All inspections: Butterwick Hospice - Care Quality Commission

Butterwick Hospice is operated by Butterwick Limited. The hospice is purpose built; is fully accessible and has appropriate facilities for day care, therapies and family support. The hospice provides adult hospice services that includes palliative and neurological day care, family support services for adults, children and young people and a home care service for palliative and end of life patients. The hospice does not have inpatient beds. We inspected the service using our comprehensive inspection methodology. We carried out an unannounced inspection on 1 and 2 February 2022. During the inspection we visited the hospice’s day care service at Bishop Auckland and one patient who was receiving care at their home.

Following this inspection. we served the provider a Warning Notice under Section 29 of the Health and Social Care Act 2008. The warning notice told the provider they were in breach of Regulation 17 and gave the provider a timescale to make improvements to achieve compliance. The principles we use when rating providers requires CQC to reflect enforcement action in our ratings. The warning notice identified concerns in the safe and well-led domain. This means that the warning notice we served has limited the rating for safe and well-led to inadequate.

Our rating of this location went down. We rated it as inadequate because:

The service did not have effective systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users.
There was no clearly defined purpose of the Hospice at Home service provided at Bishop Auckland and staff were not suitably trained to deliver care in line with the purpose.
Staff did not have appropriate policies and guidance to support them to deliver care in line with the service’s purpose. There was no appropriate oversight of the service provided at Bishop Auckland to ensure staff were delivering care in line with the service’s purpose.
The service did not have an admissions policy, operational policy, service specification, standard operating procedure or similar document which would identify the remit of the service and identify whether the service was able to meet service users’ needs.
The service did not have a policy or procedure for staff to follow in situations where service users’ risks had changed, or where a service user had deteriorated or become seriously unwell.
Not all staff had completed training in the Mental Capacity Act and Deprivation of Liberty Safeguards; Loss and Bereavement; Palliative Care; Incident Reporting; or Lone working.
Governance systems did not identify or monitor the quality of care provided and there was lack of oversight from senior leaders.

However:

Staff demonstrated caring, compassionate interactions with patients and their families.
The service had an open culture and staff felt confident to be able to raise and escalate concerns.
Service users we spoke with spoke highly of staff and the care that they received.
People could access the service when they needed it and did not have to wait too long for treatment.
Patients and families using the service were very happy with the care they had received.

Due to the focused nature of this inspection, we inspected but did not rate the service.

The service did not always provide mandatory training in key skills to all staff and did not always make sure everyone completed it. Managers did not always monitor mandatory training and did not always alert staff when they needed to update their training.
The service did not always manage safety incidents well and learn lessons from them. The provider did not collect safety information and use it to improve the service.
The service did not have robust oversight of patient outcome monitoring. They did not use the findings to make improvements and achieve good outcomes for patients.
Leaders did not always have the capacity, skills, and abilities to run the service. There remained confusion between senior leaders regarding their roles and accountabilities.
Leaders and teams did not always use systems to manage performance effectively. They did not always identify and escalate relevant risks and issues and identify actions to reduce their impact.

However:

The completion of patient records had improved, although gaps across the documentation was evident.
Some progress had been made that indicated improvements in the operation of effective governance processes within the service. The provider had taken action to establish a system to maintain oversight of the ratification process for policies.

Our inspection found significant concerns and found continued breaches of regulation which meant that the provider had not complied with the warning notice we issued following the inspection in May 2021. We have issued a notice of decision to impose conditions on the provider's registration.

We did not rate this service at this inspection because we focused only on aspects of the service that required improvement at our last inspection. We found that:

Staff did not always have training in key skills or manage safety well. The service did not always assess risks to patients or act on them and keep good care records. The service did not always manage safety incidents well and learn lessons from them. Staff did not collect safety information and used it to improve the service. There is an increased risk that people were exposed to the risk of harm or there is limited assurance about safety.
Managers did not always monitor the effectiveness of the service and make sure staff were competent. Consent was not recorded for patients receiving care and treatment. People are at risk of not receiving effective care or treatment. There is a lack of consistency in the effectiveness of the care, treatment and support that people receive.
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. Leaders did not run services well using reliable information systems or support staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. The service did not always engage well with patients and the community to plan and manage services. The governance structure was new and not embedded.

However:

The service had enough staff to care for patients and keep them safe.
The environment was visibly clean.
Staff felt respected, supported and valued.

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.

Butterwick Hospice is operated by Butterwick Limited. The hospice was purposely built; is fully accessible and has appropriate facilities for day-care, therapies and family support.

The hospice provides adult hospice services that includes; palliative and neurological day-care, family support services for adults, children and young people and a home visiting service for palliative care and end of life patients. The hospice does not have any inpatient beds. We inspected this service using our comprehensive inspection methodology.

We carried out a short-notice announced inspection on 3, 4 and 10 March 2020. During the inspection, we visited the hospice at Bishop Auckland and the day-care facility at Sedgefield community hospital. We also visited two patients at home who were receiving care from the home care team. We spoke with 15 staff including registered nurses, health care assistants, reception staff, medical staff and senior managers. We spoke with seven patients and relatives using day-care services and two patients and their family members on home visits. During our inspection, we observed patient care and interactions and reviewed ten sets of patient records. We also reviewed other information and data about the hospice and provided by the hospice to make our judgements.

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.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We rated the service as requires improvement overall. We rated safe, effective, responsive and well- led as requires improvement. We rated caring as good.

We found areas of practice that require improvement:

Patient risks were not identified, assessed and monitored in a consistent manner across all areas of the hospice and re-assessments were in-frequent.
Health and safety risks were not consistently identified assessed and document. They were not always escalated so they could not be adequately addressed and reviewed.
Policies and processes regarding management of medicines did not meet the needs of all areas and were therefore unfit for purpose. This had led to inconsistent practice in different areas.
Not all staff and leaders were clear about their roles and responsibilities in relation to governance and performance.
The provider had a large number of policies and procedures that need to be brought up to date and in line with current guidance and best practice. This was an ongoing piece of work.
Staff and managers were not clear about their responsibilities in relation to ‘Duty of Candour’
The hospice needed to improve the information it collected and how it used it, to improve services and patient outcomes. Audits were infrequent and feedback and improvement actions were not monitored. These were not always checked to see if improvements had been made or sustained.
The hospice did not monitor waiting times in all parts of the service or monitor the impact of long waits on patients.

We found good practice:

The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so
Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
Staff gave patients enough food and drink to meet their needs and improve their health. Staff gave patients and families practical support and advice to live well.
Staff supported patients to make informed decisions about their care and treatment. Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
Leaders and staff actively and openly engaged with patients, staff, the public and local organisations to plan and manage services. Staff felt respected, supported and valued and could raise concerns without fear. All staff were committed to continually learning and improving services.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notices. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals, North

The inspection took place on 10 June 2015 and was unannounced. This meant the provider or staff did not know about our inspection visit.

Butterwick Hospice provides care for up to 10 day care patients Monday to Friday. The hospice provides a sitting service within the community, a range of complementary therapies including physiotherapy and family support.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

There were sufficient numbers of staff on duty in order to meet the needs of people using the service. The provider had an effective recruitment and selection procedure in place and carried out robust checks when they employed staff.

We saw evidence that the provider and staff had a thorough knowledge of safeguarding. Staff had easy access to policies and procedures.

We saw a copy of the provider’s complaints policy and procedure and saw that complaints and concerns were always taken seriously.

Training records were up to date and staff received regular supervisions, appraisals and a personal development plan was also completed, which meant that staff were properly supported to provide care to people who used the service.

We saw staff and volunteers supporting people in the dining rooms at lunch and a variety of choices of food and drinks were being offered.

All of the care records we looked at contained care plan agreement forms, which had been signed by the person who used the service or a family member.

The hospice was exceptionally clean, spacious and suitably adapted for the people who used the service.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. We discussed DoLS with the registered manager and looked at records. We found the provider was following legal requirements in the DoLS.

People who used the service were extremely complimentary about the standard of care and support provided.

We saw staff supporting and helping to maintain people’s independence. We saw staff treated people with dignity, compassion and respect and people were encouraged to remain as independent as possible.

We saw that the hospice had a full programme of activities in place for people who used the service, including a range of complementary therapies.

All the care records we looked at showed people’s needs were assessed before they attended the hospice and we saw care plans were written in a person centred way.

The provider had a robust quality assurance system in place and gathered information about the quality of their service from a variety of sources including people who used the service and their family and friends.

During our inspection we asked the provider, staff and obtained comments from people who used the service about the following; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, comments from people using the service and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People's comments included;

"I expected to meet others with similar problems but did not appreciate how much benefit I would get from having a 'me day'.

"Having contact with other people who had experienced the same things that I have has helped me a lot.".

"Coming here has given me confidence, it's a change of scenery and it's good to meet other people".

"All the staff and volunteers can't do enough for me. I appreciate everything".

"I look forward to coming to the day hospice because it's a day when my family don't have to worry about me". "it has definitely aided my recovery".

"It is the best thing that has ever happened to me in respect of getting back to life after being so ill".

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

We saw the service had not had to make any safeguarding referrals in the past 12 months but processes were in place to support staff if it was required to do so.

We saw that the service promoted equality, diversity and human rights, and adhered to the government's 'End of Life Care Strategy' that highlighted the importance of being treated as an individual and with dignity and respect. We saw people were consulted about their preferred place of care.

The hospice had proper policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager told us no applications had needed to be submitted. However we found relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant people were safeguarded as required.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk.

Is the service effective?

There was an advocacy service available if people needed it, this meant people could access additional support when required.

People's health and care needs were assessed with them, and they or their representatives were involved in writing their plans of care. Specialist dietary, social, mobility, equipment and pain control care needs had been identified in care plans where required.

People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely. The premises had been sensitively adapted to meet the needs of people with physical, memory and mental health impairments.

Visitors were able to see people in private and that visiting times were flexible.

Is the service caring?

We saw staff and volunteers showed patience and gave encouragement when supporting people.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised, we saw these had been addressed by the provider.

People's preferences, interests, aspirations and diverse needs were recorded and care and support was provided in accordance with people's wishes.

Is the service responsive?

People completed a range of activities in and outside the service regularly. The hospice had its own adapted transport, which helped to keep people involved with their local community. This was also used to transfer people to the day hospice.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system. The records we looked at showed any shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the hospice and the quality assurance systems in place. This helped to ensure that people received a good quality service.

Staff told us they felt supported in their role and we saw staff supported each other throughout the inspection.

People or their relatives were able to give consent to the care, treatment and support they received. Comments on the patient satisfaction survey (November 2012) to the question did you receive a clear explanation of the service available included 'they were very informative' and 'just the right amount of information'.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We spoke with three people who used the service. They were all very positive about the care and support received. Comments included 'I really enjoy meeting the other patients and staff ' they give me lots of support' and 'the staff are so friendly'.

The provider had taken steps to provide care in an environment that was suitably designed and adequately maintained.

People had their health and welfare needs met by sufficient numbers of appropriate staff.

People's personal records were accurate and fit for purpose.

People who used the service told us they understood the care and support services available to them, and that they were involved in making decisions about them.

People told us they were treated respectfully by staff and the support the hospice could provide was clearly explained to them before they choose to attend the day hospice.

Everyone we spoke to was very happy with the care and support they received. One person told us with the support of a physiotherapist he used the hospice gym which he thought helped him a lot.

People told us 'There is a lovely friendly atmosphere here'. 'The staff are very kind and caring'

Butterwick Hospice Bishop Auckland had a day care service where people could enjoy social activities and a variety of treatments and therapies, including physiotherapy and aromatherapy. The day care service offered 16 places a day, 4 days a week, including daycare for specialist disease groups.

The hospice also offered outreach day centres held at local hospitals which allowed people to receive day centre services closer to home. The palliative home care service provided personal care and support for people in their own homes.

We spoke with some people using the day service and the palliative home care service. People were overwhelmingly positive about the services they received. Their comments included:

'I get lots of information here that I wouldn't have known about ' they even brought in the benefits agency and I found out about benefits that I'd never heard of before.'

'Someone always rings us up to let us know who is coming to visit.'

'I also have access to many other (nursing) services that I would struggle to see if I wasn't coming here.'

'The staff are great, they're always there to help with anything you ask for.'

'They're always asking for feedback, always asking us whether things are a benefit to us or not.'

'It's a fantastic service - it's a godsend.'

'If it wasn't for this service I would have given up. I wouldn't be here without this service.'

'The physio and aromatherapy are brilliant.'

'It depends on my stage. Each week I let the physiotherapist know what I need and they gear the exercises for me ' and my needs can change every week, so I have a full say in what my treatment is.'

'The staff are superb, I can't fault them.'

'The physios and aromatherapists are brilliant ' I wish I could have them everyday.'

'They give us feedback forms to fill in all of the time, they're very good here and they want to make the service the best it can be for us.'

These older reports are from our old approaches to inspection, including those from before CQC was created.

Butterwick Hospice

All Inspections

01-02 February 2022

During a routine inspection

09 September 2021

During an inspection looking at part of the service

04-06 May 2021

During an inspection looking at part of the service

03 to 04 March and 10 March 2020

During a routine inspection

10/06/2015

During a routine inspection

8 July 2014

During a routine inspection

17 May 2013

During a routine inspection

29 August 2012

During a routine inspection

25 October 2011

During a routine inspection

Reports under our old system of regulation