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The Hospice of Our Lady and St John Good


Inspection carried out on 24 March 2015

During a routine inspection

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 carried out on 23 June 2014

During a routine inspection

We considered all the evidence we had gathered under the outcomes we had inspected to answer questions we always ask; is the service caring? is the service responsive? is the service safe? is the service effective? is the service well lead?

This is a summary of what we found-

Is the service safe?

Patients told us they felt safe at Willen Hospice. Individual plans of care contained risk assessments to promote patients' safety such as risk assessments for malnutrition, the risk of falls and movement and handling. We saw that patients were assessed for the risks associated with the effects of pressure on the body and had access to appropriate pressure relieving equipment. We also saw that patients assessed as being at nutritional risk were closely monitored and had access to an NHS dietician.

We saw bedrooms were fitted with appropriate safety equipment such as call bells, radiator guards, and fire doors were fitted with automatic closure devices. No slip or trip hazards were identified and robust Infection control procedures were in place. Medical equipment was available for use in the event of a life threatening emergency.

We found that staffing levels were maintained to ensure that patients' needs could be met and that a training plan was in place to ensure staff had the right skills to care for people safely.

Quality assurance systems were robust and ensured that the environment and equipment was safe to use; for example regular checks were conducted to ensure that hot water was dispensed at safe temperatures, to prevent scalding.

Is the service effective?

All of the patients who received care at Willen Hospice had an individual plan of care; daily nursing and medical records showed that patient�s personal and clinical needs were effectively met in a timely way.

Care and treatment was managed according to national guidelines and staff had been suitably trained. This means that staff were providing evidence based care.

Nursing and care staff were swift to respond to the patients' needs and call bells were answered in a timely way. We found that patients were promptly referred to other health professionals when required for example for specialist pain relief, physiotherapy and speech and language therapy.

Is the service caring?

Patients and their relatives told us that the staff treated them well we saw that staff treated people with respect and consideration and were mindful of their privacy.

We also observed that staff were swift to respond to patients' needs and they supported them when they became distressed. We also observed that patients were referred to by their preferred name.

People looked well cared for and we saw that people had access to a range of aids and adaptations to support their mobility and independence.

Is the service responsive to people�s needs?

Improvements had been made to the provision and access to specialist clinical expertise within the unit. Medical staff had access to national guidelines in relation to the management of end of life care and access to training and guidance.

Staffing levels had been maintained at an appropriate level in relation to the needs of the patients; this meant that the quality of care and support that staff were able to provide was maintained.

We saw that people had access to appropriate aids and adaptations to promote their independence and mobility. Records showed that people had access to appropriate care, including access to pressure relieving equipment. Records also showed that people had access to health professionals and other NHS services.

We also saw that patients and their representatives had been consulted about their wishes in the event of a life limiting medical emergency; we saw the appropriate documentation had been completed by medical staff which demonstrated that the patient�s views and medical conditions had been taken into account.

Is the service well led?

The registered manager and the provider had conducted the appropriate checks to ensure that patients were safely cared for. Systems were in place to ensure that staff had the right skills to care for people safely. Individual plans of care had been reviewed and improvements had identified. Risk assessments were in place to reduce and manage the impact of identified risk factors.

A range of audits were conducted on a regular basis to assure the safety and quality the service provided. These included audits of the fire safety systems, hot water temperature safety checks, medication systems, infection control systems, health and safety systems and the safety of environment.

The management sought the views of patients and their relatives to identify areas for improvement to the service delivery.

Inspection carried out on 3 December 2013

During a routine inspection

We spoke with five people who were using the service, they all told us that the staff were very good. One person told us that �the staff are very attentive�, another person told us �the staff are so good, they seem to like and enjoy their job�.

We spoke with the relatives of one person, they told us that the staff were very supportive and had particularly helped one of them cope with their relative�s illness; they told us �there was someone there for them�.

We found that the Hospice was a nurse led organisation which provided palliative care. The nursing staff had a supportive network and nurses were provided with the education they required to meet people's needs. There was a lead speciality doctor who led the medical team. There was a part time consultant on two sessions (one day) a week. However neither the medical or nursing staff were aware of up to date protocols used for the control of symptoms in end stage heart or kidney failure. There had not been a medical director in the organisation for the previous five months which may have led to the Hospice becoming isolated from other hospice services or other consultants in palliative care medicine. The organisation had taken steps to rectify this and at the time of inspection was in the process of appointing a Consultant in Palliative Care Medicine, who would also become the medical director.

Inspection carried out on 27 November 2012

During a routine inspection

We spoke with patients and their relatives about the care they had received from Willen Hospice. They told us that they had received very good care and one person told us that the treatment they received improved their quality of life.

We found that Willen Hospice followed national guidelines to provide care and treatment that met people�s needs. However we found concerns over the lack of information available to those who may want to make a complaint.

Reports under our old system of regulation (including those from before CQC was created)