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

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.

Below is a summary of what we found. The summary is based on our observations during the inspection, comments from people using the service and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People's comments included;

A relative told us they were extremely happy with the care and support their relative received. They told us that the staff were extremely supportive towards them and added that the care was exceptional'.

"This is a fantastic place.'

'The nursing staff were the very best I have ever encountered, full of compassion and always professional'.

'I have absolute confidence in the staff team. Explanations given were always very clear, detailed and never condescending and always respectful'.

'The staff cared for me and supported me to turn my life around'.

'It's an excellent service'.

' Lovely staff and volunteers'.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

We saw that the service promoted equality, diversity and human rights, and adhered to the government's 'End of Life Care Strategy' that highlighted the importance of being treated as an individual and with dignity and respect. We saw people were consulted about their preferred place of care.

The hospice had proper policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk.

We looked around the new day care facilities that opened on 10 July 2014. The facilities were superb and could accommodate up to 12 people each day and provided people with a range of complimentary therapies.

Is the service effective?

There was an advocacy service available if people needed it, this meant people could access additional support when required.

People's health and care needs were assessed with them, and they or their representatives were involved in their plans of care. Specialist dietary, social, mobility, equipment and pain control care needs had been identified in care plans where required.

People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely.

Visitors were able to see people in private and that visiting times were very flexible.

Is the service caring?

We saw staff and volunteers showed patience and gave encouragement when supporting people.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised, we saw these had been addressed by the provider.

People's preferences, interests, aspirations and diverse needs were recorded and care and support was provided in accordance with people's wishes.

Is the service responsive?

People completed a range of activities in and outside of the service regularly. The hospice had its own adapted transport, which helped to keep people involved with their local community. This was also used to transfer people to the day hospice.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system. The records we looked at showed any shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the hospice and the quality assurance systems in place. This helped to ensure that people received a good quality service.

Staff told us they felt supported in their role and we saw staff supported each other throughout the inspection.

We found before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others.

We found there were effective recruitment and selection processes in place.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

Suitable arrangements were in place for people to take part in appropriate therapies and activities in line with their needs and preferences.

The relationships between staff and the people who used the hospice were good and personal support and treatment was provided in a way that promoted and protected their privacy and dignity.