Butterwick Hospice Stockton

Updated 15 November 2021

Butterwick Hospice Stockton was operated by Butterwick Limited. Butterwick Limited was registered as a charitable trust and received funding from the NHS. The hospice had seven inpatient beds and a day hospice and provided care for adults from Stockton, Middlesbrough, and surrounding areas. At the time of the inspection the hospice was admitting a maximum of two adults each week, Tuesday to Sunday for respite care.

Butterwick Hospice is registered to provide treatment of disease, disorder, or injury. We inspected hospice services for adults. At the time of our inspection there was a registered manager in post.

We previously inspected Butterwick Hospice Stockton in May 2021 and raised significant concerns with the provider by issuing a warning notice relating to breaches of Regulation 12 and 17. In addition we issued the provider with requirement notices and told the provider that it must take prompt action to comply with the regulators. In response the provider issued an action plan outlining how the service had taken action to address these concerns outlined within the warning notice.

This inspection was an unannounced focused inspection of the safe and well led domains to gain assurance the provider had acted in response to the concerns highlighted in the warning notice that had been issued to the provider following the May 2021 inspection.

Updated 15 November 2021

Our rating of this location stayed the same. We rated it as inadequate because improvements made since our last inspection did not yet justify a higher rating:

• Staff did not always receive the correct level of training on how to recognise abuse but they knew how to report it. Staff did not always complete and update risk assessments for each patient and remove or minimise risks. Staff did not always identify and quickly act upon patients at risk of deterioration.
• Staff did not always keep detailed records of patients’ care and treatment. Records were not always clear, or up to date, but were stored securely and easily available to all staff providing care.
• The service did not always use systems and processes to safely prescribe, administer, record and store medicines.
• We were not assured incident reporting had been embedded because we found examples of incidents not being investigated such as medicine discrepancies and poor admission.
• Staff did not monitor the effectiveness of care and treatment. They did not use the findings to make improvements and achieve good outcomes for patients.
• Evidence of consent to treatment was not recorded in accordance with the provider’s policy.
• The provider was undergoing a significant process of change, made up of many different programmes of work. There was an absence of any oversight or management of this. The leadership team had gaps in its skills. The governance structure was new and not embedded. Leaders did not run services well using reliable information systems but did support staff to develop their skills.

However:

• The service had enough staff of the right competence and skills to provide the respite service and day care service (physiotherapy and therapy) it was providing;
• The environment was clean and un-cluttered;
• Staff appeared enthusiastic about working at the service and said they had visible leaders.

Following our inspection, we raised significant concerns with the provider by issuing a warning notice relating to breaches of Regulation 12 and 17. In addition, we issued the provider with requirement notices and told the provider that it must take prompt action to comply with the regulations.

Updated 15 July 2021