We carried out a review of the data available to us about Derian House Children's Hospice on 6 July 2023. 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 Derian House Children's Hospice, you can give feedback on this service.
Derian House Children’s Hospice provides services for children and young people from across the North West of England with life limiting or life-threatening conditions. The hospice is set in its own grounds and provides accommodation in the main house and the adjacent lodge. At the time of inspection, the hospice was being refurbished to create facilities which were fit for the ever-changing needs of children and young people now and in the future. The main house was closed for respite during the refurbishment, but the lodge remained open. The service had reduced capacity to four beds to be able to continue providing respite with end of life care in a safe and efficient manner. Following refurbishment, the hospice will have 10 single patient rooms, one end of life care suite with a family lounge attached and five fully accessible en-suite family apartments.
We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on the 19 and 20 September 2019, along with an announced visit with the Derian at Home team on the 7 October 2019.
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.
Services we rate
Our rating of this service improved. We rated it as Outstanding overall.
We found outstanding practice in relation to the hospice:
Staff and management were fully committed to the visible person-centred approach. They all used creative ways to make sure that children and young people had accessible, tailored and inclusive methods of communication.
Staff always treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and proactively took account of their individual needs.
The service had a strong, visible person-centred culture that was exceptional at helping staff, patients and their families express their views so that they understood things from their point of view.
Staff were highly motivated and inspired to offer care that was kind and compassionate. Bereavement services were tailored to individual needs and were provided over a significant period after death.
The service had a holistic approach to supporting patients, families and carers to minimise their distress. Patients were treated as individuals and staff understood patients’ personal, cultural and religious needs.
Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Staff and management were fully committed to the visible person-centred approach.
Children, young people and their families’ needs were at the heart of all services planned and delivered by the service. The service worked with others in the wider system and local organisations to plan and deliver patient-centred care.
The service was wholly inclusive and took account of the totality of children, young people and their families individual needs and preferences. Staff made reasonable adjustments to help patients access services. They proactively coordinated care with other services and providers.
Children and young people’s care were planned proactively in partnership with them and their families. Staff used innovative and individual ways of involving them so that they felt consulted, empowered, listened to and valued.
Professionals from external services stated that the hospice was focused on providing a happy and fun environment. The implementation of the hospice values was achieving excellent feedback and was to be presented nationally.
The service was flexible and responsive to children, young people and their family’s needs. The service used innovative ways to support people in the community when they were not with them. Where required, there was a rapid response to peoples changing care needs and advice on care and support was available 24 hours per day, seven days per week.
Children, young people and their families were encouraged to give their views and raise concerns or complaints. Feedback was valued, and service users felt that the responses to the matters raised were dealt with in an open, transparent and honest way.
Leaders were committed and passionate about patient care and provided a high-quality sustainable service. They had the skills and abilities to run the service and clearly understood and managed the priorities and issues the service faced. Leaders were visible and approachable for patients and staff. They supported staff to develop their skills and take on more senior roles.
The service had an imaginative and child-centred vision and a clear strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
There was a strong emphasis on continually striving to improve. Managers recognised, promoted and regularly implemented innovative systems to provide a high-quality service. Management found innovative and creative ways to enable people to be empowered and voice their opinions.
Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff reported that the culture of the service had improved since the last inspection. The service had an open culture where patients, their families and staff could raise concerns without fear.
Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.
Leaders and staff actively and openly engaged with patients, staff, the public and a wide range of local organisations to plan and manage services. The views of patients and stakeholders were considered before changes were made and they collaborated with partner organisations to help improve services for patients.
The service was focussed on service improvement and sharing best practice externally. 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. The service worked in partnership with other organisations to make sure that they were following current practice and providing a high-quality sustainable service. They strived for excellence through consultation, research and reflective practice. They also showed how they would sustain outstanding practice and improvements over time.
We also found good practice in relation to the hospice:
The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff supported children and young people to make informed decisions about their care and treatment. They followed national guidance to gain patients consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
Anne Ford
Deputy Chief Inspector of Hospitals (North)
One recommendation was regarding processes around the disposal of drugs and the service level agreement in place for pharmacy provision. The other recommendation was ensuring that an appropriate consent policy was in place that met the guidance of the GMC and RCN and complied with the Gillick competency and that this was followed in practice. The Gillick competency is a term originating in England and is used in medical law to decide whether a child is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. At this inspection we found that our recommendation for the issues raised around medicines management had been met however a valid and appropriate consent policy was not in place and we found that consent was not always gained appropriately. We found this to be a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 in relation to regulation 11, Need for consent.
Derian House Children's Hospice provides palliative and end of life care for children and young people who have life limiting or life threatening conditions. The hospice is set in its own ground and provides accommodation for nine children in the main house and four young people in the lodge. There are four self-contained flats which are used by families. The hospice also provides a service for children and young adults in their own home. This is known as Derian at Home.
Bereavement support for parents and siblings is provided before, during and after end of life care and this support is not time limited. The hospice covers a wide geographical area including; Chorley, Preston, South Ribble, South Lakes, Fylde Coast, Wigan, Bolton, Rochdale, Blackburn, Burnley and Salford. This incorporates working with ten different Local Authorities to provide 24/7 End of Life support. Care consists of approximately 80% respite and 20% end of life care. Attendance at the hospice does vary due to the types of service offered. For the 12 month period prior to our inspection occupancy was averaging at just over 53%.
Derian House had a registered manager. 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.
We were able to have a conversation with one young person during the two days we were at Derian House and also had discussions and contact with relatives. Via conversations and through observations we had no concerns with the safety of people using the service. We received positive comments from families with regards to the safety of their loved ones when they were being cared for by Derian House staff.
Fire safety issues had been highlighted as a concern prior to us undertaking our inspection via an anonymous whistle-blower. Lancashire Fire and Rescue Service (LFRS) had visited the hospice before our inspection and they had fed back to us their recommendations. We saw evidence from LFRS and the service to show these recommendations had been undertaken and that fire safety was of paramount importance to the service. Steps had been taken to address the issues highlighted to us prior to our inspection.
Suitable recruitment processes were in place and followed ensuring that people employed as staff or recruited as volunteers, were competent and safe to work with vulnerable children and young people.
Appropriate staffing levels were observed to be in place to meet the assessed needs of the children and young people receiving care and support. Due to the short term nature of the service and the fact that people’s needs were different from week to week, rotas were designed to be flexible and accommodate this fact.
An infection prevention and control policy was in place at the hospice. During the course of our inspection we toured the premises, viewing a selected number of bedrooms and all communal parts of the hospice including bathrooms and toilets throughout all parts of Derian House. All areas were observed to be clean.
Children and young people’s medicines were managed well including how they were stored, administered, recorded and disposed of. We observed medicines to be administered in a professional and appropriate manner. The hospice had recorded 30 medicines errors for the period of 2017 up to the date of our inspection. These had been dealt with appropriately and lessons had been learnt. Changes to the medicines policy were made following conversations we had with the management of the service.
Risk assessments were not always up to date, and therefore reflective of children and young people’s latest needs. We have made a recommendation about this.
The staff we spoke with had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. They understood how the legislation impacted the people who used the service. Whilst we did find issues with how consent was gained given the nature of the service offered at Derian House, we judged the hospice to be compliant in this area.
Children and young people were supported well with their nutritional and hydration needs. The cook we spoke with was knowledgeable of children and young people’s needs as were the care staff we spoke with. Aside from one issue regarding the consistency of one person's diet, records accurately reflected needs in this area.
All the feedback we received from relatives, and from the one young person we were able to speak with, was extremely positive. We were told of a staff team that was caring, empathetic and professional. More than this, we were told countless stories of how the service was a sanctuary for families and one they could not have coped without in times of extreme difficulty. This was true from a practical and emotional perspective. Some families still received support many years following the death of their loved ones.
We found care plans to be person centred and to contain a lot of accurate information about children and young people’s general and specific needs. As with risk assessments, they were not always fully reflective of children and young people’s most up to date needs. Work was continuing within the care team to engage with external partners to ensure that the hospice was included in all reviews of care and support to ensure that when children and young people accessed Derian House, the service had a fully up to date picture of people’s needs.
The service had a robust and effective complaints system in place. The policy was on display and contained the details of external organisations as well as the hospice’s internal procedures.
A wide range of activities were offered to the children and young people who accessed Derian House. Relatives we spoke with praised the service in this area and we saw that children and young people had a choice in how they spent their time at the hospice.
The services on offer to children and young people were constantly being developed or expanded in line with local demand. We saw several good examples of new services at different stages of development, as well as existing services being realigned or expanded to meet needs.
We spoke with 57 staff, across both the care and support side of the service, some of whom were ex-employees at the hospice. A large percentage of staff we spoke with, and had contact with, told us of a working environment which we judged to be extremely unhealthy and broken. We heard many testimonies, with specific details, about how staff were bullied, belittled and how they felt unable to raise these concerns within a safe environment. Whilst the hospice had a large range of auditing and monitoring systems in place they had not picked up and/or dealt with these and other issues. This was therefore a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 in relation to regulation 17: Good Governance.
Relatives we spoke with did not raise any concerns about the atmosphere or culture within the hospice. As with all the feedback we received from families conversations about the service were extremely positive. This included any conversations we had about how they perceived the culture of Derian House. This was very positive as it meant the issues staff were experiencing were not adversely affecting the care and support offered to children and young people using the service.
You can see what action we told the provider to take at the back of the full version of the report.
Derian House Children’s Hospice provides palliative and end of life care for children and young people who have life limiting or life threatening conditions. The manager has been registered with the Care Quality Commission since September 2013. The hospice is set in its own ground and provides accommodation for nine children in the main house and four young people in the lodge. There are four self-contained flats which are used by families. The hospice also provides a service for children and young adults in their own home. This is known as Derian at home. Bereavement support for parents and siblings is provided before, during and after end of life care and this support is not time limited. We were given an example of one family who had recently come to the hospice for support ten years after their child died. Support has been given to this family.
The hospice covers a wide geographical area including; Chorley, Preston, South Ribble, South Lakes, Fylde Coast, Wigan, Bolton, Rochdale, Blackburn, Burnley and Salford. This incorporates working with ten different Local Authorities to provide 24/7 End of Life support. Support consists of approximately 80% respite and 20% end of life care. During the 12 month period prior to our inspection the hospice had supported 40 children and young people through to the end of their life.
The hospice employed 75 staff within the care team at the time of our inspection, in addition to this there were over 200 volunteers working within the hospice and externally, for example within Derian House shops or as fundraisers.
The one young person we were able to speak with told us they felt safe at the hospice. Families we spoke with also told us they felt safe leaving their children in the care of staff at the hospice. This included families whose children had very complex needs. Some of the families we spoke with became very emotional when speaking about the care and support given by Derian House as it was the only service they entrusted to look care for their children outside of their immediate family.
The hospice had a safeguarding and whistleblowing policy in place which was being followed in practice. This meant that staff had clear guidance to enable them to recognise different types of abuse and who to report it to if it was suspected. Staff were appropriately trained to recognise and respond to potential safeguarding incidents.
We looked at the systems in place at the hospice for medicines management. There was good evidence to show that medicines were audited effectively and that staff were trained and competency checked for administering medicines. However we found some issues including the current service level agreement for the provision of a pharmacy service not being an agreement between two separate legal entities, that an authorised witness to oversee the disposal of controlled drugs should be appointed and disposal records should include the two signatures of the staff involved in the disposal process. We have made a recommendation regarding these issues.
We looked at arrangements at the hospice in relation to Infection Prevention Control (IPC). An audit by an external company had taken place shortly before our inspection which had identified some minor issues. The issues had already been placed into an action plan and the hospice was working towards addressing them. The issues were mainly with reference to recording and administration. We found no issues with IPC during our inspection.
We found the service to be appropriately staffed with the correct skill mix of nursing, care and domestic staff to cater for the complex needs of the children and young people using the service. We also looked at recruitment processes and found the service had recruitment policies and procedures in place to help ensure safety in the recruitment of staff, including volunteers.
The service was working within the principles of the Mental Capacity Act and followed the Department of Health guidance for hospices in relation to Deprivation of Liberty safeguards.
Staff we spoke with told us, and training records confirmed, staff had undertaken a wide range of training to ensure they could meet people's needs effectively. There were two dedicated clinical educators at the hospice who had worked at the hospice for 16 years in various nursing roles. We could see from reviewing staff files, training records and from discussions with staff, volunteers and management that training was in place to meet the complex needs of the children and younger people using the hospice. We found that mechanisms were in place to be reactive to people’s needs and staff requests for ad hoc training as needs presented.
Staff we spoke with told us they felt supported. They confirmed they received regular one to one supervision and appraisals. This provided an opportunity for staff and management to discuss performance, training and any issues or concerns. Staff spoke highly of the management at the service and felt they had input into their own career development.
The hospice environment was appropriate for the children and young people using the service. There was a definite distinction between the two separate children and young people’s areas within the hospice in terms of décor and facilities available. Families we spoke with were very complimentary about the hospice and its facilities which included a hydrotherapy pool that catered for the very complex needs of the children and young people at the hospice.
Relatives we spoke with found it difficult at times to express how much the service meant to them, their child or young person being cared for and their immediate and sometimes wider family network. We had several emotional conversations with families who told us how the service cared for their child and also siblings and their entire family. This was mirrored via other methods of feedback such as written compliments and emails received.
It was evident from our observations and discussions with staff and relatives that staff had a very good knowledge of the children and young people they cared for. Staff that we spoke with were passionate about their roles and were clearly dedicated to making sure children and young people received the best person centred care possible.
Children and young people’s dignity was taken into consideration at all times. Children and young people have their own bedroom with en-suite facilities during their stay at Derian House. This enabled their privacy and dignity to be maintained.
We saw evidence that end of life care was provided with compassion, dignity and professionalism. Staff spoke with knowledge and passion about end of life care and how important this aspect of their work was.
There was an extensive range of information for people and families regarding the care and support Derian House could offer.
We saw that evidence based care was embedded within the care plans which were person centred, reviewed regularly and contained the information needed to provide the care and support needed.
A robust system was in place for listening to and responding to concerns and complaints. Staff we spoke with were aware of the hospice's complaints policy and how to deal with and refer people appropriately if concerns were raised.
There was a Registered Manager in place at Derian House who had worked at the service for three years. They were also the Head of Care at the hospice. We received very positive comments from people and staff about the registered manager. Staff described her as being supportive, committed and passionate about the service and the children and young people they cared for.
There was a comprehensive audit programme in place. There were also many other management mechanisms in place to monitor, measure and compare the performance of the service.
We saw a wide range of meetings and forums were in place. Meeting notes showed that all meetings were well attended and notes were of good quality and reflected what was discussed. Action plans were attached when necessary to show what progress had been made since the previous meeting.
Derian House Children’s Hospice provides palliative and end of life care for children and young people who have life limiting or life threatening conditions. The manager has been registered with the Care Quality Commission since September 2013. The hospice is set in its own ground and provides accommodation for nine children in the main house and four young people in the lodge. There are four self-contained flats which are used by families. There were two children and two young people using the service at the time of our visit. The hospice also provides a service for children and young adults in their own home. This is known as Derian at home. Bereavement support for parents and siblings is provided before, during and after end of life care.
We spoke with five parents. All told us they were happy with the service and they felt their child was safe and well cared for. We also spoke to a young person who used the service and they confirmed they enjoyed their stays in the lodge. Appropriate procedures and staff training were in place to ensure children and young people were protected from harm.
Staff had an understanding of the Mental Capacity Act 2005 and the Deprivation of Liberty safeguards. (The Act protects the rights of people who are not able to make a decision for themselves). The registered manager explained she planned to carry out staff training and implement capacity assessments. This will ensure these issues are given more consideration as part of routine care practice.
Before children and young people used the service a full assessment was carried out of their needs. This ensured they could be cared for appropriately in the hospice. Each child and young person had a care plan which was supported by a series of risk assessments. Whilst all care plans and risk assessments were up to date, we found the plans and assessments could be further developed by incorporating more information about children and young people’s wishes and preferences.
During our visit we observed staff to be attentive and sensitive to the needs of children and young people staying in the hospice. Children and young people’s dignity was maintained at all times. We found staff were motivated and worked well as a team. Staff had access to ongoing training and supervision. This meant they were well supported in their role. All staff spoken with told us they really enjoyed their work.
Children and young people received compassionate and supportive care when they were nearing the end of their life. Parents and appropriate professionals were involved in a plan of care, which was reviewed on a daily basis. This ensured staff were aware of their wishes and they could respond quickly to any changing need.
All parents and staff spoken with felt the hospice was well led and organised. The registered manager had a clear action plan and vision of how she wanted to improve the service. She had also developed ways of learning from any mistakes and was open about changes which were being made. This meant the registered manager had arrangements in place to develop and improve the hospice.
We spoke to two parents following our inspection who told us: 'Wonderful attitude, the support they give.' 'It's amazing, can't put into words the special and unique experience. Nothings too much trouble, it was the norm. All the things you thought weren't possible, were possible and effortless.'
We also spoke with two young people to ask them about their experience of Derian House, they told us: 'There is loads of stuff to do, but it is up to us.' 'I enjoy staying with other people like me; I get on well with staff as well.'
Children's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.
We saw that where other professionals were involved in the person's care, information about their involvement was documented with a summary of their latest contact.
People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.
Staff received appropriate professional development. The training lead provided us with an up to date record of induction, staff training, including staff who that had accessed National diplomas.
The provider had an effective system to regularly assess and monitor the quality of service that people receive.
We found that the manager and the committee had completed a review of the quality assurance systems and made several changes as a result. The policy for managing incidents and accidents has been revised and a new operating procedure has been introduced. Designated people are now responsible for audits and analysis of incident, accident and medicines errors. The Clinical Governance Committee monitors quality, safety and improvements on a quarterly basis. Minutes are kept to record any required actions and improvements.
Training was held for the whole staff team in November 2012 to communicate all of the new policies, procedures and documentation. Parents and carers have been kept informed of the changes.
Children and young people had an individual care plan which was reviewed each time they visited the hospice. During our visit, we saw there was positive, sensitive and kind staff interaction with the children and young people.
Staff had awareness of the safeguarding procedures relating to children and vulnerable adults and confirmed they had received appropriate training.
We found shortfalls with the systems used to manage medication and not all records were fully completed. Audits had been carried out; however, there was no evidence action had been taken to address the shortfalls.
Staff were provided with appropriate training opportunities and new staff undertook a detailed programme of induction. All young people and family members made complimentary comments about the staff team.
We found shortfalls in the monitoring of the quality of the service. There was no evidence incidents had been investigated. We also saw no evidence of appropriate action being taken to address the issues and circumstances reported in the incident reports. This meant children and young people were not fully protected from the risks of inappropriate and unsafe care.
Families and young people were fully involved in decisions about their care and their needs were fully discussed and reviewed each time a child or young person was admitted into the service. We saw evidence of this involvement in the care planning process. Therapeutic activities were arranged throughout the day in line with the children and young people's interests, age and condition. Two young adults told us how much they had enjoyed a recent trip to the pub.
The staff team comprised of a wide range of professionally qualified staff including nursing, medical, physiotherapy, play and bereavement support staff. Staff told us they were well supported in their roles and there were continual opportunities for training and development. We saw evidence of the how the staff were supported and trained in the files we looked at during the visit.