Lindsey Lodge Hospice

Updated 2 April 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the registered provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We undertook an announced focused inspection of Lindsey Lodge Hospice on 18 February 2016. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection on 18 August 2015 had been made. We inspected the service against two of five questions we ask about services is the service safe and well-led. This is because the service was not meeting some legal requirements. This inspection was completed by one adult social care inspector.

We had previously inspected this service on 18 August 2015; when it was rated requires improvement overall, with a requires improvement rating in two domains; 'safe and well-led.' On 18 August 2015 we issued a requirement notice for shortfalls found in the medicine management at the service, which was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated Requires Improvement overall because of the shortfalls in the domains 'safe' and 'well-led'. The findings from this inspection improved the quality rating in 'safe' and 'well-led' to good and the overall rating to good because we have re inspected the shortfalls within six months.

During our inspection we spoke with the hospice director/registered manager, with senior nurse's in charge of the in-patient unit and out-patient unit and with one nurse working at the service. We inspected all the medicine records and medicine storage throughout the service. We reviewed the medicine policy and procedure, we looked at minutes of meetings that had been held and at action plans that had been created and actioned following our inspection on 18 August 2015. We spoke with staff about the training and improvements that had been made in the medicine management and auditing systems following our last inspection. We did not speak with people using the service on this visit because the shortfall's we had found previously had no impact on people using the service or their symptom relief.

We toured the premises and checked the medicine storage rooms in both the in-patient and out-patient units. We looked at the storage facilities provided for medicines in patients rooms. We inspected a range of documentation including medicine records, policies and procedures, staff meeting minutes, audits and quality assurance documentation.

Updated 2 April 2016

We carried out an unannounced comprehensive inspection of this service on 18 August 2015 and a breach of legal requirements was found. After the comprehensive inspection the registered provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lindsey Lodge Hospice on our website at www.cqc.org.uk

We undertook this inspection on 18 February 2016. The inspection was announced. When we had previously inspected this service on 18 August 2015 it was rated requires improvement overall, with a requires improvement rating in two domains; 'safe and well-led.' We had issued a requirement notice for shortfalls found in the medicine management at the service, which was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we found that the registered manager had made improvements to the auditing and medicine management within the service which ensured that the shortfalls we had previously found had been addressed.

Lindsey Lodge is a purpose built hospice that provides inpatient care and treatment for a maximum of 10 people who have a life limiting condition. The service can also provide day care support for up to 14 people each day. Accommodation is provided on the ground floor with all rooms having good access to gardens and patio areas. En-suite and communal bathrooms with shower and assisted bathing facilities are provided, some with overhead hoist facilities to help meet people's mobility needs. There are two shared occupancy rooms which can be opened up to create a four bedded unit. This area can be changed to make two large bedrooms where family can stay close to their relative. There is a separate out-patient suite with craft rooms, communal areas and therapy rooms. Separate family accommodation has been recently built which is available for use; these facilities include are en-suites with televisions and tea making equipment. During our inspection there were people being cared for on

the in-patient unit and the out-patient clinic was open for people to use. Car parking facilities are provided with disabled parking by all entrances.There are local amenities, shops, a pub and garage nearby.

The service has a registered manager in place. 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 hospice director is the registered manager of this service.

We found improvements had been made in regard to the ordering of medicines, storage and monitoring of the temperature of the medicine storage room and fridge. Stock levels of medicines were monitored by staff and the management team. The medicine policy and procedure had been reviewed and had been rewritten to ensure it provided robust guidance for all staff in all areas of medicine management. We did not speak with people using the service directly about their medicines because the issues relating to medicine management that we had found at our last inspection on 18 August 2015 did not directly affect patient care or their symptom control.

We found that the registered provider and registered manager had been proactive and developed improvements to the quality monitoring systems within the service which were effective at highlighting any issues. Action plans were put in place which helped to monitor, maintain or improve the service which was provided to people.