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The Mary Stevens Hospice Good

Inspection Summary

Overall summary & rating


Updated 1 October 2016

This inspection took place on 10 and 11 May 2016 and was unannounced.

Mary Stevens Hospice is registered to provide specialist palliative care and clinical support for adults with life limiting illnesses. The service provides care on their in-patient facility which catered for up to ten people. At the time of the inspection there were six people using the service. People could also access support from specialist nurses in day hospice. The services provided included counselling and bereavement support, day hospice care, family support, chaplaincy, occupational therapy, physiotherapy and complementary therapies. The day hospice could cater for eighteen to twenty people daily some of whom had also used the inpatient facilities.

The manager was registered with us as is required by law. 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 told us they felt safe. Staff were trained and understood their responsibilities in keeping people safe from harm or abuse. They knew how to recognise and report any concerns about people’s safety. Care was centred on the needs of the individual and included the management of any risks to their health or well-being

There were clear systems in place to review and analyse accidents and incidents and take action to reduce the reoccurrence of these.

Staff were recruited safely and doctors, specialist nurses, care staff and volunteers were qualified, supported and trained to meet people’s needs. The provider had lone working arrangements to ensure staff or volunteers who worked in the community were safe. People spoke highly of the availability and skills of staff to meet their needs.

There were systems in place to safely manage and administer medicines to people. People received their medicines for pain relief or symptom management without delay. A dedicated internal pharmacy lead supported medical staff to ensure people received their medicines in a safe and timely manner.

The rights of people to make important decisions about their health or wellbeing were protected because staff followed the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

People enjoyed the meals provided which catered for a range of people with specialist diets. People were supported to eat and drink and staff worked with other health professionals to promote people’s nutritional welfare.

Staff knew each person well and understood how to support them when they were unwell or approached the end of their life. People were at the heart of the service and fully involved in the planning and review of their care. This included the management of their pain and symptoms and their preferences and wishes with regard to their end of life care including their preferred place of death. People’s emotional and spiritual needs were explored and respected and people had access to complementary therapies to help manage their symptoms.

People told us staff were very caring, kind and receptive to their needs. People’s independence was encouraged and their privacy and dignity protected. Staff worked hard to provide lasting and memorable experiences for people and their family members so that they experienced compassionate care.

Leadership was strong and consistently looked at ways to promote the provision of palliative and end of life care for people. There was a clear management structure with good communication so that everyone, including the trustees, shared the same vision and plans for the future. The monitoring of the service was consistent and links with local and national organisations ensured the provider was sharing best practice.

Inspection areas



Updated 1 October 2016

The service was safe.

People were kept safe by staff who had been trained to recognise and respond to any potential abuse.

People were confident that staff managed risks to their health and safety and measures to reduce risks were in place.

People had no concerns about the availability of staff to meet their needs.

Medicines were well managed and people had access to pain management medicines when they needed this. Staff were trained and qualified in safe administration of medicines.



Updated 1 October 2016

The service was effective.

People were cared for by staff who were specifically trained to meet their needs and who had received support to develop their skills and knowledge via the dedicated training team within the service.

Staff understood and followed the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People were involved in making decisions about all aspects of their treatment and care.

People were supported to eat food and drink food of their choice to maintain their diet. People had access to healthcare professionals to ensure the best outcomes for them.



Updated 1 October 2016

The service was very caring.

People were overwhelmingly positive about the caring approach and nature of staff and volunteers and valued their relationship with them.

People were supported to express their choices and to be involved in all aspects of their care.

People were supported in a caring way with dignity, respect and kindness.



Updated 1 October 2016

The service was responsive

People and their families experienced personalised care that reflected their wishes and what was important to them.

People were supported in planning their end of life care. Advance care plans included their end of life care preferences and choices so that care was responsive to their needs.

People knew how to make a complaint and were confident staff and managers would be receptive to their feedback.



Updated 1 October 2016

The service was well-led

The staff and management team placed people at the heart of everything they did. There was a very inclusive culture with people, families and staff feeling involved, listened to and appreciated.

There were systems in place to monitor the quality of the service and these focused on the continual improvement of the service.

The provider worked in partnership with other organisations to ensure they followed best practice and provided a high quality service.