was in line with approaches taken by other hospitals and provided additional protection for patients vulnerable to infection.

Venous Thromboembolism (VTE) risk assessment

100% of patients admitted to Caterham Dene Ward during the reporting period had a VTE risk assessment.

National Cleanliness Audit

First Community is committed to maintaining a clean and safe environment across all the settings from which we deliver care. Monthly cleaning audits are carried out at Caterham Dene Hospital Ward and the Minor Injury Unit (MIU), where the expected compliance standard is 95%.

At the Therapies Unit, audits are undertaken quarterly, with an expected standard of 85-89%. These audits follow the National Standards for Healthcare Cleanliness (2025) and we use the National Cleanliness Audit tool to monitor performance and drive improvements when needed.

In addition to our owned sites, all other clinical locations from which First Community delivers services are also audited and we oversee these audits to ensure standards are met and maintained consistently across our wider estate.

The table below shows that the Ward, MIU and Therapies Unit consistently met their required cleanliness standards throughout the reporting period. Variations in scores reflect the different demands of each setting and demonstrate how effectively IPC standards are monitored and upheld. Overall, the results indicate a consistently high level of cleanliness across these areas.

Measure

Quality	Apr-25	May-25	Jun-25	Jul-25	Aug-25	Sep-25	Oct-25	Nov-25	Dec-25	Jan-26	Feb-26	Mar-26
Caterham Dene Hospital National Cleanliness Audit %	98%	98%	100%	96%	98%	99%	98%	97%	96%	98%	99%	99%
Caterham Dene Hospital MIU National Cleanliness Audit %	98%	98%	98%	99%	98%	99%	98%	98%	96%	96%	99%	97%
Caterham Dene Therapies National Cleanliness Audit %		93%		96%			91%			96%

Staffing levels on the ward

Caterham Dene Ward has a safe staffing level which is displayed on the ward for all staff, patients and visitors to see. This is reported to our Board via our performance pack. We have an escalation plan in place to cover when staffing levels are reduced due to sickness or absence. We are flexible with our referral criteria to enable patient flow.

First Community's innovative recruitment focus means we have no vacancies for registered professionals and a small amount of non registered.

We continue to prioritise the safety of our patients and staff by risk assessing admissions and staffing levels.

There are rare occasions when our staffing levels have fallen below our recommended safer staffing levels because of absence. Actions are put in place when this occurs and it is reported to our Board.

Patient Safety Syllabus Training

The Patient Safety Syllabus training provides NHS staff with essential knowledge and skills to understand patient safety principles, recognise risks, report incidents, and contribute to safer care for patients. It is mandatory for NHS providers to ensure a consistent, system wide approach to patient safety, reduce harm, meet national standards, and support a culture of learning and continuous improvement across healthcare services.

As of 31 March 2026 98% of staff had completed level 1 Patient Safety training and 93% of relevant staff had completed level 2 patient safety training.

Patient Safety Incident Response Plan

First Community continues to work to the Patient Safety Incident Response Framework and report incidents to the Learning from Patient Safety Events. First Community has reviewed its Patient Safety Incident Response Plan for 2026 /27 and will undertake a review annually. First Community's Patient Safety Improvement Plan, you can view this plan here.

Involving patients in safety and patient safety partners

First Community has one patient safety partner, who finishes in June 2026. First Community has trained involvement leads to lead on involving patients and those close to them in patient safety investigations.

In the reporting period First Community continues to involve patients in after action reviews (AAR) where appropriate. AARs are a learning response to learn from incidents and events that go well.

National patient safety alerts

First Community has a robust system in place for the receipt and actioning of national patient safety alerts. This process has executive oversight;

• The process has been reviewed to ensure all requirements have been met;
• All alerts have been reported via performance reporting to the Board;
• All alerts received have been responded to on time.

Digital strategy

First Community's commitment to digital transformation is reflected in our steady improvement in Digital Maturity. The 2025 assessment indicated that we sit above the national average for all but two pillars within the assessment: Support Workforce and Healthy Populations.

Within the Support Workforce pillar, notable areas for improvement include workforce digital and data literacy, digital, data and technology workforce capacity and capability, and supply chain management. These are all areas we wish to address in the year ahead. We currently have an inflight project focused on optimising the use of MS Teams and the use of AI to support administrative processes. As we move further towards a Neighbourhood model of healthcare delivery, we will need to focus on population health management and our interactions with, and delivery of, this methodology.

An improved score in the Empower People pillar reflects our continued optimisation of AccuRx as a platform to communicate with patients. This year, we successfully completed the implementation of the e-RS system for Audiology, allowing direct referrals to secondary care, and we launched a self-referral pathway for falls, aligned to the 'Steady on Your Feet' programme, joining up personalised self-care pathways. The delivery of virtual wards and remote monitoring-including the use of Doccla in Heart Failure-has contributed to a steady increase in the Improve Care pillar.

We have continued to focus on the use of digital enablement to support productivity, with the successful rollout of the e-rostering project, managed by the People team. The creation and rollout of a new website and intranet to support the online journey for both staff and patients has provided clear navigation and a structure designed for maximum usability and accessibility. Ensuring our digital front door is open and accessible, with clear patient pathways, supports our vision.

This year has also seen us secure significant funding via the NHSE Wayfinder programme to implement a patient portal that fully integrates with the NHS App. The project will complement and support patient care pathways from referral to discharge, aid our digital maturity, and support the shift from analogue to digital as outlined in the NHS 10 Year Plan, by boosting the digital enablement of pathways for patients.

The portal will create an interface with our patients that enables more care to be delivered outside of appointments, increases opportunities for self-management, and introduces efficiencies in appointment management for both patients and services. By integrating with the NHS App, we will enable patients to manage their care more effectively in partnership with our teams through a single entry point-simplifying the experience and moving us collectively closer to the aim of 'one front door' for all services. This project will continue to develop over the next three years, with a staggered introduction of additional functionality.

Our move to Consort House has created a number of new opportunities for digital enablement, including the use of self-check-in kiosks for patients. We will further optimise this in the coming year by leveraging digital wayfinding and feedback tools.

This year, our digital transformation plan will align with the South East Regional Strategic Framework (NHSE) and the five transformation pillars: Prevent Ill Health; Care Close to Home; Fair Care for All; Quality That Lasts; and Smart Technology in Action. There are a number of areas of opportunity to explore, including the use of ambient voice technology, smart scheduling for community nursing, optimising medicines management, optimising digital rehabilitation tools, and optimising EPR templates for Bed-Based Care.

We remain committed to collaboration, with a number of proposed programmes of work alongside the ICB and other community providers.

Incidents

First Community has a good reporting culture which is evidenced by the number of incidents received and staff survey results.

First Community:

• Continues to provide feedback to staff involved in incidents, sharing learning across the organisation and changing practice to prevent recurrence;
• Is an open and transparent organisation and supports a 'just and learning' culture. First Community puts equal emphasis on accountability, learning and sharing.

A high level of incident reporting helps protect both patients and staff from avoidable harm by increasing opportunities to learn where things go wrong.

In the 2025 staff survey 80.3%  of staff reported that 'My organisation treats staff who are involved in an error, near miss or incident fairly' (compared to 82.1 %last year and 81% in 2023).

	Total number of incidents
1 April 2025 to 31 March 2026	1249
1 April 2024 to 31 March 2025	1394
1 April 2023 to 31 March 2024	1343
1 April 2022 to 31 March 2023	1644
1 April 2021 to 31 March 2022	1150

Medicines incidents

All incidents involving medicines management are reviewed and any relevant learning is taken forward. Medicine incident reports include an incident risk profile to highlight 'significant/high risk' incidents.

First Community incidents continue to be based on a low or moderate risk. The head of medicines management and ward pharmacist disseminate relevant research and information concerning new risks and best practice, so that staff continue to assess and manage risk appropriately.

Quarter	Total (A+NM)
Q1 2021/22	22
Q2 2021/22	24
Q3 2021/22	45
Q4 2021/22	60
2021/22 Total	151
Q1 2022/23	93
Q2 2022/23	57
Q3 2022/23	75
Q4 2022/23	69
2022/23 Total	294
Q1 2023/24	51
Q2 2023/24	47
Q3 2023/24	25
Q4 2023/24	30
2023/24 Total	153
Q1 2024/25	30
Q2 2024/25	37
Q3 2024/25	41
Q4 2024/25	21
2024/25 Total	129
Q1 2025/26	27
Q2 2025/26	35
Q3 2025/26	51
Q4 2025/26	32
2025/26 Total	145

Safeguarding Adults and Children

Staffing/team

Adult and Children Safeguarding responsibilities for First Community are led and undertaken by the Executive Lead for Safeguarding and the Adult Safeguarding Lead.  Key elements of safeguarding such as training, supervision, information sharing and assurance are jointly focused on both adults and children, and a think family approach to safeguarding is adopted within the organisation.  

The Executive Lead for Safeguarding and the Adult Safeguarding Lead represent First Community at the Surrey Safeguarding Adults Board and Surrey Safeguarding Children's Partnership.

Safeguarding Adults and Deprivation of Liberty Safeguards

First Community continue to safeguard those people who are unable to consent to being on Caterham Dene Ward by making Deprivation of Liberty Safeguard (DoLS) applications.  These applications allow First Community to restrict patients' liberty legally and safely and in their best interest where required.  During 2025/26 4 DoLS applications were made; this is a reduction from the previous year and is more in line with the numbers seen in 2023/24. Ward Staff continue to receive training in DoLS and recognise when an application is required.  A DoLS audit was completed (see audit section) which provides assurance that deprivation of liberty is recognised and applications made in line with legislation.  As a result of audit finding last year, a new DoLS information leaflet has been created to ensure that patients and their families are provided with literature to support their understanding with the process.   

Deprivation of Liberty Safeguard Numbers

• 2020/21: 12
• 2021/22: 7
• 2022/23: 11
• 2023/24: 3
• 2024/25: 8
• 2025/26: 4

Advice and support

The Adult Safeguarding Lead and Executive Lead for Safeguarding are available to provide staff with advice and support in relation to safeguarding adult and children's concerns and complex mental capacity issues.  This information is summarised in table 1.

Adults

Contacts for advice and support in relation to adults remained consistent from 216 in 2024-2025 to 214 2025-2026. 

After a significant drop in 2023-2024, the numbers of adult safeguarding concerns raised with the Multi Agency Safeguarding Hub (MASH) increased from 57 in 2024-2025 to 66 concerns in 2025-2026.  Of the 66 safeguarding concerns raised where the outcome is known 60% triggered a Section 42 Enquiry.

A Section 42 Enquiry is a statutory investigation by the local authority to determine if a person with care and support needs is at risk of abuse or neglect and what action, if any, is required to protect them.

Surrey Safeguarding Adults Data collection 2024-2025 (published November 2025) shows First Community's downward trends for raising concerns are in line with Surrey Statistic, however the 60% enquiries triggered is higher than the Surrey statistics of 54%, and 31% for England as a whole.  This conversion rate provides assurance that although the numbers of requests for support and advice have been reduced, staff continue to recognise and report concerns in line with policy and procedure, and are appropriately raised in line with Care Act 2014. 

Children 

Since 1 April 2025 there have been 30 contacts for advice in relation to children's safeguarding.  This has included 15 ad hoc supervision opportunities and 15 'Request for Support Forms' submitted.  With the transfer of the children's contract to HCRG, this reduction in Request for Support forms submitted was anticipated.  6 of these submissions were made by clinicians working with adults and identifying children's concerns within the family and demonstrates the 'think family' approach embedded in practice.    

The Adult Safeguarding Lead also provides relevant adult and children information where appropriate for the twice monthly Multi Agency Risk Assessment Conference (MARAC) in both Reigate and Banstead and Tandridge.  These conferences support the safety of those at risk of high-risk domestic abuse in the community and fulfill the role previously completed by the children's safeguarding team.  

Staff in Minor Injuries Unit continue to use The Child Protection Information System (CP-IS) to support them with appropriate information sharing.  The CP-IS service has the capacity to share key information as to whether a child is subject to a Child Protection Plan (CPP) or is a Child Looked After (CLA) and highlights those young people most vulnerable when they present at MIU. 

Table 1

Year	Adult Safeguarding Discussion	Concern raised with the MASH	Children Safeguarding discussion	Request for support forms submitted
2023-2024	251	108	Not collated	54
2024-2025	216	57	Not collated	42
2025-2026	214	66	30	15

Training

Safeguarding Training has continued to be delivered in line with the Adult and Children's Safeguarding Intercollegiate Documents, and the Surrey Heartlands joint Adult and Children's Training Strategy.  Compliance levels remain consistently high (see table 2) and are reviewed at the quarterly Safeguarding Group; any areas below 85% are discussed with a plan for increasing compliance. The training package consists of Level 2&3 Adult and Children Safeguarding, Domestic Abuse and Prevent dependent on role, and Mental Capacity and DoLS training.  It is delivered via a combination of e-learning packages, virtual and face to face sessions which are tailored to include the results of audit, safeguarding enquiries, national and local Safeguarding Adults Review, Child Practice Reviews and Domestic Abuse Related Death Reviews. 

Safeguarding training embeds the Think Family approach to safeguarding and encourages staff to consider the wider impact on families where there are safeguarding concerns.

We know that training numbers have dropped in some areas and are working to address this.

Table 2 Percentage of First Community Safeguarding Training 31 March 2026

	Safeguarding Adults Level 2	Safeguarding Children Level 2	Safeguarding Adults Level 3	Safeguarding Children Level 3	Preventing Radicalisation - Basic Prevent Awareness	Preventing Radicalisation - Level 3	Mental Capacity Act & DoLS	Domestic Abuse Level 2	Domestic Abuse Level 3
31 March 2024	95.83%	93.75%	86.06%	70%	96.63%	94.67%	85.36%	84.37%	84.38%
31 March 2025	95.58%	91.68%	90.20%	82.35%	93.60%	93.48%	84.08%	83.35%	92.67%
31 March 2026	92.94%	87.76%	82.5%	66.67%	92.93%	91.67%	77.81%	90%	95.42%

Safeguarding champions

The Adult Safeguarding Champion Group meets quarterly and there continues to be 10 Safeguarding Champions across the organisation, all with a passion for adult safeguarding. The Champions role provides a more specialised point of contact within clinical services and assists the Adult Safeguarding Lead with the sharing of information, communication of learning and any ad hoc supervision their local teams may require.  This year the group saw guest speakers from Catalyst (Specialist Outreach Service Cuckooing), Adult Social Care (sharing good practice in working with people at risk of self-neglects), Adult Social Care Substance Misuse Team and a focused safeguarding CQC session by the Head of Patient Safety and Quality. 

Supervision

Safeguarding supervision is embedded across the organisation in line with the Adult and Children Safeguarding Supervision Policy.  The Director of Quality and People and Executive Lead for Safeguarding is responsible for ensuring children's safeguarding supervision is available and accessible, alongside the Adult Safeguarding Lead who provides ad hoc telephone advice and support, planned 1-1 sessions and quarterly drop-in sessions at Phoenix House and Caterham Dene Hospital. The monthly joint children's and adult safeguarding sessions in the Minor Injuries Unit continue to run and are well attended.  Safeguarding supervision options have been well utilised by staff; a Supervision Audit is planned for 2026-2027 to evaluate the safeguarding supervision provided.  

Audit

During the period of 1 April 2025 and 31 March 2026, a number of audits have been completed that provide assurance in relation to both adult and children's safeguarding. 

Domestic Abuse Routine Enquiry Audit:

Domestic abuse remains one of the safeguarding concerns which affect both adults and children. Emis data was audited to see if the Routine Enquiry question was asked in line with the First Community Standard Operating Procedure for Routine Enquiry.  The audit showed the routine enquiry question was asked in 45% of First Attendance appointments during the audit period; this is a drop from last year (54%); it is recognised, however that due to environment and others being present etc. it is not always possible to ask the question.  The audit has demonstrated that routine enquiry is well embedded in First Community where possible, and that clinicians are recording why the routine enquiry question is not being asked.   The reason for not asking the question was recorded and remains high at 81% of records audited. 

Historic and current domestic abuse cases were highlighted as a result of routine enquiry and there are future opportunities for including additional categories to record why the question is not asked.  Domestic abuse training includes a focus on routine enquiry and provides opportunities to understand and discuss ways and means of asking the question. 

Deprivation of Liberty Safeguards (DoLS) Audit

A 'Deprivation of Liberty Safeguards (DoLS)' Audit was completed on Caterham Dene Ward July 2025. 

The audit reviewed all 25 patients who were present on the day of the audit and confirmed that all 25 patients had consented to admission and there was no unlawful deprivation of liberties on the ward 

There were 8 patients on the ward with some level of cognitive impairment including Delirium, Dementia and Parkinson's Disease; the patients 6CIT (cognitive assessment) score ranged from 0/28 to 24/28. 

Three of the patients had some level of confusion recorded in their clinical records; they had all consented to being in Caterham Dene on the day of admission, but follow-up was required from the Ward Matron to confirm that they could still all consent to admission and that a Deprivation of Liberty Safeguards application was not required.  The follow up by the Ward Matron confirmed that these patients could consent to admission and were not being deprived of their liberty.

A review of the 2024 action plan was also completed as part of the audit which identified that all previous actions had been completed, and no new actions identified. 

Mental Capacity Audit

Assessing mental capacity is common practice when working with adults in the community.  An audit was completed to provide assurance that staff have the skills and knowledge to identify and complete assessments in line with the Mental Capacity Act 2005.  The audit demonstrated that staff have a good basic understanding of the Mental Capacity Act and record outcomes of assessments appropriately using the Emis template.  The audit was limited in the ability to provide robust assurance surrounding more complex decisions as access to data was difficult to gain.  In the absence of this data, the Adult Safeguarding Lead can evidence that the workforce is trained (78.34% compliance) that there is an accessible Mental Capacity and Deprivation of Liberty Safeguards Policy, and easy to access resources available to support practitioners when involved in mental capacity assessment.  Other audits such as the Advocacy Audit (detailed below) also demonstrate that the Mental Capacity Act is followed in practice.  There is a dedicated Mental Capacity page on the intranet, and the Lead is available Monday to Friday to provide advice and support with mental capacity assessment; this support is well utilised. 

Opportunities for exploring more robust assurance for more complex mental capacity assessments is an action for the Adult Safeguarding Lead. 

Advocacy Audit 

An Advocacy audit was completed to establish if referrals to an Independent Mental Capacity Advocate (IMCA) had been made in line with the Mental Capacity Act 2005. 

An audit of all patients who were admitted from home to Caterham Dene Hospital and subsequently discharged to residential/nursing home placement between a six-month period; in total 16 patients were audited. 

The results of the audit showed there were no patients admitted to Caterham Dene Hospital where an IMCA referral was required on transfer to placement.

Of the 16 patient cases that were audited 2 patients did not have the mental capacity to make the decision regarding residential care placement.  On both occasions, the patient had a family member to support them with the process, and therefore a referral to an IMCA was not required.  The audit identified for those people without mental capacity the ward followed the Mental Capacity Act 2005 appropriately including the completion of mental capacity assessment with best interest decisions clearly documented.

The remaining 14 patients had mental capacity and a family member to support them with the process and therefore they also did not legally require an IMCA referral. There were no actions identified from this audit; a repeat audit will be completed in the future.

Paediatric Liaison Audit

First Community Health has a responsibility to safeguard young people who use our services; this includes our Minor Injuries Unit.  Outlined in the Intercollegiate Committee for Standards for Children and Young People in Emergency Care is the requirement to share information about MIU attendances (paediatric liaison). 

An audit of all children who attended the Minor Injuries Unit (MIU) at Caterham Dene Hospital was completed from the 19/10/25 to the 26/10/25 to ensure that the paediatric liaison process was completed within the agreed three working day timeframe.  The audit involved confirming that *all children who attended MIU between this time period had their discharge summary sent to the appropriate 0-19 teams so information could be shared of their attendance either with their local Health Visiting Service or School Nursing Team; a copy was also sent to their GP. 

The audit demonstrated that the paediatric liaison responsibilities were completed 100% of the time within the agreed time frame, and there were no actions from the audit. 

*Exceptions: where there is no NHS School Nurse Service: Independent Schools, Home Educated Children, Children in the workplace or at Further Education College.  In these cases, a discharge summary is always sent to the GP.

Reducing variation in lower limb care

The National Wound Care Strategy (2020) identified that there was a variation in lower limb care and that many people with leg ulcers (lower limb wound) do not receive effective evidence-based care that would increase healing and reduce recurrence. In 2019, there were an estimated 739,000 leg ulcers in England, with estimated healthcare costs of £3.1 billion per annum. This situation presents a valuable opportunity for quality improvement to deliver better patient outcomes and secure better value from existing resources.

In 2022/23 we achieved our aim to provide a consistently high standard of wound care across First Community by developing a lower limb pathway to reduce unnecessary variation in the assessment and management of lower limb wounds. We continued to promote and monitor the use of the lower limb pathway to maintain improvements in 2023/2024 and 2024/25.

In 2025/26 we transitioned from First Community's lower limb pathway to using Surrey Heartlands lower limb compression decision tool, with all district nursing teams now consistently using this tool. This ensures there is one pathway being used for all neighbourhoods in Surrey, ensuring consistency and continuity of care.

In addition to this we have also undertaken the following actions and improvements:

We continued to provide 2-day leg ulcer training to First Community clinicians involved in lower limb management and offered the training to practice nurses working in east Surrey to increase the use of Surrey Heartlands lower limb compression decision tool;

We continued to promote resources from the National Wound Care Strategy Programme through accessing Surrey Heartland's TeamNet, which is available to all;

We continue to be a part of Surrey Heartlands Wound Formulary Group, promoting the lower limb compression decision tool and the Wound Hygiene Pathway;

We are involved in a Surrey wide product evaluation on compression hosiery garments to support national recommendations on lower limb management;

We developed an aftercare for your healed leg ulcer leaflet which is given to patients on discharge to prevent reoccurrence of leg ulcers;

We purchased a toe doppler to aid those who can't tolerate an ankle-brachial pressure index (ABPI) or those with significant oedema, where the toe doppler can provide a more accurate measurement;

Additionally, as part of east Surrey, First Community demonstrate high achievement in our low use of antimicrobials , in line with antimicrobial stewardship.

First Community also participate in a local quality requirement (LQR), Lower Limb. We meet with other community providers in Surrey Heartlands, with the group capturing healing rates as an outcome measure. At present it is not possible to collect this data from the electronic patient records and therefore First Community are collating this information in a spreadsheet of those patients placed onto the lower limb pathway, while the Integrated Care Boad (ICB) explore this challenge with the Surrey Heartlands Digital Transformation Team.

Due to these limitations in data collection and the capacity and conflicting clinical demands within the teams, data collection has subsequently been limited. Table 1 below details the healing rates within the district nursing teams, as well as the number of patients healed at the point of data analysis.

Table 1

	Quarter 4 2024/25 to Quarter 2 2025/26	Quarter 3 2025/26	Quarter 4 2025/26
North Tandridge	17 weeks (5-24 weeks) 13/25 patients healed	10 weeks (2-22 weeks)	15.5 weeks (2-55 weeks) 17 patients healed
Phoenix	12 weeks (3-21 weeks) 21/32 healed	No available data	13 weeks (9-18 weeks) 4 patients healed
Horley	10.9 weeks (2-19 weeks) 30/56 healed	No available data	3 weeks (1-8 weeks) 26 patients healed
Care Collaborative	No available data	No available data	22 weeks (7-53 weeks) 13 patients healed
South Tandridge	Ongoing challenges with accurate data collection so unable to report

First Community have learnt from the data collection process across the year and are continuing to make improvements to the data completeness and accuracy. This includes working to capture all relevant patients, including those who have healed within a short time period, and ensuring recurrences are captured as a new episode.

First Community plan to continue to monitor healing rates and if the standard of 12 weeks is not met then teams will explore this further, including identifying process measures.

Some of the quality improvement and clinical audit work that has happened in the reporting period:

First Community has a Quality Improvement (QI) Pathway which underpins its ambitions for all staff to be equipped with improvement skills. We have received feedback from 76% of staff on which stage of the Quality Improvement Pathway they are on with most staff (31%) at the 'learn' and 'live' stages of the pathway (see below graph).

First Community works to support staff to progress along the pathway, develop their skills and complete quality improvement work.

In addition to our priority one activity such as infection prevention and control audits, record keeping audits, information governance audits and national audit submissions, First Community staff were able to undertake some additional quality improvement activity. A selection of work can be found below:

'To glove or not to glove' campaign

This project aimed to promote the appropriate use of non sterile gloves in clinical practice, reducing unnecessary use while supporting patient safety, cost awareness and sustainability. Although it was unable to demonstrate cost savings due to challenges obtaining accurate data, it did demonstrate reported and observed changes in practice, as well as a positive impact on environmental sustainability. Table 1 details the carbon savings and weight reduction calculated across the first six months of the project for two areas of the organisation. The Infection Prevention and Control team plan to continue ongoing clinical education and communications.

Table 1

	Carbon savings over 6 months	Carbon savings equivalent to	Weight reduction over 6 months	Weight reduction equivalent to
Minor Injuries Unit (MIU)	534kgCO2e (59.9% reduction)	39 Emergency Department (ED) visits	71.96kg	A fallow deer OR 131 walking sticks
Caterham Dene Ward	2240kgCO2e (79.5% reduction)	162 ED visits	301.59kg	A zebra OR 548 walking sticks

Text messaging partial booking letters to patients

We started to send text messages to patients on the Musculoskeletal (MSK) Physiotherapy waiting list inviting them to contact us to book an appointment, rather than sending them a letter. For the first month of implementation, this resulted in 17% of patients being booked after contacting them by text, increasing the efficiency of the booking process and resulting in both cost and carbon savings. For this first month 1.13kgCO2e were saved, the equivalent of 1 passenger travelling between Redhill and Caterham by train 4.6 times.

Updating Caterham Dene therapies EMIS templates

As part of the record keeping audit action planning, the therapy team at Caterham Dene ward decided to review their EMIS (electronic patient record) therapy templates to ensure that all information and record keeping is aligned with the First Community Record keeping standard as well as EMIS project national guidance. The new template CDH Therapies was designed to reflect our current Key Performance Indicators (KPIs) and enhance time effectiveness of completion. It utilised feedback from therapy staff and was also enhanced by the recent NICE Falls guidance (NG249, 2025), aiming to incorporate important information gathering tools for prevention and management of falls for inpatients on the rehabilitation ward. Once this has been in place for 2 months there are plans to review the data captured and collect staff feedback to identify any further improvements required in this area.

MSK outpatients and ICATS website update

The musculoskeletal (MSK) 'self-help' section on the First Community website was updated so that it included evidence-based resources for waiting list and active patients to access 'self-help', which could potentially facilitate improvement of symptoms or avoid deterioration of problems while on the wait list.

Following the website update there was:

• A significant increase in page views, from 585 to 2,986 in the six months following the update;
• A reduction in clicks required to access information, from an average of 14.5 clicks pre-update to an average of 8 clicks post update;
• Continued positive feedback regarding information clarity. 

However, it was identified that the menu navigation still needed strengthening and further actions have been identified to improve this further.

Annual Quality Improvement Day

First Community's annual Quality Improvement Day in 2025 focused on our impact and was attended by 97 members of First Community staff, as well as external guests.

73% of attendees told us that the event will help them, either a great deal or a lot, to carry out Quality Improvement (QI) work.

77% of attendees told us that the event helped them, either a great deal or a lot, to develop their understanding of QI.

94% of attendees told us that they felt either a great deal or a lot more informed about QI work across First Community.

Feedback also highlighted the value of this annual event, which has been captured in the word cloud, and included suggestions on how we can make it even better in the future.

The day included 14 presentations covering a range of quality improvement work including:

• Steady on your feet platform - in which the Long-Term Conditions team described the new platform to help reduce the risk of falls, including its impact, feedback and plans for ongoing promotion;
• The digital transfer of residents' information to SASH from Care Homes - in which the nurse advisors for care homes detailed challenges with the red bag process which aimed to provide a prompt, safe and efficient transfer of resident's information between the care home and hospital. They detailed further actions identified from these challenges, including the digital transfer of information to the acute hospital on transfer and the work they undertook to support this process;
• Integrating After Action Reviews on the ward - in which Caterham Dene ward described their transition to using After Action Reviews to support learning, sharing positive feedback from patients, families and staff who had been involved and highlighting key areas of learning identified;
• The impact of point of care CRP testing - in which the Urgent Community Response (UCR) Team described point of care testing, why this is important and the impact of using this within their team, including the number of patients who are treated and remain at home with UCR input;
• Home enteral feeding service: patient feedback - in which the dietetics team summarised largely positive feedback from patients on their home enteral feeding service and highlighted improvements they had identified;
• Learning from our radiology audit - in which the Minor Injuries Unit described their X-ray audit and how this provides assurance that the majority result in the correct interpretation, identifies any discrepancies and is used within the service as a learning tool;
• Pulmonary Rehabilitation accreditation - in which our Pulmonary Rehabilitation team described our accreditation journey to date, including improvements made, positive feedback from the assessment and further actions to achieve accreditation.

Sharing learning from improvement

There are various other ways for quality improvement work to be shared at First Community, including within our QI Leaders' Network which we have continued to develop. There are now 36 members of the QI Leader's Network, with representation from various areas within the organisation. Between 1 April 2025 and 31 March 2026 four network meetings were held, with a total of 33 members in attendance. Each meeting included teaching and an opportunity to share and learn from quality improvement work taking place in other areas of the organisation, including learning from the National Audit of Intermediate Care shared by Responsive Services, learning from Domestic Abuse related reviews shared by the adult safeguarding lead and learning from the annual Elderly Mobility Scale (EMS) audit shared by Caterham Dene ward.

Record keeping

Each year teams within First Community must undertake a main audit, which measures against organisational standards, and a service specific audit focused on a record keeping issue or area of interest specific to that team. This allows teams to individualise their audit focus and learning to meet the needs of individual areas.

Some examples of the focus of service specific audits include:

• The use of new EMIS templates;
• Care plans;
• Referrals;
• The records of observed home visits;
• Service specific record keeping standards.

The below table details the number of completed record keeping audits as a percentage of the number expected.

Year	Percentage of record keeping audits measuring against the organisational standards	Percentage of service specific record keeping audits	Percentage of teams who have completed any type of record keeping audit
2022-2023	N/A	N/A	50%
2023-2024	N/A	N/A	77%
2024-2025	62%	95%	95% (1 service not completed)
2025-2026	68%	82%	100%

We have worked each year to ensure all services complete a record keeping audit and have seen improvement from 50% in 2022 / 23 to 100% in 2025 / 26. First Community manages risk of non-completion each year through an annual report of audits and triangulation of data such as incidents and complaints. Any outstanding record keeping audits for the year are completed within three months of the next reporting period which is reported and tracked through First Community's monthly quality group.

A patient centered approach to Quality Improvement (QI)

We ensure clinical effectiveness, continual improvement and learning by providing a patient centered coaching approach to QI.

Following the completion of the QI training staff survey, which explored the barriers to accessing QI training, we have developed and launched Introduction to clinical audit and Foundations of QI e-learning. The latter has been developed to support staff to gain QI knowledge and skills, while supporting them through their own QI work and includes teaching on public and patient involvement and sustainability.  To date, two individuals have completed Introduction to clinical audit and two have completed Foundations of QI with a further four in progress. We continue to promote these training opportunities, as well as ad hoc support and training tailored to an individual's needs based on their own QI project. This year 39 ad hoc support/training meetings have been carried out, reflecting 28 QI projects or service evaluations.

We have also continued to promote our QI reporting posters to support the sharing of QI work across the organisation. Completed posters are shared on the intranet and also within our QI Leaders Network quarterly meetings.

We continue to attend our monthly corporate induction to raise the awareness of QI support and training available at First Community and increase visibility of the Quality team.

Next year we also plan to incorporate some QI training within the preceptorship programme.

Read later in the report for further details on actions we have taken in 2025-26 to promote public and patient involvement within QI and the number of improvement activities involving patients and public.

The table below provides information on the number of staff who have accessed Quality Improvement training across the previous four years. The What is QI video is most appropriate for staff who identify at the New stage of our QI pathway. Although there appears to be a significant reduction

in the number of staff accessing the What is QI video, it should be noted that 98 staff identified as New at the end of 2025/26 and so a significant number are likely to have accessed the video in the previous years.

	2022/23	2023/24	2024/25	2025/26
Number of staff who accessed What is QI video	68 across an 18 month period	119	61	40
Number of staff who accessed Introduction to QI training or e-learning	5	0	3	2
Number of staff who accessed QI training via the First Leadership training	2 cohorts	30 (2 cohorts)	24 (2 cohorts)	17 (1 cohort)
Number of staff who attended training via the QI Leaders Network	NA	25	38	33
Number of ad hoc support/ training meetings	Data not captured	Data not captured	Data not captured	39

The below table provides information on the number of clinical audit and QI work undertaken and completed across the previous four years, as well as the number of QI reporting posters completed and shared to support wider learning.

	2022/23	2023/24	2024/25	2025/26
Number of completed clinical audits and QI work	142	210	258	217
Number of QI reported posters	NA	7	29	30

Supporting and developing our staff

	1 April 2020 - 31 March 2021	1 April 2021 - 31 March 2022	1 April 2022 - 31 March 2023	1 April 2023 - 31 March 2024	1 April 2024 - 31 March 2025	1 April 2025 - 31 March 2026
% of staff who have had an achievement review during the reporting period	81%	95%	88%	90%	85%	86%

We continue to set the expectation that all achievement reviews must be completed in the first two quarters of the year.

We engage with staff and their line managers if they have not had an achievement review to support them to complete it.

We continue to remind our staff the purpose of these reviews is to enable quality conversations about performance and objective setting, to support our staff to develop and achieve a good work / life balance through the training we deliver.

We continue to use the electronic staff record (ESR) to report achievement reviews.

We know some managers have had issues completing this so have and will continue to support all staff in doing this.

We continue to report a rolling figure of the percentage of staff who have had an appraisal within the last year, in addition to those who have had an appraisal since the start of April. This provides an improved oversight of the number of staff with an achievement review which is in date.

We continue to set the expectation that staff are provided with regular one-to-ones, every six to eight weeks. Since September 2023, we have been running a one-to-one survey every six months to determine from staff who is having regular one to one meetings with their line manager to discuss their workload and wellbeing.

The table below indicates the number of staff who responded to the survey, and the percentages of staff who report they have regular one-to-one meetings, who report they do not have one-to-one meetings and who report they do have meetings but these are not regular.

	Number of staff who responded to the survey	Yes	No	Yes, but not regularly
September 2023	129	83.7%	3.1%	13.2%
April 2024	122	95.1%	0.8%	4.1%
September 2024	66	92.4%	1.5%	6.1%
April 2025	132	91%	1.5%	7.5%
September 2025	70	86%	4%	10%

This has provided assurance that the majority of staff who complete the survey, are receiving regular one-to-one meetings. It also allows us to identify services to target for further input and support. 

We continue to use these measures, including the staff survey (detailed below), staff feedback, one-to-one's feedback and appraisals, to monitor and evaluate the impact of our work, to identify areas for improvement, and inform our decision making.

We continue to prioritise the promotion of staff development and share resources across services to fill gaps and retain staff, focusing on appraisals and one-to-one's to understand people's ambitions and support meaningful conversations, and staff development to increase the uptake of development opportunities.

This year we have also delivered bespoke training following changes in the line management structure at Caterham Dene Ward. This ad hoc training includes coaching people through one-to-ones, setting objectives, Personal Development Plans (PDPs) and giving feedback. In January, the People team then introduced line management skills training to build on this which they are planning to roll out to the rest of the organisation in 2026/27.

In our 2025 staff survey...

96% of staff said they had had an appraisal in the preceding 12 months (compared to 98% in 2024 and 98% in 2023)

30% of staff reported the appraisal helped them to do their job (compared to 32% in 2024 and 30% in 2023)

42%* of staff said their appraisal helped them to agree clear objectives for their work (compared to 48% in 2024, 46% in 2023 and 35% in 2022)

39%* of staff said their appraisal left them feeling the organisation values their work (compared to 48% in 2024, 44% in 2023 and 35% in 2022)

65%* felt supported to develop their potential (compared to 73% in 2024, 72% in 2023 and 64% in 2022)

66%* were able to access the right learning and development opportunities (compared to 74% in 2024, 72% in 2023 and 68% in 2022)

*a downturn from 2024 results and above national average

We are assured that 96% of people reported they had completed their appraisal and recognise the downturn from the 2024 results means we:

• Must continue to promote regular one to ones;
• Roll out line management training across the organisation that includes how to run a successful appraisal;
• Implement reviewed paperwork for appraisal to help improve development discussions.

Reflect and learn

We aim to give staff a safe place to reflect and learn by embedding our approach to clinical supervision - 'reflect and learn'.

Each year we complete an annual evaluation of staff's experience of reflect and learn so that we can continue to make improvements to both the access to and experience of reflect and learn. In 2025, 9% of staff responded, compared to 7% the previous year, with respondents representing all services, all bandings and all disciplines.

The evaluation demonstrated that:

• Staff value the Reflect and Learn options and experience multiple benefits from accessing these opportunities, including support, personal and professional development, time for reflection, and networking. See the word cloud for some of the reported benefits;
• Facilitators of reflect and learn groups are well supported and highly valued;
• The percentage of staff who are unaware of reflect and learn remains low;
• The number of staff who have identified learning needs has remained relatively stable over the last 3 years, but those who go on to discuss these with their line manager has reduced;
• More staff are aware of and use the log books compared to last year;
• Access continues to be limited by difficulty finding the time. However, the percentage of staff who do not access reflect and learn as often as they would like has decreased over the last 3 years, and the percentage of line managers who ensure staff have protected time has increased (as reported by both line managers and staff).

Results of the evaluation were fed back to service managers, and to staff via First News (First Community's weekly staff newsletter). We have offered to attend team meetings to promote reflect and learn and discuss how the different options can fit around other service demands.

Additionally, results were discussed with reflect and learn group facilitators for learning and to identify additional actions. Subsequently we have developed a group requirements document so that new reflect and learn group members are aware of the expectations of attending. We have continued to promote facilitator training and have centralised facilitator administration to support the retention of our current facilitators. We have also developed fast-track training for those who have already completed coaching training and plan to implement this next year.

First Community also have 5 trained Professional Nurse Advocates (PNA) who can offer one-to-one or group restorative clinical supervision, as well as career conversations and support with Quality Improvement. This year PNAs carried out 43 restorative supervision sessions with 68 individuals, compared to 11 last year. They also carried out 20 career conversations (compared to 15 last year) and supported 15 quality improvement projects (compared to 21 last year)

To further incorporate our PNA offer into Reflect and Learn, this year we added the A-EQUIP (Advocating and Educating for Quality Improvement) model into our facilitator training and facilitator updates to standardise knowledge and understanding, and we continue to invite PNAs to attend our quarterly facilitator updates.

At the end of the reporting period, we have received feedback from 63% of all staff on which of the reflect and learn options they have selected from the menu. Facilitated groups is the most popular option, with 13 groups running and 44% of staff accessing reflect and learn choosing this option. Across First Community we have 27 trained facilitators, of which 21 attended one of the quarterly facilitator update meetings.

We continue to work closely with the adult safeguarding lead to monitor the frequency with which safeguarding issues are discussed at reflect and learn group sessions and to support facilitators learning needs. During the reporting period adult safeguarding concerns were discussed at reflect and learn group sessions thirteen times, ten times as a challenge and three times as an opportunity for learning. Children's safeguarding concerns were discussed at reflect and learn group sessions eleven times, seven times as a challenge and four times as an opportunity for learning.

Staff are also able to access adult safeguarding supervision. The table below indicates the number of staff who accessed adult safeguarding supervision during this reporting period and how this compares to previous reporting periods.

The number of staff recorded accessing adult safeguarding supervision has remained consistent with last year, with a small increase up from 190 last year to 197 2025-2026.  The Safeguarding Adults Lead is visible and present within the organisation and visits bases and teams regularly to capture opportunities for ad hoc and planned   supervision when required.  Support and advice can also be provided by the Safeguarding Champions, Clinical Team Leads and Service Leads who are all well equipped to provide this support; these contacts are not captured in these figures. 

Monthly Reflect and Learn sessions with the Minor Injuries Unit, and the safeguarding focused sessions are very well attended with 18 staff attending over the 9 sessions offered.

Supervision has been accessed from the adult safeguarding lead via ad-hoc supervision, 1-1 formal supervision, attendance at reflect and learn sessions, and one reflective de-brief. Drop-in sessions have continued to be offered quarterly at Phoenix House and Caterham Dene Hospital but have proved less popular than previously, as staff tend to contact the Lead for advice as and when required rather than waiting for a planned drop-in session.  Opportunities for supervision are advertised at induction, during training and via team meetings, and staff have taken these opportunities to discuss safeguarding cases that they require advice and support with.

Supervision type	Ad hoc	1-1 formal	Reflect and learn	Drop-in session	Total
2023-2024	251	16	Lead attended 3 x Reflect and Learn sessions	9 drop-in sessions arranged with 26 attendees	296
2024-2025	150	17	5	8 drop-in sessions with 17 attendees	190
2025-2026	164	7	14	8 drop-in sessions with 12 attendees	197

National Institute for Health and Care Excellence (NICE)

First Community continues to assess and implement NICE guidance relevant to the services provided. An audit of the NICE guidance implementation process was completed. This highlighted that 100% of relevant NICE guidance had undergone a gap analysis, maintaining the improvements made last year.

This year we continued to build on the improvements made last year in the number of action plans implemented within given timescales, achieving 100% compared to 60% last year and 25% the year prior. We also started to invite action plan leads to reflect on the impact of and learning from actions they have implemented, which is shared within our Clinical Quality and Effectiveness meeting. Further improvements have also been implemented this year, including quarterly checks, to ensure all new and updated guidance is captured on our planner.

Through the NICE guidance implementation process clinical staff have made significant improvements to their working practice. For example:

Following the publication of 'NG246: Overweight and Obesity Management' the dietetics team have developed a webpage of overweight and obesity management resources;

Following the publication of 'NG249: Falls: assessment and prevention in older people and in people 50 and over at higher risk' use of a validated home hazard assessment has been embedded within relevant First Community teams;

Following the publication of 'NG106: Chronic heart failure in adults: diagnosis and management' we plan to develop a care plan format which is useful and meaningful to patients;

Following the publication of 'NG253: Suspected sepsis in people aged 16 and over: recognition, assessment and early management' and 'NG255: suspected sepsis in pregnant or recently pregnant people: recognition, diagnosis and early management' the Long-Term Conditions Service plan to role out National Early Warning Score (NEWS) and sepsis training across their teams.

Readmissions to the acute setting from Caterham Dene Hospital

First Community has 10 high-dependency beds to manage and support patients who require more support and care.

We continue to monitor how many patients are readmitted to the acute setting and the reasons for this to understand if there is learning and improvements we can make. Learning has been that the support staff have to manage deterioration, Immediate Life Support training and the Deteriorating Patient training and National Early Warning Score 2 training, have been effective in escalating deterioration to the acute setting.

The chart below demonstrates that the number of re-admissions each month has not significantly changed.

The bereavement booklet is accessible on the First Community website and in paper form.

During the reporting period, we have provided training to promote the bereavement booklet, increase staff confidence and highlight the importance of having booklets on them. We have also ensured that booklets are now kept in paper notes so they are easily available and accessible, supporting staff to offer this at an appropriate time. Following identification last year that the syringe drivers are not always well stocks the nursing teams now regularly check the stock.

These actions have contributed to an improvement, demonstrating that the changes implemented have been effective. In the next reporting period, we will continue these measures and continually assess further opportunities to support staff.

We have also developed a bereavement questionnaire, which we plan to introduce in the next reporting period. The purpose of this questionnaire is to gather valuable feedback from families and carers, to help us gain a deeper understanding of their experiences. These insights will guide future developments and ensure our service continues to evolve in line with the needs of the people we care for.

Carers

Our staff have completed 67 carer's prescriptions during the reporting period which allows actions for carers to get in touch with them and offer support.

What next

• We will continue monitor the roll out of the Carers Passport by counting the number of views accessed from the Intranet;
• We will continue to provide information for staff on caring resources;
• We will continue to repeat the Carer Confident Scheme and Carer Survey to ensure we continue to improve.

The table below indicates how this compares to previous years.

Year	2021-2022	2022-2023	2023-2024	2024-2025	2025-2026
Number of carer's prescriptions completed	65	36	63	73	67

Complaints, compliments and Friends and Family Test

Friends and Family Test (FFT)

The NHS Friends and Family Test is a short feedback survey that asks patients to rate their overall experience of the care or service they received. It helps NHS services understand what is working well and where improvements are needed, based on patient experience.

During the reporting period we began to use artificial intelligence to summarise large amounts of feedback and send out summaries on a monthly basis to services who have had five or more reviews. Below is a summary that has been generated for one of First Community's community nursing teams:

1. Outstanding clinical and practical support

Patients describe the practitioners as:

• Extremely helpful
• Highly professional
• Skilled and attentive
• Able to identify needs quickly
• Effective at organising services and follow up care

Several comments emphasised that the support was life changing.

2. Being listened to and understood

A core theme:

• Staff truly listened
• Took time to understand patient and family needs
• Included family members in discussions
• Provided personalised advice rather than generic guidance

This was especially valued in home visits.

3. Home Visiting - Highly Appreciated

Patients and families were grateful for:

• Being seen in their own environment
• Practitioners seeing the full person
• Convenience for people with mobility issues
• Extra time taken during visits

Home visits are described as invaluable.

4. Emotional Support & Rapport Building

Many praised:

• Strong rapport with patients
• Kind, reassuring manner
• Ongoing support during difficult periods
• Feeling supported every step of the way

For some families, the support was essential to maintaining independence at home.

5. High Levels of Satisfaction Overall

Multiple comments stated:

• Nothing to improve
• Perfect
• We couldn't have managed without this service
• Life-changing support
• Overall satisfaction is extremely high.

Summary of Improvements

The vast majority of responses said:

• Nothing
• All fine
• Very happy with the support provided
• Cannot think of anything
•  Perfect

There were no recurring themes of concern.

The only minor observations:

• One response noted no improvements but described how valuable support had been.
• No operational, communication, or clinical issues were identified.

 

During the reporting period we have increased the number of services that use texts to get feedback. The following services are now set us to use this: Dietetics, Cardiac Rehabilitation, Community Physiotherapy, Community Stroke and Neuro Rehabilitation, Continence Team, Early Supported Discharge, Falls Team, Heart Failure Team, MND and Rare Neuro Nurse, MS Nurse, Parkinson's Nurse, Pulmonary Rehabilitation Team, Respiratory Nursing, Respiratory Physiotherapy, Speech and Language Therapy, MIU, and Urgent Community Response Team. This aligns with our sustainability plan and enables more opportunities for service users to provide feedback. We continue to ensure paper forms are available to ensure parity of feedback.

Services continue to set ambitions as to the number of reviews they receive. During 2026 / 27 we will use a dashboard that shows First Community's patient population to understand if the reviews are representative of our patient population.

FFT responses are displayed visually using a star rating.

The FFT question: Overall, how was your experience of our service?

Response options and star ratings:

What does the star rating mean?

• 1-2 star ratings are typically considered negative feedback and these trigger alerts for timely review and response.
• 3 star ratings are considered neutral.
• 4-5 star ratings indicate positive patient experience.

Free text comments alongside the star rating provide essential context and learning.

During the reporting period there have been 2639 4 and 5* reviews, 38 3* reviews and 45 1 and 2* reviews (some 1 and 2* reviews include positive feedback so it may be that the wrong star rating has been ticked, this is not uncommon due to many aspects such as digital interpretation, speed of completion, accessibility). There has been 187 recorded compliments (this is cards, emails and gifts) to services.

All 1 and 2* reviews are looked at for learning in a timely manner, learning has included reflection with staff on values and behaviours and developing information handouts and a Bluetooth clinic for audiology patients.

For the reporting period 76% of reviews were online and 24% were paper, compared with the reporting period for 2024 / 2025 when paper was 46% of responses and 54% were online. The shift towards digital FFT responses strongly supports sustainability objectives and aligns with the organisation's Green Plan. Increasing online responses significantly reduces paper consumption, printing, and physical distribution. This helps lower carbon emissions associated with paper production, transport, and waste disposal, while also reducing storage and administrative handling. Moving to digital feedback supports the Green Plan commitment to reducing environmental impact, improving resource efficiency, and embedding sustainable practice into everyday operations, while maintaining high levels of patient feedback.

Complaints

There has been a total of 20 formal complaints during the reporting period. There were 19 for 2024/2025. There has been a total of 43 informal complaints for the reporting period. There were 55 for 2024/2025.

Learning from complaints has included:

• Strengthening orthotics ordering and supplier assurance processes, improving proactive follow up with patients, and reinforcing holistic, patient centred clinical assessment and communication
• Reinforcement of holistic, patient centred assessments, including thorough history taking and listening to patients and families.
• Referrals and previous clinical information to be reviewed prior to consultations
• Clinicians reminded to clearly explain the structure of consultations and balance electronic documentation with effective verbal and non verbal communication
• Emphasis on involving families, explaining clinical decisions, and allowing time for questions and concerns.

 

We received 187 compliments during the reporting period:

At a time when we were shocked, heartbroken and frightened, you brought calm professionalism and overwhelming kindness, compassion and care and for that we are eternally grateful, you angels.

I want to thank everyone involved and praise their expertise.

Thank you all for all of your help and kindness whilst I have been at the Dene.

Audiology at First Community

First Community has held accreditation with the United Kingdom Accreditation Service (UKAS) since 2014. First Community have temporarily withdrawn from UKAS whilst future contracting requirements were discussed and clarified. This is now clear and First Community will reapply for accreditation in 2026 / 2027.

This scheme is managed and delivered by UKAS who are recognised by the Government, to assess against nationally and internationally agreed standards, contributing to quality outcomes for patients. We met all the standards and so were re-accredited in December 2024.

What our patients say:

Polite, friendly, running on time. I did not feel rushed at all.

The tips on background noises - very helpful.

I can hear-so amazing. Excellent friendly service.

My appointment was on time. The audiologist was clear and courteous. I received a hearing aid more advanced than expected. Many many thanks!

Audiology Patient Stories

A gentleman had severe to profound loss and has not had a set of adequate working aids for sometime.  When the audiologist fitted new hearing aids he struggled to converse and had moved to a care home because the decline in his cognitive ability.

The audiologist visited the gentleman when he had the new, working aids for a couple of months and the difference was significant.  He remembered the audiologist's name, shook their hand and had a discussion about the different ear mould type and the benefits of each.  His wife said since the hearing aids had been fitted they have been able to have really detailed and in depth discussions and it felt like he was coming back to her . 

An audiologist was able to visit a patient in their home who was at the end of their life.  Once fitted, the patient was able to communicate and enjoy time with their loved ones. 

Mixed sex accommodation at Caterham Dene Ward

There have been 0 mixed sex accommodation breaches during the year.

Community Forum improves services for local people

First Community Forum brings together people and organisations from across east Surrey to improve health and related services provided by First Community, with the aim of having an impact on the health of people living in east Surrey.

The forum is currently supported by over 30 voluntary sector organisations coming together to share information and developments. Some achievements for the reporting period are:

• Steady on Your Feet, was launched, a new comprehensive falls prevention solution developed for the NHS, Local authorities, Housing and healthcare providers to underpin fall prevention strategies and enhance falls pathways.  The site provides accessible information, plus a self assessment, that can be shared with family and friends and provides practical steps on how to reduce falling at home;
• Social prescribing in east Surrey, First Community is new provider of this service. This will lead on from the previous Wellbeing Prescription service and continue to support local people requiring a social prescription into hyper local services rather than frequently visiting their GP. The service will be aligned with neighbourhoods and is be supported by the Joy platform for case management, Joy marketplace and direct referrals from GPs via Joy Connect. Read later in the report for further information. 

Preventing conveyance to the acute hospital

We have continued our work to increase referrals from the South East Coast Ambulance Service (SECAmb) and NHS 111 to First Community's Responsive Services team to prevent people being conveyed to the acute hospital. First Community now have access to the SECAmb external stack portal (an electronic referral system between services) to be able to identify appropriate and safe referrals . This enables SECAmb to see what referrals are not accepted so they can ensure resources are used to make appropriate referrals.

This table shows referral numbers for the reporting period:

Month	Paramedic Referrals (2025/26 number)	Portal referrals reviewed
April 2025	27	20
May 2025	29	18
June 2025	28	14
Total Q1	84	52
July 2025	21	19
August 2025	26	17
September 2025	34	15
Total Q2	81	51
October 2025	32	19
November 2025	26	17
December 2025	42	18
Total Q3	100	54
January 2026	38	19
February 2026	18	24
March 2026	27	18
Total Q4	73	75

This SPC chart shows paramedic referral numbers for the past two reporting periods and shows the paramedic referral numbers to be stable with one period of special cause variation in January and February 2026 (an unexpected change in a process caused by a specific event) marked by a sharp spike well above the usual range.

18-week referral to treatment (RTT) targets - Audiology and Integrated Care and Assessment Treatment Service

Integrated Care and Assessment Treatment Service (ICATS) is for the assessment and treatment planning for people with musculoskeletal problems.

Audiology is for assessment and treatment for people with hearing loss and balance problems. During the reporting period:

• We have consistently achieved our target of 92% of patients referred to ICATS completing their treatment pathway in 18 weeks;
• We have not achieved our target of 100% of people referred to audiology completing their treatment within 18 weeks of their referral date, instead achieving 89 to 100% over the past 12 months in Sussex and 46% in Surrey. We are working across the region with NHSE to address the demand for audiology;
• We achieved our target of contacting 100% of people who referred to the Audiology service within six weeks.

Minor Injury Unit (MIU)

Demand for same day care has grown over the past year. In collaboration with local health and care partners, we have developed pathways to ensure that the patient receives the best experience from the most appropriate clinician and in a timely manner. Improved same day options from other services such as pharmacy and 111 has ensured that presentations at the minor injuries unit are able to respond and meet the needs of East Surrey residents who require an experienced nurse assessment and treatment. A recent audit demonstrated that only 4.5% of presentations within a one month period were redirected to the Emergency Department. 98% of these referrals originated from the streaming/ triage process indicating that the MIU is providing a suitable alternative to the Emergency Department.  As part of our monitoring and review of patient data, we noted an increase in patients requiring an x-ray as part of their assessment. Following the change in provision at the unit to see children over 5, the increase was largely due to appropriate X-ray of Children's limbs and digits following accident and injury. This review of X-ray provision has assured us that our clinicians are following best practice guidance and only requesting imaging when necessary, reducing unnecessary exposure to radiation. Patients registered with a neighbouring GP practice continue to be able to access the unit helping keep the acute hospitals available for those who need it most.

In April 2024 the MIU started to see children aged five and above for minor injuries.

The number of people visiting our MIU has increased and for the reporting period 2024 / 25 onwards includes children aged five and over.

Reporting period	2020/21	2021/22	2022/23	2023/24	2024/25	2025/26
Number of people seen	20,863	16,586	21,982	27,196	30,237	31,008

What people who use the MIU say:

The feeling in the MIU was one of calm with the reception staff very helpful. The lady clinician who examined me was very thorough and I didn't feel rushed. I was given advice to help promote my recovery which I found extremely reassuring. Overall the experience at Caterham MIU was outstanding. 

The service was very quick, from arriving, to leaving was only 2 and a half hours. In that time I was booked in, assessed, saw a doctor, X-rayed and had a cast put on. The staff were all very helpful and friendly/professional. Very impressed with the service delivered. 

The staff were really helpful, friendly and knowledgeable. Despite being really busy they didn't make me feel like an inconvenience.

Bed occupancy and length of stay on Caterham Dene Ward

Our target for bed occupancy is 95% to ensure we use our resources effectively. During the reporting period we met this target in 10 out of 12 months.

Month	April 2024	May 2024	June 2024	July 2024	August 2024	September 2024	October 2024	November 2024	December 2024	January 2025	February 2025	March 2025
Bed occupancy	96.07%	100%	96.31%	98.50%	92.05%	99.64%	95.39%	97.62%	99.65%	95.62%	99.49%	91.13%
Month	April 2025	May 2025	June 2025	July 2025	August 2025	September 2025	October 2025	November 2025	December 2025	January 2026	February 2026	March 2026
Bed occupancy	89.6%	86.3%	98.9%	96.7%	85.9%	73%	87.21%	77.5%	92.17%	91.01%	94.13%	93.78%

We measure the average length of stay at our inpatient ward to ensure we are rehabilitating people to return home in a timely way. We recognise the complexity of people's needs varies and this is reflected in the average length of stay each month.

Month	April 2024	May 2024	June 2024	July 2024	August 2024	September 2024	October 2024	November 2024	December 2024	January 2025	February 2025	March 2025
Average length of stay	23	29	24	27	25	25	35	29	30	31	28	33
Month	April 2025	May 2025	June 2025	July 2025	August 2025	September 2025	October 2025	November 2025	December 2025	January 2026	February 2026	March 2026
Average length of stay in days	37	30	32	37	35	26	26	31	28	26	24	34

Ageing well

A key achievement of our work around ageing well is the increase in people not being admitted to the acute setting (admission avoidance) due to being supported by our Responsive Services teams comprising of Urgent Community Response, Intermediate Care Team and Virtual Ward.

Referrals for admission avoidance continue to rise in First Community's Responsive Services teams as we develop and adapt pathways to meet the needs of the ageing community and support people to remain in their own homes when they are unwell. Services work collaboratively across the community and once patients have recovered from their acute episode with Responsive Services they are referred onto their Neighbourhood teams to support their longer term needs.

Part of ageing well is a timely discharge from hospital once a patient no longer needs inpatient care and the increase in referrals to Virtual Ward have enabled patients to be safely managed at home. Intermediate Care team have also been engaging with the acute hospital with the implementation of the Home first pathway. 

The Statistical Process Control (SPC) chart below tracks referral numbers from April 2023 to February 2026. The SPC chart shows that referral volumes increased significantly in late 2023, stabilised at a much higher level throughout 2024-25.

Council of Governors (CoG)  

The Council of Governors is an elected group of staff that represent shareholder views, opinions, ideas and concerns and acts as an interface between staff and the Board. Governors support the company's strategic areas of work to ensure that shareholder's interests are represented and designed into the solutions that we as a company generate.

First Community operates an opt-out shareholding model and to date no staff have opted out of being a shareholder.

CoGs portfolios in the past year have included:

• Resolving shareholder concerns;
• Raising the awareness of the role of CoG;
• Publicising the benefits of employee ownership to staff;
• Publicising the benefits of being a social enterprise to staff;
• Recruitment of an executive director and a non-executive director;
• Continuing to review how we hold the non-executive directors to account;
• Attending building user groups, committees, board meetings, and the staff survey working group to represent shareholders voice;
• Attending every induction day to speak about CoG and the benefits of being a shareholder;
• Sharing ideas with other community interest companies on how to maximise the benefits of employee ownership;
• Speaking at the Annual General Meeting;
• Seeking shareholder feedback on the visibility and effectiveness of CoG;
• Implementing actions to improve the visibility of CoG and its individual governors;
• Reviewing the data we collect to demonstrate our impact;
• Communicating key messages to shareholders directly via governors, and via First News, our weekly internal staff newsletter.

Duty of Candour

As an NHS organisation we have a statutory and contractual commitment to be open and honest with our patients when something goes wrong with their treatment or care causes harm. This includes an apology to the patient or the patient's carer or family.

First Community has undertaken four duty of candour conversations during the reporting period.

Patient and public involvement

We continue with our ambition to strengthen patient and public participation in all that we do to help us shape the way we provide care and services. We have continued to develop our network of people, known as the First Community Network, who are willing to be involved and share their perspectives and experience to help inform some of the work that is being undertaken by teams in First Community. This year we have reviewed the membership to ensure the network continues to be representative of those who would like to be involved and subsequently we now have 13 members.

This year, members of the First Community Network have contributed to four of our five priorities under the Patient Safety Incident Response Framework (PSIRF), and their involvement has been invaluable in helping us to reduce risk to patients. Another member of the First Community Network sits on our public involvement group, which now meets annually to review our activity related to patient and public involvement and set objectives for how we can continue to develop and improve within this area.

In addition to this, First Community Network has been involved in eleven additional pieces of work. Additionally, patients not on First Community Network were also involved in five further pieces of quality improvement work and are also regularly involved in After Acton Reviews on the ward to support the learning process.

We have one patient safety partner (PSP) who is currently working with First Community to be the voice of the patient in our safety governance framework. This PSP is a member of our group that oversees safety and quality governance. By attending this monthly meeting, they play a key role in supporting the organisation to understand what matters to patients by challenging and providing the group with an alternative viewpoint and being an advocate for people who use our services.

We aim to continue to progress further with our involvement work and build on the organisational culture where patient and public involvement is at the heart of everything we do as a matter of course. We aim to continue to promote patient and public involvement, with positive communication outreach to patient and staff, focusing on quality, not just quantity, of involvement.

Staff survey

First Community was delighted to again receive positive results from the staff survey 2025 results. Our response rate and ranking compared to other similar community organisations was very strong. We ranked second against all comparable community organisations where 3 of those were joint first.

66% of eligible staff completed the survey. The results of the annual staff survey showed that 73% of staff would recommend First Community as a place to work. 88% would be happy with the standard of care provided if a friend /relative needed treatment. 84% found that the care of patients and service users is the organisations top priority.

Equality, diversity and inclusion

Equality, diversity and inclusion (EDI) remains a key priority for First community and features explicitly in our business plan, both in terms of workforce and the patients and communities we serve. We have Two equality objectives for the period 2025-2027:

• Objective 1 To develop inclusive and compassionate leaders to support a diverse and representative workforce to continue to deliver outstanding care to meet the individual needs of our patients and communities
• Objective 2 All changes and improvements made to our services are taken with the needs of our population (using population health management insights) with meaningful consideration given to improve or address health inequalities.

Key steps towards achieving these objectives during the last year were:

1. Improvements in NHS staff survey 'recommend the organisation as a place to work' for disabled, lesbian, gay, bisexual and transgender/transsexual (LGBT+) and black, Asian and minority ethnic (BAME) staff, with all groups scoring better than the NHS average;
2. An increase in staff from ethnic minority communities working for First Community and reflective of the communities we serve;
3. The embedding of 'reasonable adjustment' flags within patient electronic records which enable professionals to personalise care when they see people with a disability.

Reach and Neurodiversity Network

The REACH (Race Ethnicity and Cultural Heritage) Network provides support and a safe space for staff who identify as part of the network (i.e., Black, Asian and Minority Ethnic) and holds First Community to account on its activities to make the organisation a more inclusive workplace for all staff.

First Community recognised as a finalist for Employer of the Year at Tandridge Business Awards 2025

First Community was recognised as a finalist in the prestigious Employer of the Year category at the Tandridge Business Awards 2025 on 15 October. 

The recognition highlights First Community's continued commitment to creating an inclusive, kind and rewarding workplace for its people, while delivering first-rate community health services across Tandridge.

Read more here: https://www.firstcommunityhealthcare.co.uk/blogs-news/first-community-recognised-as-a-finalist-for-employer-of-the-year-at-tandridge-business-awards-2025-1950

First Community achieves prestigious Pulmonary Rehabilitation accreditation

First Community has successfully achieved accreditation under the Pulmonary Rehabilitation Services Accreditation Scheme (PRSAS).

Following a rigorous assessment visit on 29 April 2025, the Pulmonary Rehabilitation service was recognised for meeting nationally recognised standards of excellence in the care and support of people living with long-term respiratory conditions.

The PRSAS accreditation is a highly respected quality standard that recognises services delivering safe, effective and patient-centred pulmonary rehabilitation. Achieving five-year accreditation is a significant achievement and reflects the dedication, professionalism and teamwork shown across the service.

Read more here: https://www.firstcommunityhealthcare.co.uk/blogs-news/first-community-achieves-prestigious-pulmonary-rehabilitation-accreditation-2035

Awards recognition for virtual care

First Community's Heart Failure and Frailty Virtual Ward services (part of the Surrey Heartlands and Doccla UK partnership) were shortlisted as a finalist for the Best Partnership Delivering Virtual Care category at the HSJ Partnership Awards on 19 March.

The partnership delivers virtual care across the region and is focused on enhancing patient care, reducing hospital pressures, and allowing patients to recover safely at home.

Their work for heart failure admission avoidance proactive monitoring, has seen more than 140 people living well, with heart failure reassured by virtual monitoring. Many of these patients are aged over 65 years, busting the myth that older people cannot use technology.

Read more: https://www.firstcommunityhealthcare.co.uk/blogs-news/awards-recognition-for-virtual-care-2106

Speaking up: Raising concerns

The freedom to speak up guardian is an important role identified in the freedom to speak up review to act as an independent and impartial source of advice to staff at any stage of raising a concern. The freedom to speak up guardian is available to anyone with access to anyone in the organisation, including the chief executive, or if necessary, outside the organisation.

First Community staff can speak up or raise concerns by phone, in person or by email to one of the following:

• Line managers;
• The chief executive who has board responsibility for speaking up;
• The non-executive director with responsibility for speaking up;
• Floor to Board in five minutes (any of the executive or non-executive directors);
• Chair of the board;
• The clinical governance manager;
• The People team;
• Council of Governors (with additional freedom to speak up ambassador role);
• Adult safeguarding lead;
• Children's safeguarding lead;
• Local counter fraud specialist or director of finance for fraud concerns;
• Union representative;
• REACH (race, ethnicity and cultural heritage) network chair.

Board oversight of freedom to speak up

• The Board is given high level information about all concerns raised by our staff and what we are doing to address any problems;
• The freedom to speak up guardians have developed a dashboard that collates themes from all of the speaking up avenues in First Community. This and this is reported through our governance framework annually;
• The Board supports staff raising concerns and the freedom to speak up guardians, with the chief executive providing direct support as the executive lead for speaking up;
• During the reporting period there have been seven freedom to speak up issues raised. The table below shows the number of cases raised for the past five reporting periods. The FTSUGs have worked to increase their visibility and colleague's understanding of the role, which may account for the continued increase in numbers. The FTSUGs remain vigilant of the themes and numbers of people speaking up so timely actions can be taken if required.

2025/2026	2024/2025	2023/2024	2022/2023	2021/2022
9	9	4	3	4

Staff survey and speaking up

A Freedom to Speak Up sub-score (called the Raising Concerns sub-score in NHS Staff Survey reports) has been calculated since 2021 and can be used as a benchmark. The Freedom to Speak Up sub-score in the 2025 NHS Staff Survey has fallen nationally to 6.37 compared to 6.45 in 2024. First Community's sub score is 7.53 which has also fallen from 7.89 in 2024. 

First Community has seen a fall across all of the speaking up questions. The freedom to speak up guardians will be taking a deep dive into the results to understand more about the speaking up culture at team level to enable us to focus our work in 2026 /27.

• 85% of First Community staff reported they would feel secure raising concerns about unsafe clinical practice compared to 87% in 2024;
• 81% of First Community staff reported that they would feel confident the organisation would address concerns about unsafe clinical practice compared to 85% in 2024;
• 80% (compared to 83% in 2024) of staff reported they felt safe to speak up about anything that concerns them in the organisation;
• 72% of staff reported that if they spoke up about something that concerned them, they would be confident the organisation would address their concern, compared to 81% in 2024.

Sustainability Strategy - Green Plan

In June 2022, First Community launched its Green Plan, setting out the organisation's commitment to delivery and describing our approach to 'Care Without Carbon', in line with NHS England's climate change strategy 'Delivering a Net Zero National Health Service'. It includes targets to reach Net Zero Carbon (NZC) by 2040 for direct emissions, and 2045 for indirect emissions.

To deliver sustainable healthcare, First Community is working firstly to minimise the need for healthcare activity; to reduce its environmental or health impact, whilst at the same time improving health outcomes. 

This is reflected in the organisation's sustainable healthcare principles: 

1. Healthier lives: Making use of every opportunity to help people to be well, to minimise preventable ill- health, health inequalities and unnecessary treatment, and to support independence and wellbeing. 
2. Streamlined processes and pathways: Minimising waste and duplication within the organisation and wider health system to ensure delivery of safe and effective care. 
3. Respecting resources: Where resources are required, prioritising use of treatments, products, technologies, processes and pathways with lower carbon, environmental and health impacts. 

We have established sustainability across the organisation and made substantial progress across all the elements of our Green Plan; our key successes are highlighted in our Green Plan.

How have we engaged with staff:

• The behaviours framework has been refreshed and includes sustainability recommendations under 'transparent and accountable'.  
• Integrated sustainability into our staff induction marketplace and online training for all staff.
• Urgent Community Response team (UCR), Physiotherapy, Dietetics, Infection Prevention and Control and digital transformation are now engaged in streamlining processes and improving care in a sustainable way; 
• Salary sacrifice car scheme - provides the option of electric cars, and hybrids based on individual circumstances.  
• Recruited green envoys to support the work in the Green Plan.
• We have encouraged staff to challenge their processes and ways of working, to look for efficiencies and cost savings.
• Launched a staff travel survey which will be repeated every year;.
• Weekly news articles, training, and webinars in First News (staff internal newsletter), in line with National Campaigns and our own internal communications plan.

Successful projects from our internal teams:

• The dietetics team have successfully trialed a scheme reducing the impact on sustainability for enteral feeding equipment (syringes), resulting in cost savings of £14,800 per year and 1383 kg saving of carbon. This equates to 32 road trips to Edinburgh or 132 hospital operations.  See news to access the full article. 
• To glove or not to glove campaign was launched to reduce the unnecessary use of non-sterile disposable gloves for patients; See news to access the full article. 
• Tiger bags for our offensive waste defined as 'non clinical waste' reducing our orange waste from 93% in Feb 24 to 4%, with offensive (tiger) bag use now up to 90% of our health care waste. See news to access the full article. 
• Musculoskeletal (MSK) physiotherapists have encouraged sustainable travel for patients and offer online sessions and exercise rehabilitation programs, reducing the need for face-to-face appointments. See news to access the full article. 

What have we Introduced:

• Battery collection points across our sites;  
• Improved utility reporting across our sites to help us to calculate our carbon footprint and reach our target for carbon emissions. 
• non offensive waste stream at Caterham Dene, reducing our levels of clinical waste and the need for rubbish to be incinerated at high temperatures.
• Sustainability award in our annual staff awards;. 
• Electric bike for staff travel
• We are fully engaged with our sustainability colleagues in the local Integrated Care System (ICS), Surrey Heartlands, and with our local authorities Reigate and Banstead Borough Council and Tandridge District Council
• Updated new supplier forms to align with Evergreen requirements, to allow for better quality data to be collected from our new suppliers; 
• Established a health and wellbeing strategy that aligns with the Green Plan. 

Looking ahead: The launch of our new 2026 green plan demonstrates and shows our success so far. It will also support and guide us on the next phase of our sustainability journey.