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The Mary Stevens Hospice Outstanding


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about The Mary Stevens Hospice on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Mary Stevens Hospice, you can give feedback on this service.

Inspection carried out on 25 and 26 February 2020

During a routine inspection

The Mary Stevens Hospice provides specialist palliative care to adults aged 18 years and older.

The inpatient unit could provide services for up to ten patients at a time, with 24 hour nursing and medical support. Patients could be referred to the inpatient facility for symptom control, terminal care, respite care and crisis intervention.

The day services unit offered a full range of care, therapy and support services for those with life-limiting illnesses which includes medical advice and support, physiotherapy and occupational therapy, complementary therapies, recreation activities and social activities. The day service unit has capacity to accommodate up to 25 patients a day, Monday to Friday.

This was the second inspection of this service. It was previously inspected in 2016 and rated Good overall. We inspected this service using our comprehensive inspection methodology. This was an unannounced inspection (they did not know that we were coming). We carried out our inspection on the 25 and 26 February 2020.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Services we rate

Our rating of this service improved. We rated it as Outstanding overall.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Risk assessments considered patients who were deteriorating and in the last days or hours of their life.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Patient’s needs were constantly assessed and identified with treatments and opportunities aligned to their needs and wishes. Patients nearing the end of their life were encouraged to think about wish lists to allow the staff and those close to fulfil those that were possible.
  • People’s individual needs and preferences were central to the delivery of tailored services. The service had innovative ways to provide integrated person-centred pathways. Services were flexible to meet patient’s needs.
  • The service took a proactive approach in understanding the needs and preferences of different groups of people and delivered care which met these needs. Staff made reasonable adjustments to meet the needs of patients, including those with protected characteristics.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and fully aligned to local plans within the wider health economy.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals (Midlands)

Inspection carried out on 11 May 2016

During a routine inspection

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 carried out on 5 December 2013

During a routine inspection

The service was undergoing some refurbishment to change one of their three bedded wards into three separate en-suite rooms. During this change, there were seven places available for people. There were four people using the service at the time of our inspection. We spoke with one person, two relatives, eight staff members and the registered manager of the service.

People�s care plans were detailed to include information about their needs. We saw that people received person centred care. One person told us, �It is very good here, excellent really.�

Staff were aware of their duties to protect people. We found that arrangements were in place to ensure that people were protected from the risk of abuse.

Selection and recruitment processes were robust. We found that staff had the necessary checks completed before they worked at the service.

The service had robust systems in place to monitor the quality of the service. We found that improvements were made and action was taken when needed. One relative said, �We really can�t complain, they are very good.�

Inspection carried out on 16 January 2013

During a routine inspection

We spoke with the nominated individual, three nursing staff, two domestic staff, staff who worked in the day hospice providing complementary therapies, and volunteer staff. We visited the ward and the day hospice and spoke with eight people receiving a service.

People told us staff told us the hospice staff treated them with respect, were professional and helped them with many aspects of their daily lives. One person commented how staff explained everything and how they enjoyed the activities and therapies provided.

People told us they were made very comfortable and were fully involved in all decisions about their care and treatment. People told us that staff were supportive and friendly. One person said, "They tell me about the treatments available and they listen to what I want and don�t want, it makes a big difference to how you feel".

We saw the hospice was clean and well maintained. One person commented, "It is very clean, it�s comfortable and not much like a hospital setting. It�s fairly private because we have the curtains around our beds�.

We found that people had their pain relief as they needed it. One person told us, �As soon as I need a new pain relief the nurses sort it out, this is so much quicker than if I was at home�.

People told us they were confident in the abilities of all the staff.

Inspection carried out on 7 July 2011

During a routine inspection

People we spoke to were very complimentary about the home.

They told us

" The staff are very good"

"The care is very individual and personal"

"The staff are great they care for me very well"

People told us that they were very happy with the care they received and that the care was very specific to their individual needs.

People told us that staff are very approachable, helpful and caring.They told us they can have something to eat and drink when they want. They told us staff always consult them about their individual needs.

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