Fair Havens Community Hospice Service is operated by Havens Christian Hospice. The service provides community hospice care across Essex.

We inspected this service using our comprehensive inspection methodology. Our inspection was announced 48 hours prior to the inspection, to ensure that everyone we needed to talk to was available. The service was inspected on 29 November 2018.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We rated this service as Good overall because:

• Staff kept patients safe from harm and abuse. Risks were assessed, monitored and managed appropriately.

• Staff followed best practice in relation to infection prevention and control. The maintenance and use of equipment kept people safe.

• Care and treatment records were accurate, stored securely and provided comprehensive details of care and treatment.

• Staff recognised incidents and knew how to report them. Managers investigated incidents and made improvements to the service.

• Staff had the appropriate skills, training, knowledge and experience to deliver effective care and treatment.

• Staff delivered care and treatment in line with evidence-based practice.

• Information about the outcomes of patient care and treatment was routinely collected and monitored.

• Staff involved patients and carers in decisions about their care and treatment.

• Staff cared for patients with compassion, treating them with dignity and respect.

• The service was planned based on the needs of local people, and new initiatives were set up to improve the service.

• There were clear processes for staff to manage complaints and concerns.

• There was an open and transparent culture, with engaged and experienced leadership.

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

• Learning from incidents was not consistently shared amongst staff.

• Progress was not documented on the community risk register; therefore, it was unclear which items had been reviewed and remained a risk.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals