Community Health Care (Nutricia), provided active support to approximately 21,000 adults or children at any given time, either living in a care home or in their own home. The nationwide service employed 98 registered nurses (of which 12 were paediatric nurses) who worked in regions, and were line managed by 11 clinical nurse managers. Four health care assistants were also employed in the team.

The feedback received from people using the service and their families, from people working for the service, and from other health professionals was incredibly positive. Comments such as ""xxxx has been amazing, she listens to what we have to say. We hadn't been told much from the hospital but xxxx brought the PEG (percutaneous gastrostomy tube) with her and explained how it would work" and "I have never had such support in any other job, from day one I had my mentor who was then with me for four or five weeks after induction", and "we are offered all opportunities for training and development".

The Nutricia nurses were usually introduced to the person requiring support and training at the point of hospital discharge, and then a follow up visit arranged for the following day. A support call would generally be made one week later, following which a three monthly review would be undertaken. The person or their family would be followed up as often as they needed to ensure they were comfortable and confident with their enteral feeding regime.

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.