Provide Community Interest Company

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

Letter from the Chief Inspector of Hospitals

Provide Community Interest Company is a community social enterprise, which cares for patients across a wide range of services, delivered from 54 sites. They work from a variety of community settings, such as three community hospitals, community clinics, schools, nursing homes and primary care settings, as well as within peoples’ homes to provide over 50 services to children, families and adults. The service provides services across Essex and in Peterborough and Cambridgeshire, as well as the two London boroughs of Waltham Forest and Redbridge. Provide employs approximately 1,100 staff, serving a patient population of more than one million

This was the organisations first inspection under the current name using our comprehensive inspection methodology. We had previously inspected this organisation under its previous name Central Essex Community Services (CECS) that changed to Provide in September 2013 during our pilot-testing phase in 2013 but we did not publish any ratings.

There had been two compliance action issued against this provider at the time of our last inspection, these were issued under 2010 regulations, which were superseded by new regulations in 2014. Compliance actions are now known as requirement notices. In our 2013 inspection we found that the service provided was not meeting legal requirements and we set two requirement notices in relation to:

• Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.The provider did not protected people by means of an effective operation of systems to identify, assess and manage risks relating to the health, welfare and safety of service users.

• Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.The provider did not ensured that at all times there are sufficient numbers of sufficiently qualified, skilled and experienced persons employed for the purpose of carrying on the regulated activity.

We carried out this comprehensive inspection between the 12 and 15 December 2016. We also carried out an unannounced inspection on 22 December 2016.

We inspected the following core services:

• Community health services for adults
• Community health services for children, young people and families
• Community end of life care
• Community health inpatient services

We did not inspect the following Primary Medical Services at the time of this inspection

• Steeple Bumpstead Surgery.

Overall, we found the organisation was performing at a level, which led to the judgement of good, with some elements of outstanding. We inspected four core services all were rated good overall

Our key findings were as follows:

• A culture of putting the patient first was evident throughout the organisation.
• Staff were committed to providing and ensuring patients received a good care and treatment.
• Across the organisation, we found staffing levels were generally meeting the needs of patients, we received very little feedback from staff that staffing levels were of concern to them. Similarly, we did not receive feedback relating to concerns about staffing levels from patients, relatives or carers. There were some staffing vacancies but these were being appropriately managed.
• Patients could access the right care at the right time, including those with urgent needs. The organisation was achieving all of the referral to treatment times.
• Services were plan and delivered in a way that met the needs of the local population. The different needs of patients were taken into account and we saw that the service was meeting the needs of meeting the needs of patients in vulnerable circumstances such as those living with dementia.
• We observed staff to be complying with best practice with regard to infection prevention and control policies.
• There were infection prevention and control policies and procedures in place, which were readily available to staff on the organisation’s intranet. Infection prevention and control was included in the mandatory training programme and high numbers of staff across all core services had completed this.
• There had been no MRSA bacteraemias since April 2015.
• Recent patient led assessment of the care environment (PLACE) data that demonstrated a high compliance rate of cleanliness in the ward areas of 99.82%, which is above the national average of 98.1%.
• Without exception, patients were treated with kindness, compassion, dignity and respect throughout all of the services we inspected and feedback from patients, families and carers was consistently positive about the way staff treated them.
• Our inspection teams across all core services found that local team leadership was effective. Without exception, staff we spoke with said their line managers supported them and local leaders were visible and approachable.
• We found an open, honest and supportive culture with staff being very engaged, open to new ideas and interested in sharing best practice.
• Morale was mostly good throughout the organisation. The majority of staff were happy in their jobs and liked working for the organisation.

We saw several areas of outstanding practice including:

• The specialist healthcare team delivered child specific training to professionals and carers. This service contributed to the safety, health and wellbeing of children with complexed needs across mid Essex.
• There was a sensory room at Moulsham Grange clinic, which provided a stimulating environment for children with additional needs. Parents could reserve a time slot for their child to use at the families convenience. Parking was directly outside of the clinic to enable easy access to the external ramped entrance.
• Therapy staff at Moulsham Grange clinic used motorised wheelchairs to teach children’s motor functions. Staff offered children with mobility issues the opportunity to move when other children were developing and learning to walk.
• Lone working devices, which looked like a car fob, had a panic button and Global Positioning System (GPS) tracker, had been introduced, which improved the safety of staff working alone in the community.
• The speech and language therapy team utilised skype and facetime for patient consultations, which was more convenient for the patients, meant speech, and language therapy staff saved travel time.
• At Courtauld Ward, we observed staff arranging for a packed lunch, bread and milk to be sent home with a patient who was being discharged that day.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service

We rated the services as good overall because:

• Systems and processes were in place to protect people from harm. Staff reported and investigated incidents and managers shared learning across the organisation.
• Staff understood their role in safeguarding patients and robust policies and procedures were in place to support them.
• Premises and facilities were visibly clean and managers/staff implemented infection prevention and control measures in the areas we inspected.
• The organisation had clear business continuity plans in place to avoid disruption to services and we found staffing levels to be adequate to deliver safe services.
• Evidence based practice was implemented across the services we inspected and patient outcomes were measured benchmarked and contributed to improvements in patient care.
• Multidisciplinary teams worked well together, all staff had the skills and expertise to deliver effective care and treatment. Referrals were managed effectively through central point of access systems.
• Systems were in place for transferring care to other services and providers and discharges were planned with the patient carer and members of the multi-disciplinary team.
• Staff had access to the information they needed to deliver effective care and understood the Mental Capacity Act and Deprivation of Liberty standards.
• We found patients were cared for with compassion, dignity and respect. We observed staff interactions were caring, kind and respectful. Patients and carers all spoke positively about staff.
• Staff supported patients to manage their own health and wellbeing and carers were involved in decision making when appropriate.
• The organisation planned and delivered services to meet the needs of people. Systems were in place to ensure people were treated equally and could communicate effectively.
• The care of the most vulnerable and complex patients was managed by community matron. Patients could access services easily. Appointments and visiting were flexible to suit the needs of patients and carers.
• Care and treatment was prioritised according to need with the most urgent cases being seen within four hours.
• Staff managed complaints effectively and staff and patients knew about the complaints process.
• Staff shared and understood the organisation’s vision and values. Staff felt involved in the decision-making and development of services.
• Comprehensive governance structures were in place. Risk registers reflected current risks and the board received assurance on the quality and performance of services through regular, accurate and up to date reports.
• Leaders demonstrated capability and had capacity to perform effectively; they valued staff and staff felt supported.
• The organisation had a caring culture and could be open and honest and raise concerns easily. The organisation was attentive to the health and well-being of staff and systems were in place to keep staff safe at work.
• Public and patient engagement was important to the organisation and methods were in place to gather people’s opinions.
• Staff were invited to complete a survey annually and the results were discussed at board level. The organisation was innovative and continually looked for ways of improving the service.

However we also found:

• Some medication administration records did not have patient allergy/sensitivity status recorded.
• We found medication and stock items were out of date in one location, which staff immediately removed.
• The integrated care team service specification was out of date and the central point of access service did not have a voice recording system in place.
• The organisation did not routinely monitor restraint or consent processes.
• Where ‘did not attend' appointments were raised, we did not see action plans to reduce these.

Overall rating for this core service

We rated the specialist children’s service and the children’s public health service as good because:

• There were arrangements to minimise and mitigate the risks to children and young people receiving care.
• The organisation had met the 2015 staffing target in response to the National Health Visitor Implementation plan. The National Health Visitor Implementation Plan ‘A Call to Action’ aimed to expand and strengthen Health Visiting services.
• Staff met the organisations mandatory level three safeguarding training target of 95%. There was a good awareness of safeguarding procedures, which meant staff had the ability to protect children and young people from abuse and avoidable harm.
• Staff reported and investigated Incidents appropriately; however, learning from incidents was inconsistent.
• There were care pathways and transition arrangements for young people with complex care needs moving to adult services.
• Staff had achieved the organisations target (90%) for appraisals, meaning staff had their learning needs identified and/or supported to undertake training and development.
• There were policies and procedures in place to support staff and ensure they delivered services effectively and efficiently.
• We saw effective multi-disciplinary working including with external partners and good arrangements around consent.
• Staff treated children, young people and their families with dignity and respect and were involved as partners in their care.
• Staff provided children with Information about care and treatment in such a way they could make informed choices.
• Staff were dedicated to achieving the best care for their patients and worked hard to achieve this.
• Emotional support was available for patients in need. Staff were compassionate, committed and flexible to meet the needs of their patients.
• Services were planned and delivered for children and young people, to meet the needs of the local population.
• Services were flexible and staff took into account the needs of different people.
• The service had a clear vision and strategy.
• We found a positive, patient-focused culture, leaders were supportive and staff felt valued.

Overall rating for this core service

We rated community health inpatient services as good because:

• There was a good culture of incident reporting. There was evidence lessons were learnt from incidents in order to improve patient safety, and safety performance was monitored monthly.
• Staff had received appropriate safeguarding training and was aware of their responsibility to safeguard patients from abuse. Patients consent was sought before care was given, and staff applied the Mental Capacity Act and deprivation of Liberty Safeguards appropriately. Staff had taken actions to improve the care and treatment provided for patients living with dementia
• Equipment, including resuscitation equipment, was readily available. There was a system in place for the repair, servicing and maintenance of medical equipment.
• Patients’ care records were complete, up to date and stored securely. Risk assessments were carried out for patients and steps taken to reduce risks.
• The organisation was addressing the vacancies within the nursing establishment and had taken action to reduce the risk.
• Effective multidisciplinary working supported coordinated care delivery, which was evidence based and reflected national guidance.
• Patients’ pain was well managed. Patients had their nutrition and hydration needs assessed and met, however protected mealtimes were not implemented fully.
• There was programme for audit and patient outcomes were measured. Generally, these outcomes were positive.
• Staff education and professional development was supported and staff undertook regular clinical supervision.
• All patients we spoke with were overwhelmingly positive about the care and treatment they had experienced. Patients told us that staff were kind and friendly, responded quickly to their needs and that nothing was too much trouble for the staff.
• Patients were treated with dignity and interactions we observed between patients and staff were consistently respectful and compassionate, with staff taking time to support, listen and reassure.
• The organisation sought regular feedback from patients through the patient experience survey and this feedback was positive.
• Patients had timely access to minor operations and podiatric surgery.
• Services were designed to provide rehabilitation, admission avoidance and end of life care with clear pathways and processes in place for the admission and discharge of patients.
• The service had few complaints, with staff being encouraged to resolve complaints and concerns locally.
• There was a clear strategy and vision for the service and staff were familiar with the organisation’s values.
• There were effective governance arrangements in place to monitor quality, performance and patient safety.
• Leadership was effective and staff we spoke with said their line managers, who were visible and approachable, supported them.

However:

• Formal apology letters had not been sent, in line with the duty of candour regulation, to patients and families when things had gone wrong with their care and treatment.
• Patients’ observations and national early warning scores (NEWS) were not always recorded appropriately and the correct escalation was not always followed in line with the organisation policy, this did not put patients at significant risk as they were deemed fit. The service was taking steps to address this and local audits showed signs of improvement.
• Hand washbasins in the patients’ rooms at St Peter’s Ward were not compliant with regulations set out in the Health Building Note (HBN) 00-09 Infection Control in the Built Environment.

We rated end of life care as good overall because:

• Openness and transparency about safety was encouraged.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and where incidents had been raised actions were taken to improve processes.
• Safeguarding was given sufficient priority. Staff had a good understanding of how to protect patients from abuse. Staff described what safeguarding was and the process to follow if they suspected a patient was at risk of avoidable harm or abuse.
• Arrangements to minimise risks to patients were in place with measures to prevent falls, malnutrition and pressure ulcers. We observed staff followed good infection and prevention control practices.
• Staff recognised and responded to the changing needs of patients with anticipatory medications readily available and care needs assessed and reviewed appropriately.
• Specialist equipment needed to provide care and treatment to patients in their home was appropriate and fit for purpose so that patients were safe. Syringe drivers were mostly maintained and used in accordance with professional recommendations.
• End of life care was planned and delivered in line with best practice guidance. Care and treatment was planned and delivered in a personalised and holistic way and care plans took into account patients health and social care needs.
• Our observation of practice, review of records and discussion with staff confirmed there were effective multidisciplinary team (MDT) working practices. Staff worked collaboratively to understand and meet the range and complexity of patients’ needs.
• Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
• We observed a holistic person-centred approach to patient care. Patients were treated with compassion, kindness, dignity and respect.
• Without exception, feedback from patients and relatives was positive.
• Without exception, staff were not only committed to providing sensitive care to patients, but also for the well-being of their families.
• Staff provided emotional support for patients and their families, and signposted them to other sources of support where appropriate.
• As part of the care provision for children with palliative care needs, the provider delivered respite care services for Essex Palliative Integrated Care Children’s Respite Service (EPIC). EPIC was part of Provides children’s specialist services business unit and sat within the children’s specialists services.
• The provider engaged with external organisations and the local community to ensure the services met the needs of patients and those close to them who required end of life care.
• Patients could access the service in a timely manner that suited their individual needs.
• Data provided by the trust showed the end of life care service received one complaint between November 2015 and November 2016 specific to the service.
• The leadership, governance and culture mostly promoted the delivery of high quality person-centred care.
• The locality leads, clinical nurse specialists and community staff were able to articulate the purpose of their service, to provide care and support for patients in their last year of life, and their role within the integrated locality team. All staff, including very senior managers understood the importance of end of life care.
• There were good governance structures in place for end of life care through the integrated governance structure.
• The lead for end of life care was visible, and there was good local support and leadership for end of life care. Staff had confidence in their managers to ensure training and expertise knowledge was available to improve end of life care experiences for patients and those who were close to them.
• There was good public and staff engagement throughout end of life care services.

However;

• There was no safety performance dashboard related to end of life care. This meant there was no visual aid to advise staff. A dashboard is a toolset developed by the National Health Service (NHS) to provide clinicians with relevant and timely information they need to inform daily decisions that improve the quality of patient care. The toolset gives clinicians access to data that is being captured locally, in a visual and usable format. The safety dashboard displays local relevant safety information alongside relevant national data.