You are here

Trinity Hospice and Palliative Care Services Limited Outstanding

All reports

Inspection report

Date of Inspection: 20 September 2012
Date of Publication: 16 October 2012
Inspection Report published 16 October 2012 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 20 September 2012, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with staff and talked with stakeholders.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people received.

Reasons for our judgement

We saw the hospice used a number of monitoring procedures in order to assess and review the quality of the service.

The hospice governance structure included an audit committee of trustees. The committee met on a regular basis. We saw evidence of published audits aimed at informing people of the outcomes of surveys, good practice guidance and relevant professional research projects appropriate for the development of the service. These published audits were in the reception area and available to all stakeholders of the service, as well as the public. This meant the service was open and transparent in how it was being managed.

We saw evidence staff were encouraged to report clinical incidents, significant events and near misses. These were reviewed at the clinical governance meetings, with actions and responsibilities agreed. We looked at revised incident forms and documentation for medication errors. This meant the service responded to issues which had the potential to have a negative impact on people using the service.

In order to manage risk we saw evidence senior staff had been responsible for health and safety risk audits. This took account of all areas of the service and demonstrated the hospice had systems in place to manage risk at an operational level.

The hospice received national and local alerts, which were looked at and actioned if appropriate.

We saw evidence there were systems in place for monitoring and responding to complaints, and monitoring compliments. Patient satisfaction surveys were undertaken in order to monitor performance. A recent survey showed people were ‘very satisfied’ with the care and support they had received using the inpatient services.