5 August 2017
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 provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place on 27 and 28 September 2016 and was unannounced.
The inspection was carried out by an adult social care inspector, a pharmacy inspector, a specialist advisor and an expert by experience. A specialist advisor is someone who has recognised clinical experience and knowledge in a particular field. In this case the specialist advisor had expertise, skills and knowledge in relation to palliative end of life care in a hospice environment. The expert by experience was a person who had personal experience of having used a similar service and had cared for someone who had used a similar type of care service.
Before the inspection we read all of the notifications received about the service. Providers have to tell us about important and significant events relating to the service they provide using a notification. We reviewed the Provider Information Return (PIR) about the service. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also looked at the provider’s website to identify their values and details of the care and services they provided.
We spoke with 18 people who used the in-patient unit (IPU), hospice at home and day care service, and eight relatives. We spoke with 26 staff, including the hospice at home lead, the day service lead, lead for the Living Well Centre, the physiotherapy lead, 16 nurses and care staff, the two housekeepers, one chef, three social workers and 10 volunteers.
We also spoke with the provider’s registered manager (also known as the head of clinical services/Matron), the chief executive, the medical director, the director of quality, the lead psychologist and two doctors specialising in palliative care.
We used a range of different methods to help us understand the experiences of people using the service who were not always able to tell us personally. These included observations and pathway tracking. Pathway tracking is a process which enables us to look in detail at the care received by an individual. We pathway tracked the care of three people using the IPU service and one using the hospice at home service. Throughout the inspection we observed how staff interacted and cared for people across the course of the day, including mealtimes, during activities and when medicines were administered.
We looked at 11 staff recruitment files, and reviewed the provider’s training records. We reviewed the provider’s policies, procedures and records relating to the management of the service. We considered how comments from people, staff and others, as well as quality assurance audits, were used to drive improvements in the service. We looked at a selection of six medicine records to check medicines were managed safely.
5 August 2017
This inspection took place on the 27 and 28 September 2016. The last comprehensive inspection of the Rowans Hospice took place on 19 February, 2014. During this inspection we found the service’s systems for the storage and disposal of medicines were not safe. At this inspection we found that the provider had taken the required action to ensure medicines were stored and disposed of safely.
The Rowans Hospice (aka The Rowans or Rowans) is a charity dedicated to improving the lives of people and their families in Portsmouth and South East Hampshire living with life-limiting illness. The Rowans Hospice provides specialist palliative care to people, carers and families who are facing complex physical, emotional and practical difficulties arising from advanced progressive life limiting illness. This may be cancer or other diseases. The service delivers physical, emotional, spiritual and holistic care through teams of nurses, doctors, counsellors and other professionals including therapists. The service provides care for people through an inpatient unit (IPU), outpatient day service, a hospice at home service and Living Well Clinics.
There are nineteen in-patient beds, all in single room accommodation with en- suite bathrooms. At the time of our inspection there were 15 people using the in-patient service. The hospice at home service offers additional support to people and their family carers, enabling people to stay at home and receive high quality end of life care. The service is available 365 days a year and provides people and carers access to specialist advice and nursing visits on a 24 hour basis. The Rowans Hospice also has a Day Care service which provides short-term placements.
The service had a registered manager in post. 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 registered manager at The Rowans Hospice was the Director of Clinical Service (akaThe Matron).
People who used the different aspects of the service told us the quality of care and kindness provided by professional staff made them feel safe. Staff were able to explain their role and responsibility to protect people from abuse.
Care records demonstrated that potential risks to people’s safety were identified and plans were created to mitigate them. Risks to each person's health and well-being had been considered and assessed, for example people's mobility, skin care and nutritional needs. We observed staff supporting people to prevent any identified risks in accordance with people’s risk assessments.
There were sufficient staff to meet people’s needs. The relevant head of department completed a daily staffing analysis to ensure there were sufficient suitably qualified staff available to meet people’s needs. When people’s health deteriorated quickly we observed the staff ability to provide one to one care increased people’s safety and reduced the risks of harm to them.
The provider ensured that robust pre- employment checks were completed on all staff and volunteers as part of their recruitment. People were cared for safely because all staff and volunteers suitability for their role had been effectively assessed before they were appointed.
People were protected from harm because there were safe systems in place to ensure patients were not exposed to the risks associated with medicines.
People spoke positively about the quality of care and support they received from staff. Due to the expertise and knowledge demonstrated by staff, people were confident that they were well trained and supervised.
Staff had been trained to deliver best practice in relation to end of life care. Staff also had to complete regular training in relation to people’s clinical needs. This ensured staff had the appropriate knowledge and skills to support people effectively and were enabled to retain and update their skills as required.
The hospice at home staff knew people’s needs and managed risks to people being supported to live with their illness at home, in accordance with their wishes, for example; physiotherapists arranged specialist equipment to be installed in people’s homes to provide the support required.
Staff had received training in relation to the Mental Capacity Act 2005 (MCA) and were able to explain the main principles. Records demonstrated that the provider operated processes of mental capacity assessment and best interest decisions which promoted people’s safety and welfare when necessary and protected their human rights.
People had nutrition and hydration assessments and plans, which were up-to-date and where necessary recording of people’s intake had been completed.
People’s healthcare needs were described in their care plans which took account of the person, their family and friends and their wishes regarding their treatment and aspirations. People were supported at the end of their life to have a comfortable, dignified and pain free death.
People received outstanding care from exceptional staff who were compassionate, understanding, enabling and who had distinctive skills in supporting people living with a life limiting illness. Staff consistently cared for people that mattered to the person using the service with empathy and understanding.
An outstanding feature of the bereavement service provided to children were the ‘Meerkat Service’ which is run from an office in the in-patient unit called ‘Meerkat Central’. The Meerkat Service’ provides specialist support to children and young people who have a significant adult, such as a parent or grandparent with a life-limiting illness or who have been bereaved of an adult close to them.
The hospice was outstandingly responsive to the needs of the people in their community and services offered by the hospice were shaped to meet these needs. Whilst Rowans Hospice provided a responsive service to meet individual’s needs the provider was also responsive at a strategic level, for example; extending the geographical area it covered within Hampshire to meet the needs of a greater community at the request of GP’s and commissioning groups.
People in the community with complex dementia and end of life care needs were now supported by a Dementia Voice Nurse (DVN) as part of a joint initiative led by The Rowans. This initiative demonstrated the Hospice’s commitment to serve their local community and to implement innovative practices to drive quality across the service. The environment in the IPU was dementia friendly and the hospice worked with local care services to ensure people living with dementia received end of life care when needed.
In line with recommendations from the ‘Bridging the Gap’ report (Woolf Institute) which looked at ways of strengthening relations between hospices and different cultures the registered manager had continued to embed the provider’s community engagement strategy to include visits to local mosques and synagogues.
The provider sought feedback from people, their relatives, staff and community professionals using various methods, which was overwhelmingly positive. All concerns and complaints had been reported, recorded and investigated in accordance with the provider’s complaints policy. The provider used concerns and complaints as an opportunity for learning and improvement.
People and their families made positive comments about the high quality of care provided and the effective management of each aspect of the service. Governance of the service was of a high standard and robust quality assurance systems were in place to ensure shortfalls would be identified and improvements made when needed. The Rowans Hospice annual Quality Account which is published on the provider’s website sets out the priorities for the service which are focused on patient safety, patient experience and clinical effectiveness.
The organisation’s vision and values emphasised respect for each other, put people at the heart of the service and focused upon enhancing the lives and wellbeing of people who used the services. We observed staff demonstrating these values in their everyday care practice.