Archived: Anglian Community Enterprise Community Interest Company (ACE CIC)

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

The Care Quality Commission (CQC) carried out a comprehensive inspection of Anglian Community Enterprise between the 5-8 December 2016, with an unannounced inspection on 22 December 2016 to Clacton and Harwich Hospital.

This community enterprise company provides a number of NHS community services to the population of North East Essex. During our inspection we visited the three registered locations at Clacton, Harwich and Kennedy House, as well as a number of small clinics and services run across the region.

Prior to undertaking this inspection we spoke with stakeholders, and reviewed the information we held about the provider. The provider had undergone significant change since 2011, when it left the NHS and became Anglian Community Enterprise. In 2015 Anglian Community Enterprise (ACE) was awarded one of England’s largest current healthcare contracts to deliver Care Closer to Home (community based health services).

The comprehensive inspections resulted in a provider being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each core service receives an individual rating, which, in turn, informs an overall provider rating. The inspection found that overall the provider has a rating of

Overall, we have found that the provider was performaing at a level which led to the judgement of Good with some elements of Requires Imporvment.

We inspected four cores services, Urgent Care, Community health for adults, Community inpatient services

and Community services for children and young people.

Our key findings were as follows:

Safe

• There was an open culture for reporting incidents, with clear action plans and learning within teams.
• There was a good understanding of safeguarding adults and childrens across the services.
• Staff were knowledgeable about Duty of Candour.
• Mandatory training was above target in most areas.

Effective

• Evidence based practice was embed through the organisation and services followed national guidance.

• The provider participated in the NHS safety Thermometer and the NHS Medication Safety Thermometer, which overall showed that patients were receiving safe and harm free care.
• There were good examples of multi-disciplinary working to improve patients outcomes.
• In Community, Urgent Care and Childrens services there was a good understanding of Mental Capacity and Deprivation of Liberty and both Fraser guidelines and Gillick competence.

Caring

• Patients were treated with kindness, compassion, dignity and respect throughout all of the services we inspected.
• Patients were involved on their care and staff were focussed on the individual needs of the patients.
• There were examples of staff going above and beyond what they were expected to do.

Responsive

• Services were planned around the needs of the patients and there was on going work to fulfil the “care closer to home” contract.
• There was a flagging system in use within the electronic patient records to identify vulnerable patients such as those with a learning disability.

• The provider was part of the Maternal Early Childhood Sustained Home Vising (MESCH ) programme, which provided support by health visitors to vulnerable families.
• People were supported to raise concerns, complaints and compliments across the service, and there was evidence in how learning from complaints was used to change practice

Well Led

• There was a vision and strategy in place which focussed on integrated working and the changing needs and commissioning environment of healthcare, with the introduction of the “care closer to home” contract.
• 50% of staff owned a share in the company.

• Overall staff felt that the provider was supportive and that engagement and training opportunities were good.
• There was a corporate risk register, rating risks from low through to very high. Risks were clearly documented with summary updates, ownership of risks and actions taken to mitigate risk.

We saw several areas of outstanding practice including:

• ACE was awarded the Stage 3 Unicef Baby Friendly Accreditation in January 2016.
• ACE had been nominated as a finalist in the UK Social Enterprise Award 2016.
• The provider was in the process of deploying new technology phones, following a successful pilot project, in the use of wound photography in community nursing service.

Importantly, the provider must:

• Complete and submit Notifications as required by the Care Quality Commission ( applicable to all ex-NHS Community Interest Companies), for changes, events and incidents affecting the service or the people who use it.

However, there were also areas of poor practice where the provider needs to make improvements.

• The provider should consider reviewing the children’s waiting areas in urgent care, to ensure they provide visual and audible separation from the adult waiting areas in line with intercollegiate standards for Children and Young People in Emergency Care settings.
• The provider should ensure medicines including are stored in line with provider policy at all times.
• The provider should ensure equipment is stored safely and in line with provider policy at all times.
• The provider should ensure equipment is fit for purpose and ensure maintenance and servicing is completed in line with provider policy at all times.
• The provider should ensure compliance rate for mandatory training courses is in line with the provider’s compliance target.
• The provider should maintain staffing levels in line with recommendations in their staffing report and Royal College of Nursing guidance.
• The provider should ensure that knowledge of Mental capacity and Deprivation of Liberty is embedded in learning and practice.
• The provider should consider the level of safeguarding training provided to non-registered staff providing clinical care.
• The provider should ensure that all relevant standard operating procedures are updated and implemented across the organisation.

Professor Sir Mike Richards

​Chief Inspector of Hospitals

We rated Adult Community Services as good because;

• There were robust processes in place for reporting and learning from incidents. All members of staff we spoke with were aware of incident reporting and their responsibilities in relation to incident reporting. We saw evidence of managers discussing incidents at staff meetings.
• There was awareness and a pro-active approach to following safeguarding procedures. Staff knew how to raise a safeguarding concern and could give examples of what they would report.
• Care that was delivered took account of national guidance such as the National Institute for Health and Care Excellence (NICE) guidelines.
• Staff had received an annual appraisal, and had opportunities for their personal development. The average target for appraisals was set at 75% and community adult services had exceeded this target. Staff we spoke with provided examples of training and development that they had accessed.
• We saw good examples of multidisciplinary team working and coordinated care pathways.
• Staff treated patients with kindness and respect and always protected their privacy and dignity when delivering care.
• Relationships between patients, their relatives and staff were caring and supportive. Staff recognised and considered the personal, cultural, emotional and social needs of the patient.
• Patients were involved in making decisions around care planning.
• Patients were given information about how to make complaints. Complaints were investigated and patients were informed of the outcome.
• Staff had access to interpretation services.
• There was a well-embedded governance structure in place, this fed from locality teams upwards into the executive board.
• Staff valued the support and dedication of their immediate managers.
• We saw good examples of innovative practice.
• All staff we spoke to told us that there was a patient centred culture.
• The organisation was pro-active in celebrating staff achievements with several members of the adult community teams receiving awards recently.

However;

• Equipment was not always fit for purpose. We found items in use that were either out of date or had no date for maintenance testing.
• Vacancies impacted on services provided by some of the community teams, for example the respiratory service.
• Some specialist teams within the community adult service expressed ‘feeling isolated’. The absence of clinical lead in the respiratory service also made staff feel losing a link with the wider service.

We rated this service good because:

• Mandatory training compliance across children and young people’s (CYP) services was above Anglian Community Enterprises (ACE) target of 95%, achieving 98.5% in November 2016.
• Staff knowledge and understanding of safeguarding children and young people was good. Staff undertook regular safeguarding training.
• We found staffing was sufficient for the workload. Senior managers reviewed staffing using an evidence based tool and reallocated staff accordingly.
• Documentation on patient’s electronic records was detailed, accurate and timely.
• Policies and guidelines were evidence based and in line with current national best practice.
• Staff received yearly appraisals.
• We found evidence of effective and consistent multidisciplinary working across CYP services.
• Staff had good knowledge and understanding of the Mental Capacity Act 2005. The looked after children team showed a good knowledge of Deprivation of Liberty Safeguards and the Mental Health Act.
• Staff were caring, compassionate and considerate towards children, young people and their families, and included them in care decisions.
• Staff demonstrated a thorough understanding of the communities and families that they worked in.
• Staff planned services in accordance with the needs of the communities and schools they worked in.
• Staff were positive about local leadership and we found a culture of openness and learning.
• The integrated care managers showed a strong understanding of the risks within the service

However:

• Not all clinical staff had received safeguarding children level three training, in line with the intercollegiate document.
• Environmental infection control procedures were not consistent across all areas. We found carpeted floors and fabric chairs in clinical areas without risk assessments or cleaning schedules.
• Staff did not consistently update standard operating procedures, which could lead to staff using out of date best practice guidance.
• Knowledge of risk and risk management within local teams and amongst team managers was limited.

We rated community health inpatient services overall as requires improvement because:

• There was a general shortage of permanent nursing staff, which led to a high number of nursing shifts being filled by agency staff, particularly on night shifts on Kate Grant ward.
• There was evidence of poor leadership found on Kate Grant ward, which included delays in responding to a complaint, lack of knowledge regarding key performance indicators and staff feeling undervalued and under pressure.
• Staff had poor understanding of mental capacity and deprivation of liberty assessments most notably on Trinity ward.
• We found out of date electrical equipment and consumable items on St Osyth Priory ward and out of date medication on Trinity ward.
• Senior ward staff had limited understanding of assessing and managing risk and no local ownership of risk.
• Staff and patients had concerns regarding the competency of agency staff although it was acknowledged that many of the agency staff worked regular shifts on the wards.
• Staff told us that they frequently worked beyond their scheduled hours to complete work that they did not have time to finish whilst on duty. Staff also said that they felt the senior management did not listen to their concerns.

• Numbers of complaints were low. However, most complaints for the inpatient wards were regarding Kate Grant ward. A senior staff member on Kate Grant ward expressed concerns about dealing with complaints in a timely manner due to their workload. We saw evidence of one complaint that was not dealt with in a timely way during our inspection.

• Access to speech and language therapy service was delayed due to understaffing and patient visits could take up to five working days following a referral.

However;

• Patients were given appropriate and timely support and information to cope emotionally with their care, treatment and condition.

• We saw evidence of learning from a complaint and a change that had been made as a result.
• There were good examples of multidisciplinary working between the nurses and technical instructors (TIs) on all three wards.

We rated urgent care services provided at ACE Minor Injuries Units (MIU) as good, because:

• Clinical areas were visibly clean and tidy and good infection control practices were in place and monitored.

• Staff completed patient records in full with all the relevant clinical information, consent, treatment, and discharge recorded.

• Staff knew the requirements of Duty of Candour and able to explain these.

• All staff were up to date with their appraisals and mandatory training levels.

• Clinical guidelines used in both MIUs followed the most recent best practice guidance.

• Patients’ care and treatment was planned and delivered in line with current evidence based guidance and standards

• Staff were qualified and had the skills they needed to carry out their roles effectively.

• The service exceeded targets in respect of time spent in MIUs and the time patients waited for treatment.

• The hospital had a clear statement of vision and values, driven by quality and safety.

• Unit managers had the experience, capacity and capability to lead the services and prioritised safe, high quality, compassionate care.

• Staff satisfaction was high. Staff said they were encouraged and supported to develop.

However:

• Staff did not always record medicine fridge temperatures in the MIUs in line with policy and there was no formal process for escalating concerns when a fridge was outside defined temperatures.