Provide Community Interest Company

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment we rated this key question good. At this assessment the rating has remained good. However, the service was in breach of the regulation for safe care and treatment. The service did not always make sure that medicines and treatments were safe, available, and met people’s needs, capacities and preferences.

However, patient areas were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

There were systems in place for the recording of incidents and immediate actions taken to address these. The service had an incident reporting and management policy, which was last updated in February 2025. This policy outlined the processes for reporting, investigating and learning from incidents. Staff recorded incidents on an electronic incident reporting system and clearly in line with provider policy.

Since 2023, the organisation had implemented the Patient Safety Incident Response Framework (PSIRF) to ensure incidents were investigated appropriately and learning was captured and shared. All incidents were recorded in the incident reporting system, with harm levels reviewed, outcomes documented, and actions taken.

Near misses and low-harm incidents were managed locally within two weeks, with learning shared with relevant teams and swarm huddles held where appropriate.Moderate harm incidents were reviewed by senior management and the quality and safety team at the incident review panel.Action plans arising from incidents were monitored at the monthly quality reference group, a subcommittee of the quality and safety committee, to ensure actions were completed and embedded. Severe harm incidents and deaths were escalated through the incident process for formal investigation and management.

The service used data from their incident reporting system to identify and analyse themes and trends across all wards. Between 1 October 2024 and 17 October 2025, there were no serious incidents or severe harm incidents reported across the wards.

Halstead Ward reported one moderate harm incident relating to a prescribing error, which was reviewed at the Incident Review Panel (IRP). The Duty of Candour process was applied, and learning was shared with the ward team.

In addition, there were 10 no or low-harm incidents relating to patient falls, which were reviewed by the IRP. Swarm huddles were held following each fall to analyse causes, identify learning, and implement actions to reduce patient risk.

During the reporting period, Bayman Ward recorded a total of 28 incidents. All incidents were reviewed at the IRP where there were 20 falls-related incidents, 13 no-harm, 6 low-harm and 1 under review incident (harm level to be confirmed). Learning identified that the volume of fall alarm alerts were not sufficiently loud to be heard outside of the patient’s bed space, potentially delaying staff response. This learning was shared with all staff via the IRP bulletin to support awareness and improvement in falls management.

In April 2025, the quality and safety team completed a deep dive of falls to identify themes, learning and to prevent occurrence. The deep dive aimed to analyse contributory factors, assess the effectiveness of existing falls prevention measures, and identify opportunities for improvement across both wards.

The service had effective processes in place for learning from incidents and complaints which were shared with staff. Staff told us they had received feedback following safety incidents and where actions had been taken. Ward managers shared learning during handover periods and ward meetings to provide timely feedback to staff. Monthly ‘Lunch and Learn’ webinars were held to disseminate learning from incident themes, trends, complaints, and other learning events. Senior leaders also published a learning bulletin on the staff intranet, summarising key themes from IRPs to promote wider organisational learning.

Incidents and trends were reviewed weekly at health senior leadership team meetings to ensure any incidents of concern were addressed promptly and appropriately. The learning from deaths forum provided oversight of all deaths and facilitated shared learning from these reviews.

The service also shared learning from incidents with external organisations involved or identified as the source of the incident, supporting system-wide learning and safety improvement. The chief nurse and chief executive officer for health shared incidents of concern weekly with the executive leadership team to ensure appropriate governance and oversight.

For all incidents, a consideration of duty of candour was reviewed and acted on as appropriate.

We scored the service as 3. The evidence showed a good standard. The service worked with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. They ensured continuity of care, including when people moved between different services.

The service worked closely with system wide partners across the community collaborative made up of Provide, Essex Partnership University Trust, and Northeast London Foundation Trust to manage system flow across intermediate care and stroke beds.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The service had a standard operating procedure outlining the referral, admission and discharge process from and to the service. Managers demonstrated a clear admission and exclusion criteria that they used prior to accepting admissions to the wards. This ensured bed use was maximised and there was a daily focus on discharge in daily system flow meetings to maximise capacity. We observed a system flow meeting where partners worked collaboratively together to ensure effective system flow and capacity between services in the local system.

Staff considered risk and prioritised patients individual needs and pathway journeys when making decisions together about referrals, admissions and discharges. The service published their bed vacancies daily, which allowed system partners to review them.

Patients outside the established admission criteria were reviewed and considered for admission when there were empty beds on the wards. Short stay patients were prioritised when the system was under pressure.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Our review of records from Multi-Disciplinary Team (MDT) meetings indicated involvement of family members, key stakeholders, and care teams in discussing patient progress, future care planning, transitions and discharges.

We observed the ward round meeting with patients, attended by the doctor and two nurses. The team reviewed patients’ care needs and medication and discussed discharge plans for those approaching discharge. Patients were seen individually and asked about their wellbeing and any concerns. Staff and the doctor communicated kindly and respectfully and engaged warmly with patients.

The service ensured that staff used a discharge checklist to confirm all required actions were completed, supporting a safe and well-coordinated discharge process.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand what being safe means to them as well as with their partners on the best way to achieve this. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and made sure they shared concerns quickly and appropriately.

The service had systems in place to protect people from harm, supported by safeguarding policies for both children and adults. Safeguarding training formed part of ongoing mandatory training which all staff had to complete regularly. Staff we spoke with demonstrated an understanding of how to identify and report safeguarding concerns. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

All staff completed mandatory safeguarding training, and at the time of inspection, compliance was at 100% for safeguarding adults Level 1, 2 and 3, 100% for level 1 safeguarding children and 96.61% for level 2 safeguarding children.

The service had a safeguarding team who covered all areas of the organisation and were available to support staff. The team had created a safeguarding inbox monitored by an allocated member of the safeguarding team who were available for urgent enquiries, requests or support. The safeguarding team supported the organisation by providing training and supervision sessions with staff. They attended Multi-Disciplinary Team and professional meetings relating to active cases, provided real time advice, attended incident review panels and safety groups. The team fed into the safeguarding strategic group and the quality and safety committee to provide oversight of safeguarding incidents, emerging themes, and organisational learning.

The team facilitated Schwartz rounds and de-briefs (a structured forum where staff can discuss the social and emotional impact of working in the healthcare setting after incidents) and conducting After Action Reviews (AAR) to identify learning following safeguarding incidents. The safeguarding team also liaised with other stakeholders including the police, adult social care, the integrated care board and the local authority designated officer (LADO).

There were no active safeguarding referrals at the time of the inspection. Between October 2024 and September 2025, 8 safeguarding referrals were raised relating to patients on Halstead ward. Four of these were not substantiated. The service reviewed each concern and found 2 emerging themes, including improving documentation practices and effectively communicating relevant information during a patient discharge.

Records were up to date, included details about safeguarding incidents and if they were being investigated internally or by the local authority.

Safeguarding learning was shared in various forums including staff meetings, reflective sessions and supervision.

We spoke with family members of people at the service. All told us that they felt their loved one had been safe at the service and they knew how to raise concerns if they needed to. All patients said they felt safe.

Staff followed clear procedures to keep children visiting the ward safe. Visits from children took place in other areas at the hospital. At the time of inspection, 100% of staff had completed training in safeguarding children.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enabled them to do the things that mattered to them.

Risk assessments were completed on admission and updated if patients deteriorated or improved. We reviewed 11 patients records and saw a standard risk assessment tool alongside additional risk screens to determine risk levels of patients. Risk areas assessed included activities of daily living, falls risk, sepsis risk, use of bed rails, nutrition and dietary needs and communication. Mini mental state assessments were also used to assess for cognitive functioning and any mental health risks. Home assessments were used to assess for needs and risks on discharge.

The multi-disciplinary team would monitor, review and update risks for patients. Shift changes and handovers included all necessary key information to keep patients safe.

Staff assessed and monitored patients using the New Early Warning Score 2 (NEWS) tool. This assessment indicates to staff any signs a patient is deteriorating and is based on several recorded vital signs and how responsive the patient is. We reviewed 11 sets of patient records; all assessments were completed with the NEWS 2 scores calculated correctly and recorded.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. This included picture charts, alphabet charts, a loop system, interpreters, British sign language and custom-made communication aids if required.

The inpatient wards were nurse-led with access to medical assistance daily, Monday to Friday. If a patient deteriorated, staff told us that they would contact the local out of hours service or contact the emergency services to transfer a patient to the local NHS acute hospital.

There was a resuscitation trolley on each inpatient ward. All staff completed basic life support (BLS) as part of their mandatory training. The service achieved a compliance rate of 100% BLS training. Qualified nursing staff completed immediate adult life support (ILS) training. However, the service had only achieved a compliance rate of 79% against the target of 90%.

Patient records contained venous thromboembolism (VTE) risk assessments, which staff completed prior to admission. Venous thromboembolism (VTE) is a life-threatening condition in which a blood clot forms in a vein. The risk assessments identified whether preventative treatment was required.

Staff completed, or arranged, psychological assessments and risk assessments for patients thought to be at risk of self-harm or suicide. At Halstead ward, staff would refer patients to talking therapies, crisis teams and dementia services as required. On Bayman ward, a local mental health trust provided psychological assessments and therapeutic interventions to patients and families on the ward.

Staff shared key information to keep patients safe when handing over their care to others.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the care environment, including building compliance audits, health and safety audits, fire risk assessments, Legionella risk assessment, and ventilation audits. Comprehensive health and safety workplace audits covered all key areas such as fire evacuation, environmental checks, risk of falls, staffing, medical devices, violence and aggression, and general safety inspections. Action plans were developed to address any issues identified, with clear actions and completion dates to ensure improvements were implemented and embedded. NHS Property Services own Brentwood Community Hospital where Bayman ward is situated.

The wards had up to date fire risk assessments in place. Results showed a good standard, with only minor improvements recommended. Fire drills were carried out followed by debriefs to identify learning and actions to improve the fire evacuation process. As part of one fire drill learning had been identified where refresher training was actioned for all staff including the fire marshals. Fire equipment, including fire extinguishers, were available, in date, and regularly checked.

The service had business continuity plans (BCPs) in place for each ward. Managers discussed the BCPs with staff during staff meetings and ensured staff received training on business continuity arrangements.

Ward layouts did not allow staff to observe all parts of the ward. However, all patients had call bells that they could use if they required support from staff. Staff had easy access to alarms.

Clinic rooms were fully equipped. The wards had accessible resuscitation equipment and emergency drugs that staff checked regularly. We checked the resuscitation trolleys and equipment. The resuscitation trolleys had the required equipment available for use during an emergency procedure Records we reviewed confirmed completed daily checks had been undertaken regularly.

The service had enough suitable equipment to help them to safely care for patients. Equipment included seated and standing hoists, ceiling track hoists, chair risers and recliners, tilt chairs, standing aids, slide sheets, treadmills and exercise bikes. Occupational therapy and physiotherapy staff checked all equipment weekly, reported any faults and repaired or replaced equipment as necessary. Equipment was regularly cleaned and recorded on cleaning logs.

All equipment was serviced regularly to ensure they were in good working order.

Medical devices were regularly tested with in date asset tags to demonstrate testing and maintenance checks had taken place.

Albac emergency evacuation rescue mats, designed to roll over any surface like a stretcher to support the safe evacuation of disabled or mobility-impaired patients, were available.

Staff disposed of clinical waste safely.

Bayman Ward was managing an occurrence of Legionella in the water system (Legionella bacteria can be present in water systems, such as taps, showers, and storage tanks. If inhaled in small droplets, it can cause Legionnaires’ disease, a serious form of pneumonia). The ward had a Legionella risk assessment in place and was following an action plan to reduce the risk. This included regular monitoring and testing of the water for Legionella and monitoring temperature levels. Filters had been fitted to taps and shower heads.

In 2024, the Patient-Led Assessment of the Care Environment (PLACE) for Bayman ward achieved high scores across all areas, including cleanliness (99.1%), food (93–99%), privacy and dignity (98.5%), and accessibility for dementia (98.3%) and disability (98.4%), with condition, appearance, and maintenance slightly lower at 90.6%.

Halstead Hospital was due to have its PLACE assessment in November 2025.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that meets people’s individual needs.

At the time of the inspection both wards had a staffing establishment of 27.38 full time equivalent (FTE) registered nurses and 35.01 FTE healthcare assistants. The services vacancies for healthcare assistants were 5.86 and 1.01 for registered nurses.

The number of shifts covered by agency staff was low. Between July and September 2025, agency usage ranged from 10% to 18%, with substantive and bank staff covering most shifts (82% to 90%). During this period, a small number of shifts were not filled, with a maximum shortfall of 2.5% in one month. These shortages were managed on the wards by the multidisciplinary team. Managers requested staff familiar with the service.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.

Managers accurately calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants needed for each shift in accordance with national guidance. The ward manager could adjust staffing levels daily according to the needs of patients.

The service had low sickness rates. In August 2025 sickness rates were 0.56% and in September 2025 these were 1.66% for both wards.

The service had low turnover rates. Bayman Ward reported a turnover rate of 2.82% in July 2025 and 0% in both August and September 2025. Halstead Ward also demonstrated low turnover, recording 0% from May to August 2025, with a slight increase to 3.23% in September 2025.

Nursing staff told us they felt supported, and a buddy system had recently been introduced that enabled one-to-one meetings with allocated buddies. Staff were up to date with mandatory training, with compliance levels not falling below 79% across any area. Overall, the service had an 98% compliance rate across all mandatory training courses. Training provided was appropriate to the needs of the patient group and ensured staff had the necessary skills and knowledge to deliver safe and effective care. Managers monitored mandatory training and alerted staff when they needed to update their training.

The service was a nurse led service and had medical staff available during the day. This included a ward doctor and consultant. Medical staff had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Out of hours, the wards provide 24 hour internal on-call support via members of the senior leadership team and would access further medical or emergency treatment through the local general hospital.

Clinical staff completed training on recognising and responding to patients with learning disabilities, autism, and dementia. Compliance with the Oliver McGowan training was 100%, and dementia training compliance was 98.55% for Tier 1 and 98.33% for Tier 2.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

The ward environment was tidy and free from clutter, allowing patients to mobilise safely. Cleaning records were up to date and demonstrated that all areas were cleaned regularly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Staff adhered to infection prevention and control (IPC) principles, including effective hand hygiene practices. Handwashing facilities, signage, and alcohol-based hand gel were readily available throughout the wards.

Staff followed infection control principles including the use of personal protective equipment (PPE).

The wards had effective systems and processes in place for the segregation and management of clinical and non-clinical waste. Clinical waste bins were clearly identified and located throughout the separate areas. Different coloured lining bags were in use to ensure correct segregation of hazardous and non-hazardous waste.

Sharps containers were correctly labelled and all within safe ‘fill’ limits.

Domestic staff were visible in the department throughout our inspection and constantly engaged in cleaning activities.

Patient trolleys and equipment were visibly clean throughout the wards. We observed staff routinely cleaning equipment and ward areas. Staff completed daily cleaning records. Disposable curtains were placed around the bed areas and used to protect the patient’s dignity and privacy. We checked the curtains which were visibly clean and dated as last changed in October 2025. Staff confirmed the curtains were changed every 6 months or immediately replaced when soiled.

Regular IPC audits were carried out, including, hand hygiene, catheter care, cleaning and decontamination, IVI and central line audits, and Prevent Infection and Chronic Wounds audits. Results were 100% between April and September 2025. Community ward assurance visits were carried out/ All assurance visits included action plans outlining identified issues, required actions and recorded completion dates. All audits were completed, with actions taken as required.

Whilst visiting Bayman ward, we observed that 3 patients had been isolated in their bedrooms due to suspected or confirmed infections, in line with the provider’s policy. All patients had been reviewed by the infection prevention and control team, and appropriate measures were implemented to prevent the spread of infection. Precautions included decontamination of equipment, adherence to hand hygiene, avoiding patients crossing paths with others, and restricting the use of communal areas when patients attended therapy as part of their treatment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines, including controlled drugs (CDs), were stored securely, with appropriate temperature monitoring, and access was restricted to authorised staff. CD balances were accurate, and we saw evidence that quarterly audits were undertaken.

Allergies were clearly recorded, and medicines were administered as prescribed. Where doses were omitted, there was clear documentation as to why this had occurred. However, we noted that some medicines requiring separation from other medicines or food, were documented as being given at the same time.

A pharmacist and pharmacy technician visited the ward once a week, including attendance on multidisciplinary team ward rounds. Staff told us the pharmacy team could be contacted when not on site, and staff had mechanisms in place to be able to access medicines out of hours. Upon admission, there was a process to reconcile medication (the process of gathering accurate information about a person’s prescribed medicines) for patients. However, we could not be assured that the medicines reconciliation process was robust. For example, we identified a patient with two medicines missing from their medication history, one of which was present in the patient’s own medication box.However, following the inspection, the service rectified this issue.

Most medicines waste was disposed of promptly and safely, although there were no cytostatic (purple-lidded) waste bins on the ward, despite patients receiving cytostatic medicines such as finasteride.

Following previous concerns with stock levels of medicines a different way of working had been introduced where all medicines were accounted for using balance sheets. We found that staff were not following the current policy and could not account for some medicines.

We found several pill cutters containing powdered medicine residue and an unclean pill crusher creating a risk of cross-contamination and poor infection control. Some medicines did not have the date of opening on them.

We found one adrenaline injection (used for cardiopulmonary arrest) stored in the controlled drugs cupboard, which was out of date. We checked the resus trolley and there were no further adrenaline injections available to use in the event of a cardiac arrest. This is not in line with resus council guidance for community hospitals who state that adrenaline for intravenous use needs to be immediately available. We were told that nursing staff were not authorised to give intravenous drugs, however there was a bag of intravenous fluid and intravenous equipment as part of the resus trolley equipment. The target for nursing staff for Immediate Life Support (ILS) training is 90% which includes the administration of adrenaline for cardiopulmonary resuscitation. Current figures showed a completion rate of 79%. There was adrenaline available to treat anaphylaxis which is given by intramuscular injection and this was checked regularly.

We found expired medicines, including 4 boxes of different medicines all of which had expired in September 2025, and one box that expired in August 2025. We informed the pharmacy staff of each item, and they disposed of them immediately. We were informed that there had been some confusion regarding the recording of stock medicines, however, this was immediately rectified through the introduction of a single stock checklist. Managers added this to their immediate action plan, which they shared with CQC following our inspection. The action plan also included a review of the medicines policy and associated processes.

The service had a self-administration policy in place to enable people to administer their medicines themselves as part of their rehabilitation but no one we saw during our inspection was administering their own medicines.

Staff told us they knew how to report medicines incidents and that they received feedback and lessons were learned.

The service completed venous thromboembolism (VTE) risk assessments on all patients within 24 hours and documented it electronically. Completion of a risk assessment was monitored regularly; however, the provider did not measure the quality of the assessment.