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The Hospice of Our Lady and St John Good

Inspection Summary

Overall summary & rating


Updated 3 June 2015

The inspection took place on 24 March 2015 and was unannounced.

The Hospice of Our Lady and St John is known locally as Willen hospice. It provides up to 15 in-patient beds and out-patient care for adults who have complex needs and who are terminally ill.

There was a registered manager. 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.

People felt safe. They all had risk assessments in place, which were developed with input from the extended staff team.

Staff were aware of what they considered to be abuse and how to report this.

There were enough staff on duty, supported by volunteers, to ensure people were able to receive personalised care and support.

Effective recruitment processes were in place.

New staff were not allowed to start to work until provider mandatory induction and training had been completed.

Staff and volunteers attended a variety of training to enable them to support people using best practice techniques.

Medication was managed safely and processes in place ensured the handling and administration of medication was suitable.

People were supported to make decisions about their life and treatment plans. Staff were knowledgeable about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Capacity assessments had been carried out when required.

All of the food was freshly prepared, including home-made cakes, biscuits and ice cream. People were supported to eat and drink when required. People could ask for what they wanted to eat at any time.

Staff were very kind and caring.

There were health care professionals on site, including physiotherapists, and doctors, to support people’s health care needs.

We observed staff gaining consent to enter people’s rooms, before undertaking their therapy sessions and to enable inspectors to access confidential information.

People had up to date care/treatment plans, which they had been involved in developing.

The service had developed a 24/7 advice line for people, relatives and other healthcare professionals.

The service had a ‘wellbeing’ centre for people to use with support of therapists and health practitioners.

People’s privacy and dignity was respected at all times.

There was an effective complaints procedure in place, and lessons had been learned from past concerns.

People were complimentary about the registered manager and staff. It was obvious from our observations that staff, people who used the service and the management had good relationships.

We saw that effective quality monitoring systems were in place. A variety of audits were carried out and used to drive improvements.

Inspection areas



Updated 3 June 2015

The service was safe.

People felt safe.

Staff knew how to protect people from harm and abuse.

There were enough staff to ensure people were able to receive personalised care and support.

Medication was stored and administered effectively.



Updated 3 June 2015

The service was effective.

Staff were supported with regular supervision and annual appraisals.

Staff understood the Mental Capacity Act 2005 (MCA) which enabled them to support people to make decisions.

People were involved in menu planning, and supported to eat and drink if required.

People had access to health care professionals on a regular basis as part of their treatment.



Updated 3 June 2015

The service was caring.

People were complimentary about the care and support provided.

People were involved in the planning and review of their care plan.

People were treated with dignity and respect, and had the privacy they required.

Visitors were welcomed at any time.



Updated 3 June 2015

The service was responsive.

People had person centred care/treatment plans which they had been involved in writing.

The service had a 'wellbeing' centre, which included therapist and nurses, for people to access.

The service had a complaints system which was used effectively.



Updated 3 June 2015

The service was well led.

The service had a registered manager who was supported by a staff team and a board of trustees.

There were internal quality audit systems in place.

A service user group had been set up to promote service user involvement.