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Archived: St Clare's Hospice Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 3 December 2018

St Clare’s Hospice is a standalone hospice provider, which is a charitable incorporated organisation but receives over 40% funding by the local commissioning group. The hospice which had been in operation since 1987, is based in Jarrow and offers specialist palliative care for adults who live south of the Tyne. The health of people in South Tyneside is worse than the England average. Deprivation is higher than average and life expectancy for both men and women is lower than the England average. 2.9% (2011 census) of Jarrow’s population is non-white British making Jarrow the least ethnically diverse major urban area in Tyneside. The service operates both day hospice and inpatient hospice services and provides palliative and end of life care for over 451 patients.

The inpatient unit is an eight-bed facility which provides respite and longer term care for adults with a life limiting illness including, chronic obstructive pulmonary disease, motor neurone disease, supranuclea palsy, heart failure as well as cancer. The Hospice has a day care facility which caters for up to 15 patients per day Tuesday to Friday. In addition the hospice offers bereavement counselling and befriending services.

The hospice is situated in a single story building within the grounds of a local hospital. All rooms have wheelchair access with all inpatient rooms leading to a paved garden area.

We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 12 and 13 September.

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

Our rating of this service went down. We rated it as inadequate overall.

We found areas of practice that were inadequate in relation to St Clare’s:

  • We saw significant safety concerns in areas such as medicines management, risk identification and incident investigation and subsequent learning. Safety is not sufficient priority and we saw patient harm had occurred as a result of this.
  • There is insufficient attention to safeguarding. Staff displayed limited safeguarding understanding and the interim safeguard lead was appointed to the role without agreement or knowledge of doing so.
  • Staff were not supported with mandatory training and managers had no oversight of training needs required for the role.
  • Patient records and assessments were incomplete and routine assessments were not completed for all patients, including those deemed to be high risk. Opportunities to prevent or minimise harm were missed.
  • Patients care and treatment does not reflect current evidence based guidance, standards and practice.
  • None of the nursing staff had received an appraisal in the 12 months leading to inspection.
  • There is no formal process to monitor patient’s outcomes of care and treatment and there was little appetite by managers to drive improvement.
  • Patients receive care from staff that do not always have the skills or training that is needed through regular completion of mandatory training.
  • Staff and teams work largely in isolation and do not seek support or input to actively improve services for patients.
  • People are unable to access the care they need. Access and flow within the service was interrupted without due consideration for patients waiting for services.
  • Complaints and concerns are not taken seriously and patients concerns and complaints do not lead to improvements in the quality of care.
  • Staff do not understand the vision and values and the strategy is not underpinned by detailed realistic objectives and plans.
  • The governance arrangements and their purposes are unclear. Financial and quality governance are not integrated to support decision making.
  • Leaders do not have the necessary experience, knowledge, capacity, capability or integrity to lead effectively.
  • Staff told us there was a culture of bullying and instances of conflict between individuals.
  • There is minimal engagement with people who use the service, staff and public.
  • There is minimal evidence of learning and reflective practice.

Following this inspection we undertook due process regarding the significant safety concerns and had begun the process to suspend related activities at the hospice. However following a discussion with the provider they chose to voluntarily suspended services. In addition, we told the provider that it must take some actions to comply with the regulations. We also issued the provider with five requirement notices that affected St Clare’s Hospice. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)

Inspection areas

Safe

Inadequate

Updated 3 December 2018

The service was previously rated requires improvement in safe and the provider had failed to improve in several areas. We found significant safety concerns across several areas which impacted negatively on the rating. We rated safe as inadequate because:

  • The service did not have reliable systems and processes to manage staff training. Managers were unable to identify which mandatory training staff should undertake, and did not monitor when staff had completed training. This meant staff were not trained adequately to work safely within their role for example only 40% of nurses had completed basic life support training.
  • The provider failed to recognise concerns, incidents or near misses. Action plans following incidents were incomplete, learning was not identified or shared. Staff were not always transparent when reporting concerns.
  • Care premises were unsafe as patients were not protected from potential risks within the building.
  • The provider took insufficient attention to safeguarding. Staff were not clear in relation to their responsibilities when reporting or investigating safeguard concerns.
  • The provider did not follow best practice regarding the administration of medicines. We saw evidence of several medication errors, resulting in patient harm.
  • Risk assessments were not completed consistently and patients deemed to be at high risk were not routinely re-assessed, resulting in patient harm.

Effective

Inadequate

Updated 3 December 2018

The service was previously rated good in effective, however found significant concerns which impacted negatively on the rating.

We rated effective as inadequate because:

  • The provider did not have processes in place to ensure care and treatment was delivered and monitored against evidenced based guidance and best national practice.
  • There was limited monitoring of patient outcomes. Where patient care and treatment outcomes were monitored they were not consistently reviewed.

  • Patient’s nutritional needs were not consistently assessed and staff did not always accurately monitor and record the amount of food or fluids taken.

  • None of the clinical staff received clinical competency supervision, to ensure staff delivered effective care.
  • None of the nurses at St Clare’s had received an appraisal within the 12 months leading up to inspection.
  • A number of patients were currently being reviewed at the time of inspection. Staff were unclear which patients had given consent in relation to DNACPR.
  • We saw low numbers of mental capacity assessments and no best interest assessments had been completed.

However,

  • The service worked alongside colleagues at the local healthcare trust to support patient care and delivery.

Caring

Good

Updated 3 December 2018

The service was previously rated good in caring. Feedback remained consistently positive.

We rated caring as good because:

  • Staff cared for patients with compassion. Most of the feedback from patients and their relatives confirmed staff treated them well and with kindness.
  • The service had received many thank you cards which showed patients and relatives felt staff treated them with compassion and care.
  • Staff provided emotional support to patients and relatives to minimise their distress. The family bereavement support and counselling services offered ongoing emotional support was not time limited.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients told us they and their relatives had been involved in developing their care plan and we saw evidence of this in patient care records.
  • Patients told us they felt involved in their care and recent changes to the décor at the hospice were felt to be positive.

However

  • We were not assured staff had received the appropriate training in relation to dignified end of life care.

Responsive

Inadequate

Updated 3 December 2018

The service was previously rated good in responsive, however, found significant concerns which impacted negatively on the rating:

We rated responsive as inadequate because:

  • The service did not plan and provide services in a way which met the needs of local people. We did not see evidence of understanding of the needs of the local population.
  • We saw limited engagement with patients and their families to shape and steer the design of the service.
  • The service did not provide facilities to meet the cultural and spiritual needs of patients of different faiths and cultural backgrounds.
  • Staff were unclear as to which translation services were available and how to use them.
  • The provider was did not assess patients in a consistent manner. Care plans were generic and did not reflect the individual’s needs. This is a repeated breach from the January 2018 inspection
  • Patients were unable to access the care they needed at the right time due to the providers decision to stop admissions at the day hospice. In addition we saw interruption to the access and flow with patients coming to the hospice for many years without an agreed outcome.
  • The provider did not have a robust system to capture and investigate complaints. Patients told us they had raised concerns but we did not see evidence of these issues and no actions taken or improvements made, as a result of them being raised.

However,

  • Some areas within the hospice had been changed as a result of feedback from patients and carers, such as the colour of the walls.

Well-led

Inadequate

Updated 3 December 2018

The service was previously rated requires improvement in well-led, however, found significant concerns which impacted negatively on the rating:

We rated well-led as inadequate because:

  • Staff working within leadership roles at the hospice had not had the necessary training or support to perform the role effectively.
  • The provider’s strategy and vision was not embedded within the service and staff were unclear when asked to describe it.
  • Morale was varied at the hospice. Some staff reported improvements in the atmosphere, whilst others told us there remained a bullying culture.
  • We were not assured managers understood how to monitor and improve quality for the patients at the hospice. Commissioning for quality and innovation (CQUIN) targets, in place to support improvement were not progressed in a timely manner and there was limited appetite to measure improvement.
  • The post action improvement plan following the January 2018 inspection had not been completed. There were no definitive dates for completion or accountable owners recorded against the actions.
  • The provider displayed a lack of understanding in relation to its clinical and professional responsibilities at all levels.
  • Risks to the service were not recorded, investigated or monitored effectively. Specific risks were not always identified by the provider and managers displayed a lack of ownership when asked about risk management.
  • The provider failed to learn following incidents and did not have a robust system in place to ensure incidents were managed effectively.
  • We saw the board of trustees lacked oversight of operational concerns and we did not see any level of scrutiny applied to key clinical issues. For example medication errors.
  • The provider did not have a robust system to record and investigate complaints
  • Access and flow within the hospice was not fluid and we saw patients were prevented from being admitted due to a failing system, which was not responsive to the needs of the community.

However,

  • The day hospice had developed educational wellbeing days, which had been received positively by the community.
  • The provider was due to commence a number of reflection days to support staff following difficult experiences.
Checks on specific services

Hospice services for adults

Inadequate

Updated 3 December 2018

Hospices for adults was the only activity provided at this location.

The hospice had 8 inpatient rooms providing palliative and end of life care, including respite. At the time of our inspection four patients were accommodated.

Day Hospice, bereavement and counselling services were also provided.

We rated this service as inadequate because we saw concerns across four of the five domains which impacted negatively on the ratings.