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Inspection Summary


Overall summary & rating

Updated 22 June 2017

Nutricia Homeward is part of Community Health Care (Nutricia Limited) which provides services for adults and children who have specialist feeding requirements. The organisation supplies and delivers nutritional feeds and provides nursing support for patients with feeding tubes. Community Health Care (Nutricia Limited) call their enteral feeding and nursing service Nutricia Homeward. Nutricia Homeward services are specific to patient nutrition. This report includes the Community Adults service and also reports on the services delivered to children and young people in the community, where appropriate.

NHS trusts, Clinical Commissioning Groups and independent health providers negotiate services with the organisation to form a contractual agreement. The organisation then deliver services under a service level agreement. The NHS trust or independent health providers who have commissioned these services retain overall responsibility for healthcare delivery to their patients and allocate a managing health care professional for each patient. This managing healthcare professional liaises with the organisation about the level of service and specific needs of each patient. The organisation and the managing health care professional coordinate the delivery of care for the patient regarding enteral feeding.

Nursing staff provide nursing care, support and training about enteral feeding for patients, their families and carers. This is in line with the service level agreement with the NHS Trust or independent health provider. The regulated activities for the organisation are to provide patients with treatment of disease, disorder or injury.

As of March 2017 Nutricia Homeward was supporting 22,797 patients in England. Of these 13,544 (59.4%) were adult patients and 9,253 (40.5%) were children and young people.

We found the following areas of good practice:

  • Competency training for nursing and call centre staff equipped them to carry out the functions of their roles. Staff felt supported and valued by their managers.
  • Staff followed policies and protocols to prevent and control infection.
  • Staff showed respect to patients and their carers giving time and explanations which were suitable for their needs. Children were treated appropriately for their age and responses by the nurses to support them during emotional upset showed a clear understanding of children’s needs.
  • There was good multi agency working. Nursing staff were clear on their scope of practice and when they needed to liaise with other health professionals.
  • The organisation supported patients to maintain as much independence as they could. A travel and holiday service helped patients plan trips both in the UK and abroad.
  • Staff showed a comprehensive understanding of best practice when it came to obtaining patient consent for both adults and children.
  • Staff were flexible in the care they provided giving time to patients when they needed it, treating patients with sensitivity and compassion.
  • The organisation showed commitment towards continual improvement. They engaged with service users to gather feedback on how to improve services for their patients and acted on information they received; collaborated with other healthcare professionals to research improvements in care; used secure mobile technology to improve the services provided for patients.

However, we also found the following issues that the service provider needs to improve:

  • Some staff were not aware of the impact that reporting incidents and near misses could have on patient safety. They were not always aware of what type of incident or near miss needed to be reported.
  • Some staff seemed unsure of what constituted a safeguarding concern and how to report it without their manager’s support.
  • There was no written information about procedures that was suitable for patients living with learning disabilities or dementia. Staff adapted the information used for children.
  • There was some governance of procedures to promote patient safety but overview at a senior level was not embedded. However, processes were being developed to improve oversight.
  • Fit and proper person processes and procedures were not robust.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We issued the provider with two requirement notices that affected the adults and children’s services. Details are at the end of the report.

Inspection areas

Safe

Updated 22 June 2017

We found that;

  • Nurse staffing was appropriate for their caseload of patients. Nurses were able to give time for each visit as the patient needed.

  • Nurses followed best practice infection prevention and control procedures in the community.

  • Staff underwent a comprehensive training and induction programme to allow them to operate as enteral feeding specialist nurses, which included an ongoing programme of validation. Staff were 100% compliant with mandatory training.

  • Nursing staff were trained in safeguarding of adults and children to an appropriate level for their roles.

  • Nurses arranged their stock of equipment to deal with common problems on their visits. This prevented disruption for the patient.

  • Any learning from incidents was taken seriously and used to improve practice.

  • Equipment was properly maintained and suitable for use by the patient.

  • Patient records were kept securely and completed in a timely way. Quality of records was audited with actions taken if any were below an agreed standard.

  • The organisation developed a system to support patients at times of severe weather and supplied an additional week of feed supply.

  • Patient risk was assessed and responded to appropriately with the managing healthcare professional being informed of any problems.

  • There was an open and honest culture in the organisation although some staff were not aware of legal requirements of duty of candour.

However;

  • Some staff were unsure of what should be reported as an incident or near miss. This meant there was poor oversight of incidents occurring in the community and learning opportunities missed. However, incidents that were reported were thoroughly investigated and learning shared.

  • Some staff were unsure of what would need to be reported as a safeguarding concern and there were no formal arrangements for staff to engage in safeguarding supervision. However, staff were able to seek support from safeguarding leads who would advise on appropriate actions.

Effective

Updated 22 June 2017

We found that;

  • Available best practice evidence was used to provide care for patients. The organisation was committed to using evidence to drive improvements in their service.

  • Nursing staff were clear on their scope of practice and knew what they were contracted to do.

  • There was clear and meaningful multidisciplinary working between the service and other healthcare providers to ensure patients received appropriate care.

  • The organisation was committed to reducing patients being admitted to hospital for procedures that could be safely performed in the home. Managers and nursing staff were working with specialists in gastroenterology to research and develop evidence that supported reduced hospital admissions.

  • Relevant information was available for staff who were involved in patient care in a timely way and included those outside of Nutricia Homeward.

  • Technology was used to improve systems that supported staff to provide more timely care for patients and information sharing with professionals. This included texting services and mobile devices for electronic record keeping.

  • Staff showed a comprehensive understanding of best practice when it came to obtaining patient consent for both adults and children.

  • Staff were actively encouraged to maintain their competencies and were monitored by their managers with support to complete nursing revalidation.

However;

  • Monitoring of patient outcomes at a senior level was limited. Senior managers were in the process of developing systems which would monitor patient outcomes in more detail.

Caring

Updated 22 June 2017

We found that;

  • Staff adapted the way they communicated with patients and relatives in line with their individual needs, and provided additional training and support where people needed extra help.

  • Staff used play specialists to help anxious children cope with the care and treatment associated with their tubes.

  • Nursing staff were sensitive to children’s needs and used skills to enable children to cope with the procedure.

  • Staff acknowledged when patients and relatives were not coping with their tubes and pumps, and tailored their training to suit the patient.

  • Information was given to patients in a way they could understand.

  • Patients felt supported and were overwhelmingly positive about the care they received.

Responsive

Updated 22 June 2017

We found that;

  • Contracts with each individual organisation were monitored by Nutricia Homeward. Where targets were not being met, the organisation investigated and identified the specific reasons why.

  • Treatment was only delayed or cancelled when absolutely necessary and reasons were clearly explained to patients. Nursing staff were flexible in providing care depending on the patient’s needs at the time of their visit. Patients had access to a support service out of normal working hours and troubleshooting visits were arranged as the patient required.

  • Services helped patients to remain as independent as they could and equipment was provided to support patient lifestyles. A travel and holiday service helped patients plan trips both in the UK and abroad.

  • Staff were aware of cultural and religious needs and were able to provide nutrition in a way that suited individual patients’ beliefs.

  • Nurses contacted and visited patients in a timely way when they were due for discharge from hospital. They also ensured the managing health care professionals had information about the care they provided to the patient and any changes that were observed.

  • Complaints procedures were clear for patients and were investigated with responses sent to complainants within 10 working days.

However;

  • Staff did not have access to written information or leaflets for patients with learning difficulties or dementia. Instead, picture and children’s guides were adapted for these patient groups.

Well-led

Updated 22 June 2017

We found that;

  • There was focussed commitment towards continual improvement and innovation at all levels.

  • There was a clear strategy and vision and investment in the service was taking place to improve support to staff and care to patients

  • The service actively sought and was responsive to feedback from patients, staff and external stakeholders, taking action where they could.

  • Managers were visible, approachable and accessible to all staff, and welcomed engagement.

  • All staff we spoke with were proud of the service they delivered and positive about working for Nutricia Homeward. They felt valued and supported by every level of manager.

  • The organisation was keen to collaborate in research that would improve services and sustainability of the service.

However;

  • Oversight of safety and clinical governance was not embedded at senior staff and director level. A process had been instigated within the previous 12 months but it was not robust.

  • Processes to ensure staff at director level were fit and able to perform their tasks were not robustly enforced according to the Fit and Proper Persons Requirement (regulation 5) of the Health and Social Care Act 2014.

  • Requirements of the workforce race equality standard were not being fully met.

Checks on specific services

Community health services for adults

Updated 22 June 2017

  • Staff followed policies and protocols to protect patients from experiencing avoidable harm.

  • Training for staff was effective and thorough to enable them to fulfil their roles.

  • There was good multidisciplinary working. Nursing staff were clear on their scope of practice and when they needed to liaise with other healthcare professionals.

  • Staff showed a comprehensive understanding of best practice for obtaining patient consent.

  • Staff responded appropriately to the needs of patients and their carers.

  • Treatment was only delayed or cancelled when absolutely necessary.

  • Where targets were not being met, the organisation investigated reasons why.

  • Patients were supported to be independent.

  • There was focussed commitment towards continual improvement and innovation using patient feedback and conducting research.

  • Managers were visible, approachable and supportive.

However;

  • Staff were unsure of what should be reported as an incident or near miss.

  • Staff were unsure of what a safeguarding concern would be.

  • Staff did not have access to written information for patients with learning difficulties or dementia.

  • Some governance of the procedures for patient safety were in place but more detailed procedures were in development.

  • Fit and proper person processes for director level and were not robust.