The Heart of Kent Hospice

The service cares for people in two types of settings: at the hospice in a 10 beds ‘Inpatient Unit’, or in their own home with the support of a community palliative care team. In addition, the Heart of Kent Hospice provides an Outpatient Centre, ‘Magnolia Place’, which is open three days a week, where people can access advice, support, and take part in individual and group therapeutic activities. A weekly Drop-in Centre and a dementia café provide an environment where people and their families can receive support from the team as well as talk to others facing a similar situation.

At our last inspection on February 2016, we issued three requirement notices in relation to three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that care and treatment was not provided in a safe way for people; medicines were not properly and safely managed; documentation regarding staff training, advance care planning, people's individual likes and dislikes, complaints logs and recruitment was not appropriately completed; systems and processes were not established and operating effectively to ensure compliance; there was a lack of staff competency checks; and staff did not receive appropriate support, training, supervision as is necessary to enable them to carry out their duties. The registered provider sent an action plan to us detailing the improvements they would make. They confirmed they would be meeting the requirements of the regulations by February 2017 and that new systems would be embedded and sustained over time. They kept us informed of their progress.

This inspection was carried out on 20 and 21 February 2017 to follow up on compliance with these notices. At this inspection we found that the registered provider had met the requirements detailed in the requirement notices and had made significant improvements to the culture of the service and the care people received. At the time of our inspection, six people resided in the Inpatient Unit and 575 people were open to the community palliative care team, 170 of whom lived with dementia.

There was a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

Staff knew how to recognise signs of abuse and how to raise an alert if they had any concerns in regard to people’s safety. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm.

There were sufficient staff on duty to meet people’s needs across the service. New recruitment systems were embedded in practice and ensured relevant checks and records were appropriately completed.

Improvements had been made in regard to the secure storage of medicine, competency checks for nursing staff and records of administration of medicine. People received medicines that were appropriately stored, documented and administered by competent staff.

People could be confident that staff had been appropriately trained. Essential mandatory training was provided and the monitoring of staff training had been improved. A new system to monitor all staff training had been implemented and embedded in practice. All members of care staff received regular one to one supervision sessions to support them in their role. There were members of staff who took the lead in a speciality, offering guidance to other staff so people could be confident about staff particular expertise.

People were fully involved in the planning and review of their care, treatment and support while in the Inpatient Unit (IPU) and while receiving support in the community. Staff delivered care and support to people according to their individual plans.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to hospices. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options were considered in accordance with the Mental Capacity Act 2005 requirements.

The staff provided meals that were in sufficient quantity and met people’s needs and choices. People praised the food they received and they enjoyed their meal times. Staff knew about and provided for people’s dietary preferences, restrictions and reduced appetite.

Staff knew each person well and understood how people may feel when they were unwell or approached the end of their life. They responded to people’s individual communication needs and treated them with genuine kindness and respect.

Staff were outstandingly caring. Staff approach was kind, compassionate and pro-active; they were skilled at giving people the information and explanations they needed in a sensitive manner. They often went beyond the scope of their duties to meet people and their families’ needs.

Clear information about the service, the facilities, and how to complain was provided to people and visitors. People’s privacy was respected and people were assisted in a way that respected their dignity. Staff sought and respected people’s consent or refusal before they supported them.

People and relatives told us they were extremely satisfied about the staff approach and about how care and treatment was delivered. They described the way staff responded to their needs in emphatic terms. Dementia care was provided by the service as an innovative response to the increase of dementia in the community.

The service responded to the community’s need for information on palliative care, aiming to take the stigma out of hospice care. People’s feedback was sought, valued and acted on.

A new robust quality assurance system was implemented and embedded in practice. A range of audits and checks were carried out throughout the service to identify how the service could improve and action was planned and taken as a result.

The service cares for people in two types of settings: at the hospice in a 10 beds ‘Inpatient Unit’, or in their own home with the support of a community palliative care team. In addition, the Heart of Kent Hospice provides a day therapy centre, ‘Magnolia Place’, which is open three days a week, where people can access advice, support, and take part in individual and group therapeutic activities. A weekly Drop-in Centre and a dementia café provide an environment where people and their families can receive support from the team as well as talk to others facing a similar situation.

This inspection was carried out on 08 and 09 February 2016.

There was a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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. The registered manager was on extended leave and had not been in post since July 2015. The Chief Executive Officer had appointed the Deputy Patient Services Director as acting manager until the registered manager’s return, to ensure continuity of management. The acting manager had been in post since August 2015.

Staff knew how to recognise signs of abuse and how to raise an alert if they had any concerns in regard to people’s safety. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm.

There were sufficient staff on duty to meet people’s needs and arrangements in place to ensure there were always enough staff to meet people's needs during any short notice absence.

There were recruitment procedures in place which included the checking of references. New recruitment systems were being set up, however as these improved recruitment systems were not yet embedded and needed to be sustained over time, this is an area for improvement which we will review at our next inspection.

We found improvements were needed in regard to the secure storage of medicine, competency checks for nursing staff and records of administration of medicine. We have required the provider to take action to ensure that people receive medicines that are appropriately stored, documented and delivered by competent staff.

There were members of staff who took the lead in a speciality such as dementia, motor neurone disease, renal impairment and infection control. They offered specialist guidance to other staff so people could be confident about staff particular expertise.

Essential mandatory training was provided although the system for the monitoring of staff training was not effective. This meant that people could not be confident that staff had been appropriately trained. There were plans in place for a new system to monitor all staff training. However, this improved system was not yet implemented. This is an area for improvement which we will review at our next inspection.

Care staff competency about their role was not regularly checked during their induction, and not all members of care staff received regular one to one supervision sessions to support them in their role. We have required the provider to take remedial action.

People were fully involved in the planning and review of their care, treatment and support while in the Inpatient Unit. Staff delivered support to people according to their individual plans.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to hospices. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options were considered in accordance with the Mental Capacity Act 2005 requirements.

The staff provided meals that were in sufficient quantity and met people’s needs and choices. People praised the food they received and they enjoyed their meal times. Staff knew about and provided for people’s dietary preferences, restrictions and reduced appetite.

Staff knew each person well and understood how people may feel when they were unwell or approached the end of their life. They responded to people’s individual communication needs and treated them with genuine kindness and respect.

People and relatives were consistently very positive about the quality of service they received. They told us they were extremely satisfied about the staff approach and about how their care and treatment was delivered. People told us, “They provide outstanding care, the staff are exceptional”, “This place is amazing; the staff are amazing; the care is amazing; there is no other word to describe it” and, “The staff go above and beyond the call of duty, they are so dedicated and passionate about what they do.” Staff approach was kind, compassionate and pro-active; they were skilled at giving people the information and explanations they needed in a sensitive manner. They often went beyond the scope of their duties to meet people and their families’ needs.

Clear information about the service, the facilities, and how to complain was provided to people and visitors. People’s privacy was respected and people were assisted in a way that respected their dignity. Staff sought and respected people’s consent or refusal before they supported them.

People’s feedback was sought and acted on. Audits were carried out to identify how the service could improve and action was planned as a result. However some of the action plans had not yet been implemented and new monitoring systems were not yet in place. As new monitoring systems were not yet embedded and needed to be sustained over time, this is an area for improvement which we will review at our next inspection.

We spoke with the registered manager, a community team manager, two nurses, a healthcare assistant and two relatives of people who used the service. At the time of our visit, eight persons were staying in the hospice ward and we talked with one person who used the service. We looked at the service's surveys, the minutes of hospice users' meetings and team meetings, and at people's comments; we checked policies relevant to people's involvement and consent, the planning and delivery of end of life care and complaints. We checked staff's training records and viewed eight sets of records for people who used the service in the hospice.

- Is the service safe?

CQC monitors the operation of Deprivation of Liberty Safeguards (DoLS) which applies to hospices. We spoke with the registered manager who demonstrated their knowledge of the protocols to follow. Systems were in place for the service to submit an application for DoLS, although no application had been warranted to date. We saw evidence that all staff had been trained in the safeguarding of vulnerable adults, first aid and mental capacity. We found that people's mental capacity was assessed and best interest meetings were held according to legal requirements. We found risk assessments with clear action plans were in place to ensure people remained safe. We saw that the risks associated with carrying out the care, support and treatment had been assessed and minimised. There were plans in place for dealing with emergencies which would, if they arose, affect the provision of services.

-Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they had received appropriate training. People we talked with who used the service and their relatives were satisfied with the service provided. A relative said, "They are very efficient and make our Mum as comfortable as possible while giving excellent care". We saw comments that included, "Every aspect of my care is fantastic".

-Is the service caring ?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. We saw that staff interacted positively with people who used the service and people we talked with about the service told us that staff were caring and friendly. A relative of a person who used the service said, "The care is lovely and the staff are really dedicated, we have no concerns and no complaints". People's needs had been assessed before they moved into the hospice. We saw that each person had a named key worker and that systems were in place that enabled care plans to be reviewed and updated. We observed that staff asked people for their views and permission before providing any care or treatment. Records confirmed people's preferences and diverse needs had been accommodated.

-Is the service responsive?

The hospice provided a range of services that responded to people's needs when they had a life-limiting illness. The services included medical care, pain management, day therapy services, spiritual care, counselling, social work advice and community care. The hospice promoted a stress-free environment where people could relax and rest. A member of staff who told us, "We are very aware of the need and promote a calm environment". People were encouraged to feedback on the quality of the care and services provided and their views were taken into account. The hospice maintained close links with the community. The hospice trained volunteers in the community who were active participants in some aspects of the service.

-Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. We found that comprehensive policies and procedures that addressed every aspect of the service were in place. People and their relatives or representatives were consulted about how the service was run and annual survey questionnaires were collected and analysed. Staff told us they were able and encouraged to express their views and concerns they may have and were listened to. A member of staff told us, "We can raise any concerns and make suggestions, the management have an open door policy and they listen to us". Complaints, incidents and accidents were appropriately recorded and audited. There were audit processes in place to monitor risks, safety and wellbeing. The registered manager operated a system of quality assurance and completed audits to identify how to improve the service.

Care records showed that people who used the services of the hospice were supported with their care in a way that was individual and in accordance with their wishes. The care records reflected the health and personal care that people needed, and was appropriately checked and agreed with their next of kin and/or other professionals.

Medicines were handled appropriately and people who used the service had their medicines given to them in a safe way.

We found that there was a robust recruitment process in place that helped to make sure that only people who were deemed as suitable were employed to care for people who used the service.

We saw that there were monitoring processes in place that ensured that people were protected against the risks of inappropriate or unsafe care and treatment as the service regularly assessed and monitored the quality of the service provided.

People who used the services of the hospice commented, 'The staff are really good, and even though I arrived late in the day I was offered a choice of meals'; 'They offer you everything, there is nothing that they will not do for you'; 'We were greeted by two people who helped settle us in, and within five minutes it felt like we were home'; and, 'They are amazing'.

Comments received from people who completed patient satisfaction surveys during 2013 included, 'Overall help to me has been wonderful and I have been very happy during the entire time of my stay here'; 'I have never received such kindness, thoughtfulness and respect from all staff and volunteers as I have had here. They are all very dedicated and considerate;' and, 'As a family we have been pleased with the level of care provided by both nursing and medical staff. X was treated in a very dignified and caring manner which makes us all feel that X is in the right place'.