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Inspection report

Date of Inspection: 9 February 2012
Date of Publication: 2 March 2012
Inspection Report published 2 March 2012 PDF | 53.28 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We reviewed all the information we hold about this provider, carried out a visit on 09/02/2012, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

People who come to Cotswold Care Hospice benefit from safe quality care, treatment and support. This is due to effective decision making from a service that monitors and assesses the quality of care.

Overall, we found that Cotswold Care Hospice was meeting this essential standard.

User experience

We asked people about giving feedback to the organisation about their care or other aspects of the service. One person said that they knew that they could give feedback verbally and would "write to them when I am discharged". One person had read a patient survey on the organisation website. People told us that they knew how to make a complaint. Although none of the people we talked with had made or had cause to make a complaint, they all said they felt it would be effectively dealt with.

Other evidence

We talked with the head of care services about how the service had assessed and monitored the quality of its care. The organisation was governed by a board of trustees drawn from local professional people. The hospice had two governance committees: a clinical governance committee and a resources and corporate governance committee.

The clinical governance committee met every eight weeks. We looked at minutes from the meetings in September 2011, November 2011 and January 2012. We saw that the organisation took account of the health and safety report and reports from the different areas of practice at the hospice. The committee also were made aware of achievements, significant events, critical incidents, and complaints. Future strategy was also discussed.

The clinical governance committee were presented with reports and data throughout the year. We saw reports that included a comparison for the hospice services with national data on hospices; drug and medical device alerts; referrals to services; and a six-month review of business plans.

The resources and corporate governance committee met every eight weeks. We saw minutes of the meetings from October 2011 and December 2011. Among the areas that this committee reviewed were the incidents and complaints, human resources, financial matters and business plans.

The organisation undertook a patient survey annually. The results of the 2011 survey were being collated and had not yet been presented to the board. We reviewed the results from 2010. The organisation had received feedback from 153 people. The report of the results of the service had an action plan to address areas where the service saw that improvements could be made. We saw evidence that some of the recommendations had been carried out when we visited. This included providing a covered walkway for people to use when entering the premises and making the carpark safer in cold weather. Overall, the report was positive with 92% of patients saying that care was either 'excellent' (85%) or good (7%).

The service had a number of regular staff meetings to discuss governance matters. This included heads of department meetings each week and regular other staff meetings. There was also regular one-to-one staff supervision and annual appraisals where staff could raise concerns.

The organisation had a complaints process and followed up complaints within policy guidelines. All complaints and responses were reviewed by the chief executive. The head of care services told us that lessons learned were cascaded through the organisation and practice was changed if there were any identifiable trends from accidents, incidents, near misses, and complaints.