Hospiscare

Updated 1 July 2016

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. The service was last inspected in November 2013 and found to be compliant in all areas inspected. This inspection took place on 21, 22, 24 March and 11 April 2016. The first day was unannounced and subsequent visits were organised to ensure we met with key people within the service.

The inspection team consisted of a lead inspector, a bank inspector, a pharmacist inspector, an expert by experience and a specialist advisor in palliative care. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert-by-experience who took part in the inspection had specific knowledge of caring for older people who approached the end of their lives.

Before our inspection we looked at records that were sent to us by the registered manager and the local authority to inform us of significant changes and events. The registered manager sent us a Provider Information Return (PIR). The PIR is a form that asks the provider to give some key information about the service, what the service does well and what improvements they plan to make.

We looked at the premises, spent time in Searle House inpatient unit, outpatient clinics and day services and went out on visits with the community nurse specialists (CNS) and a Hospice at Home community nurse specialist. We were able to visit people in their own homes with their permission. We looked at ten sets of records that related to people’s care on the electronic computer record system. We looked at the systems in place for managing medicines, spoke to staff involved in the administration of medicines, and examined ten people’s medicines charts. We looked at six people’s assessments of needs and care plans, two hospice at home records and records for people in the community. We consulted documentation that related to staff management, training and supervision and four staff recruitment files. We looked at records concerning the monitoring, safety and quality of the service and the activities programme. We observed a ‘ward round’, staff handover, a community palliative care team meeting, multidisciplinary team meetings and the administration of medicines. We sampled the service’s policies and procedures.

We toured all areas of Searle House inpatient unit and spoke with three people who were receiving care in the inpatient unit and three of their relatives. We spoke with two people in the outpatient clinic and their relatives. We also spoke with three people receiving care from the Hospice at Home service and one relative and two people and three relatives in their homes who had visits from the community nurse specialist team. We visited the specialist dementia day centre spending time with eight people and spoke to the community nurse specialists and chef based there. We also visited a nursing home participating in a care home training project with the hospice.

We spoke with the registered manager/director of nursing, assistant director, the chief executive, chaplain, the inpatient unit manager and eight registered nurses, four doctors, two specialist palliative care consultants, the Hospice at Home team leader, health care assistant and six community nurse specialists. We also spoke with the kitchen staff, training team manager and assistant, an administrator, a volunteer and the estates manager. We obtained their feedback about their experience of the service.

Updated 1 July 2016

Hospiscare is a charity which was founded in 1982 as a community service which expanded to include the building of a purpose built inpatient unit in 1992. Hospiscare serves the people of Exeter, Mid and East Devon. In 1995 Hospiscare appointed a specialist nurse to work at the Royal Devon and Exeter Hospital to visit patients and provide education and this has grown to a small specialist team. Hospiscare provide palliative and end of life care, advice and clinical support for people with progressive, life limiting illnesses and their families and carers. They deliver physical, emotional and holistic care including counselling and bereavement support, outpatient clinics, occupational and creative therapy, complementary therapy, chaplaincy and volunteer services. The hospice inpatient unit at Searle House Hospice is registered to provide care for up to 12 adults who require complex symptom control or end of life care. The average length of stay is two weeks. The service provides acute care for people and does not provide a respite service or have longer stay beds. In 2006 a new visitor accommodation was opened allowing families to stay close to the ward. The majority of people are cared for in the community, currently around 770 people. Last year Hospiscare cared for 2,225 people, their families and loved ones. The service also has sister charities which provide community care for people in Exmouth, Budleigh Salterton and Sidmouth and three day centres, a Wellbeing Suite in Exeter and day centres in Tiverton and Honiton.

The service continuously looked at the local community to see how best they could provide the service. This had resulted in the expansion of day service provision and the Hospice at Home service in Seaton, East Devon. This comprised of a team of registered nurses, community nurse specialists and health care assistants working closely with local GPs. This meant that people in Seaton benefitted from a holistic service from the Hospiscare Hospice at Home team who could also provide district nursing support in people’s homes therefore maintaining consistency and reducing the number of professionals visiting their homes. The Hospiscare Hospice at Home service started in July 2015 and provides responsive end of life care and support to patients and their families in their own home or a care home. The service operates 24 hours a day, 7 days a week with access to doctors, registered nurses and health care assistants as well as ancillary staff and therapists.

The Hospice at Home staff were all employed by Hospiscare and worked with other health care professionals in the community. Services were free to people and Hospiscare was largely dependent on a large team of volunteers, donations and fund-raising. A comprehensive training centre in Exeter also offered advice and support to Hospiscare staff and external health professionals such as those in nursing and residential care settings in the community. The service had also recognised a need to provide specialist training and end of life care for people living with dementia and their carers, recently employing a specialist dementia care nurse, and had established links with the local prison service. The service was outstanding in the way they explored and maintained close partnerships with a wide range of external services providing end of life care such as other charities, community health professionals, hospitals and on-call out of hours services, agencies and care providers. The service worked in partnership with other organisations to drive improvements at national level for the benefit of people who used hospice services as a whole .

This inspection was carried out on 21, 22, 24 March and 11 April 2016 as it was a large service covering Exeter, East and Mid Devon. It was carried out by a lead inspector, a bank inspector, a pharmacist inspector, an expert by experience and a specialist advisor in palliative care. It was an unannounced inspection. There was a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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. They oversaw the running of the service and were supported by a leadership team that included the chief executive and directors, assistant directors and department managers. The service was last inspected in November 2013 and found to be compliant in all areas inspected.

The service provided outstanding end of life care and people were enabled to experience a comfortable, dignified and pain-free death in the place of their choice as much as possible.

Staff were trained appropriately and had excellent knowledge of each person and of how to meet their specific support needs. Staff went that extra mile to ensure people’s needs were met in a holistic way including support for people’s loved ones. Hospiscare were pro-active in providing support and training for external services and health professionals in the community and had a culture of sharing knowledge and education. Staff had received essential training including end of life care and were scheduled for regular refresher courses. Staff had received further training specific to the needs of the people they supported. All members of care and support service staff received regular one to one or group supervision and support with clinical supervision and professional validation. This ensured they were supported to work to the expected standards and career progression and knowledge was encouraged.

People’s feedback was actively sought, encouraged and acted on. People and relatives were overwhelmingly positive about the service they received. They told us they were extremely satisfied about the staff approach and about how their care and treatment was delivered. Staff approach was kind and compassionate. Relatives told us staff were very supportive and kind and nothing was too much trouble for them. People’s feedback about the caring approach of the service and staff was overwhelmingly positive and described it as “amazing.” Clear information about the service, the facilities, and how to complain or comment was provided to people and visitors and there was opportunity for people to be directly involved in providing comment and feedback linked to formal audits.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm. Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced.

There were sufficient staff on duty to meet people’s needs. Staffing levels were calculated and adjusted according to people’s changing needs. There were thorough recruitment procedures in place which included the checking of past conduct and suitability from previous employment to ensure staff were suitable to work with vulnerable people.

Staff communicated effectively with people, responded to their needs promptly, and treated them with genuine kindness and respect. Staff knew each person well and understood how people may feel when they were unwell or approached the end of their life. They responded to people’s communication needs. People and/or their families were at the heart of the service and were fully involved in the planning and review of their care, treatment and support. One relative confirmed, “I am always informed if there’s any problem or change in the care plan.” Plans in regard to all aspects of peoples’ medical, emotional and spiritual needs were personalised and written in partnership with people. Staff delivered support to people according to their individual plans and provided outstanding care.

The environment of the inpatient unit was purpose built and had been well utilised for ease of access for people. It was welcoming, well maintained and suited people’s needs. The clinics, therapies, day centre and support groups were held in the same building in Exeter surrounded by well maintained, accessible and beautiful grounds. The building was opposite the Royal Devon and Exeter Hospital with whom they had a close relationship and the Palliative Care Hospital Team was based in Searle House.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to hospices. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options were considered the requirements of the Mental Capacity Act 2005. People’s privacy was respected and people were assisted in a way that respected their dignity. Staff sought and respected people’s consent or refusal before they supported them.

The staff provided meals that were in sufficient quantity and met people’s needs and choices. People praised the food they received and they enjoyed their meal times. Staff knew about and provided for people’s dietary preferences, restrictions and reduced appetite.

People were involved in the planning of activities that responded to their individual needs. The hospice mainly cared for people with acute needs meaning they were unwell or at the end of their lives. Therefore, activities in the inpatient unit were more based on therapeutic methods such as therapies and spending time with people. Day centres provided more varied and creative activities based on people’s needs such as a specialist day centre for people living with dementia. Attention was paid to people’s individual social and psychological needs.

The registered manager was open and transpa