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Inspection report

Date of Inspection: 19 December 2013
Date of Publication: 17 January 2014
Inspection Report published 17 January 2014 PDF | 89.35 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 19 December 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

We found that the provider had appropriate quality assurance monitoring procedures in place which ensured that the provider had asked the views of people regarding the service


The provider had a three year audit/survey programme which outlined the areas to be covered and the implementation dates. We saw that the following had been completed the health and safety and the infection control audits and also the complaints policy had been updated. We saw audits/surveys in place for 2014 which included consent to share information and a "user feedback survey."

We saw the last provider visit which looked at the premises and complaints. The provider also conducted interviews with people who use the hospice and staff. Feedback from people were positive with the only concerns identified being the use of the word "hospice" and its perception.

We noted the incidents; accidents and complaints policies outlined the procedures to follow. We saw the "your comments matter" brochure which outlined how to make a complaint. People and staff we spoke with said they knew how to make and complaint and had no issues in doing so. Staff informed us that the manager had an "open door" policy for any issues or concerns. The chief executive told us they reviewed all complaints and we saw in place three monthly reports which outlined the accidents, incidents and complaints. The chief executive told us they collated all the quarterly reviews and submitted an annual review to the board which reported the trends for example, the number of personal accidents, clinical incidents, fire incidents and any violence/abuse. We noted complaints were completed in line with company policy. The accident report log and the incident report log included details of the accident/incident, the treatment given and the action taken.

The chief executive showed us a "learning from our mistakes or being blamed for them" leaflet they had produced. The chief executive informed us they gave a copy to staff and would discuss the merits of the leaflet with staff personally. The leaflet identified what staff should do in the event of identifying an error/mistake and how they company did not have a blame culture but supported staff in learning from the errors.

We saw compliments received which included "my counselling sessions have been so helpful" and how they "helped me cope with my grief." We saw a thank you to staff for being "pleasant, king and caring."

The provider completed a review of staff turnover which included an overview of staff retention and the reasons for staff leaving. The overview identified a reduction of lost staff down from 24% to 20% over the last three years. This was attributed to improved management practices around recruitment and skills.

We saw the provider held monthly meetings with staff which covered a variety of topics for example, competency framework, absence procedures and training.

We noted the hospice certificates and risk assessments had been regularly reviewed for example, cuts and bruises, slips and falls, electrical certificates. We saw the health and safety records covered emergency evacuation procedures. We noted that the fire alarm checks had been regularly tested. Overall, this meant the provider had systems and procedures in place to assess the quality of the service provided.