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Willow Burn Good Also known as Maiden Law Hospital, Maiden Law Hospital,DH7 0QS

Inspection Summary

Overall summary & rating


Updated 15 September 2016

Willow Burn Hospice provides a range of services focusing on relieving and preventing the suffering of people with life limiting illnesses. These include specialist day care services, palliative care and an outreach service. There were four people using the inpatient service on the day of our visit and approximately nine people attending the day hospice facility.

There was not a registered manager employed for this service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service had appointed a very experienced manager [head of care] who had joined the service six weeks previously with a background in hospice care. During the inspection the provider clarified the position of the responsible individual [who also has legal responsibilities with CQC] in the temporary absence of the previous appointee.

Some of the systems and processes to ensure the hospice was well led had lapsed following the absence of a registered manager at the home. Work to review and implement improvements to the governance of the service had only been recently introduced by the present manager [head of care] and included joint work with staff, senior colleagues and an externally appointed consultant.

People and their families told us that staff were kind and compassionate. People told us that staff were caring and listened to them. People we spoke with who received personal care felt the staff were knowledgeable, skilled and their care and support package met their needs not just in terms of physical care but also in relation to their emotional support. People using the day hospice spoke very highly of the complementary therapies that were available to both people who used the service and relatives. The hospice provided family support, counselling and bereavement support which people told us made a massive impact to their lives.

The staff undertook the management of medicines safely and in line with people’s care plans. The service had health and safety related procedures, including systems for reporting and recording accidents and incidents. The care records we looked at included risk assessments, which had been completed to identify any risks associated with delivering the person’s care and their environment. The hospice environment was maintained and there were regular checks on safety and equipment.

People were protected by the service’s approach to safeguarding and whistle blowing. People who used the service told us that they were safe, could raise concerns if they needed to and were listened to by staff. Staff were able to describe how they ensured the welfare of vulnerable people was protected through the organisation’s whistle blowing and safeguarding procedures.

Staff recruitment processes were followed with the appropriate checks being carried out. There were sufficient staff on duty to meet people’s needs and the service had a team of volunteers who provided additional support. The hospice had a bank of staff who they could contact if they needed additional staff.

The service had a care planning system that we saw recorded people’s admission assessment and on-going plan of care. Care plans were personalised to include people’s wishes and views. Care plans were regularly reviewed in a multi-disciplinary framework. We observed staff caring for patients in a way that respected their individual choices and beliefs. There was evidence of advance care planning and specific guidance ‘Deciding Right’ [a good practice initiative] was used to capture people’s choices and planning for future anticipated emergencies. Staff knew peoples’ preferences about treatment as they approached the end of life stages and these were recorded. However the service did not follow best practice because there was not a specific care plan for caring for patients in the last days of life. CQC recommended that the provider considers best practice in advanced care planning.

Staff and volunteers received a thorough induction and regular training to ensure they had the knowledge and skills to deliver high quality care. However, although staff told us they felt supported, arrangements for one to one supervision, appraisal and clinical supervision for qualified staff [nurses] had only recently been introduced by the manager [head of care].

Staff told us they were very supported by their management and could get help and support if they needed it at any time. Staff members told us they felt part of a team and were proud to work for the hospice.

People had choices about their care and their consent was sought by staff and their rights were being protected whilst at the hospice. However records of the assessment of people’s mental capacity was insufficiently detailed in relation to the Mental Capacity Act 2005 [MCA]. CQC recommended that the registered provider improve the capacity assessment documentation so that judgements in line with the MCA could be demonstrated.

People were supported to receive a nutritious diet at the service. Their appetite was assessed through talking to them which led to the chefs being able to give the person the type and amount of food they would be able to eat. There was a choice of menu on the day we inspected and drinks and snacks were available at any time.

People were confident expressing any concerns to staff at the service and knew who to approach if they were not satisfied with the response.

Inspection areas



Updated 15 September 2016

The service was safe.

Checks of the building and equipment were completed to make sure it was safe.

Staff were knowledgeable and there were systems in place to protect people from the risk of harm and abuse.

Staffing numbers and skills mix were sufficient to provide a good level of care to keep people safe.

Robust recruitment procedures were in place to make sure staff were suitable to work with vulnerable adults.



Updated 15 September 2016

The service was effective.

People�s healthcare needs were monitored and discussed with people who used the service and their family members.

The service needed to improve its assessment process to demonstrate people had the mental capacity to make decisions.

Staff of all levels had access to on-going training to meet the needs of the people they supported.



Updated 15 September 2016

The service was caring.

People told us that staff were kind and compassionate at all times and treated everyone with dignity and respect.

The service provided emotional support to people, their family and friends via a team of counsellors, nurses and healthcare staff on an ongoing basis.

People were supported spiritually. People were encouraged and supported to make decisions about their care and given time to make their own choices; this included their end of life care.



Updated 15 September 2016

The service was responsive.

People told us they felt confident to express any concerns or complaints about the service they received.

People and their families were fully involved in assessing their needs and planning how their care should be given.

Staff delivered people�s care in a person-centred way, treating them as individuals and encouraging them to make choices about their daily lives.


Requires improvement

Updated 15 September 2016

The service was not always well led.

Staff told us they felt supported by their colleagues but there was not an established programme for supervision and support.

The provider had very recently appointed a knowledgeable and experienced manager to lead the service.

Key areas of development were being planned for to safeguard current practice and implement improvements.