21 March 2016
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was carried out to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection was carried out on 7, 9 and 10 December 2015 and was unannounced. The inspection team consisted of one inspector, a pharmacist inspector and a specialist advisor in palliative care.
Before our inspection we looked at records that were sent to us by the registered manager to inform us of significant changes and events. We reviewed the Provider Information Record (PIR) and previous inspection reports. The PIR is a form that asks the provider to give some key information about the service, what the service does well and the improvements they plan to make.
At the last inspection carried out on 3 January 2014 we did not identify any concerns with the care provided to people.
We spoke with one person who was staying in the IPU and two relatives, two people receiving care in their own home, their relative and a friend and six people who used the day centre, community services and advice line. We spoke to five volunteers across the service, five health care assistants and senior health care assistants, seven nursing staff including community nurse specialists, two clinical co-ordinators in the CRC who managed calls to the 24 hour advice/referral line, the spiritual care co-ordinator and volunteer, head chef and three medical staff, an occupational therapist and a social worker. We spoke with the registered manager, the clinical director, the lead IPU nurse, head of human rescources and the human resources co-ordinator and the education co-ordinator. We contacted two GPs who worked with the service for their feedback about St Margaret’s Hospice.
We looked at the premises. We looked at eight sets of records that related to people’s care (five on the in patient unit, two in the community and one in the day centre) and examined four people’s medicines charts. We looked at people’s assessments of needs and care plans and observed care. We consulted documentation that related to staff management, training and three staff recruitment files. We looked at records concerning the monitoring, safety and quality of the service and the activities programme. We observed a ‘ward round’, spent time in the day centre and visited two people receiving a service in their own homes with their permission. We also spent time in the Centralised Referral Centre (CRC) and attended a multidisciplinary team meeting (MDT). We sampled the services’ policies and procedures.
During our inspection we looked at the systems in place for managing medicines; spoke to six members of staff involved with prescribing and giving people their medicines, including the pharmacist lead nurse, looked at eight people’s medicines charts and spoke to three people using the service and one person’s relative in relation to medicines management.
21 March 2016
St Margaret’s Somerset Hospice is a charity which provides a range of hospice services for adult patients with life-limiting illnesses or advanced progressive conditions and support for their families and carers. This means they provide a service for people with a range of conditions including cancer. Services include an inpatient unit (IPU) with 16 beds. Twelve beds are used regularly with two further beds commissioned via ‘winter pressure funding’. This means the hospice are able to prioritise beds for those people with more complex symptom control or end of life care needs. The majority of people are supported by community services with over 600 people supported across the Somerset community at any given time.
This inspection was carried out on 7, 9 and 10 December 2015 by one inspector, a pharmacist inspector and a specialist advisor. This was an unannounced inspection.
There is a registered manager who is responsible for the service. 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 and associated Regulations about how the service is run. There is a second St Margaret’s Hospice in Yeovil and the two services work closely together. Services are free to people, with St Margaret’s receiving some NHS funding and the remaining funds are achieved through fundraising and charitable donations. The hospices are largely dependent on donations and fund-raising and are assisted by over 1200 volunteers.
The service provided includes specialist advice and input, symptom control and liaison with healthcare professionals. The hospice has a 24 hour out of hours advice line and central referral centre (CRC). Referral to the hospice was usually prompted by the presence of uncontrollable symptoms, physical, psychological and spiritual or complex end of life care needs or referral to other hospice services. The average length of stay was two weeks with some people being discharged home or to a local care home. The service was clear about their local demographic meaning that they had an understanding of the community they served and continuously monitored how best the service could meet their needs. They followed national guidelines such as the National End of Life Care Strategy. The aim of the National End of Life Care Strategy is to enable people to die in the place of their choice and this was the aim of St Margaret’s as much as possible.
The registered manager was open and transparent in their approach. They provided excellent leadership ensuring all staff were engaged in providing an excellent service to individuals and striving to constantly improve. Staff told us they felt valued and inspired by the leadership team and the registered manager to provide a high quality service. Emphasis was placed on continuous improvement of the service. Comprehensive audits were carried out about every aspect of the service to identify how it could improve. Where the need for improvement was identified, remedial action was taken to improve the quality of the service and care. The service worked in partnership with other organisations to drive improvements at national level, participating in research projects and end of life care awareness which positively benefitted people in their care.
An excellent on site academy training centre provides advice and support to St Margaret’s staff as well as staff in care settings in the community. St Margaret’s were committed to sharing good practice and enabling other health professionals to provide a high standard of specialist care. People could access counselling, family and bereavement support, a lymphoedema service (a chronic long term condition that causes swelling in body tissues. It can be a primary or secondary condition), occupational and creative therapy, physiotherapy, complementary therapy and spiritual support. There was also support from social workers and advice on practical matters such as finances. The day centre offered activities and support for people over a 12 week period and were able to signpost people to other local services. There were also a range of support groups and courses tailored for people with life limiting illnesses as well as their carers pre and post bereavement.
Staff received very comprehensive essential training based on best practice, national guidelines and research including end of life care and were scheduled for refresher courses. Staff had a wide range of opportunities for further training specific to the needs of the people they supported. All members of care staff received regular one to one supervision sessions and an annual appraisal. This ensured they were supported to work to the expected standards and valued by the service. Staff were encouraged to always, “See what else we can do” to improve the service and to submit ideas for improvement.
There was excellent communication and delivery using a multidisciplinary and holistic approach. The service was responsive with people able to access a one stop referral centre and advice line for advice and support. The service continuously looked at the local community demographic to see how best they could provide the service. This included dementia champions and links with homeless communities. People were involved in the planning of activities that responded to their individual needs. A broad range of activities was available that included creative ways to keep people occupied, engaged and stimulated. Attention was paid to people’s individual social and psychological needs in a holistic way that included support pre and post bereavement for carers. There was an excellent spiritual care service which was inclusive and their ethos was person centred. At St Margaret’s “spiritual care honours the human spirit and cares for each individual as a spiritual person” however that may be.
People benefitted from a bespoke meal service that was tailored to their specific needs, likes and dislikes including when people felt like eating. 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 communicated effectively with people, responded to their needs promptly, and treated them with genuine kindness and respect.
Staff were trained in how to protect people from the risk of abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns. 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. Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced.
There were sufficient staff on duty to meet people’s needs. Staffing levels were calculated and adjusted according to people’s changing needs. There were thorough recruitment procedures in place which included the checking of references.
People were at the heart of the service and were fully involved in the planning and review of their care, treatment and support. Staff knew each person well and understood how people may feel when they were unwell or approaching the end of their life. They responded well to people’s communication needs and worked in a holistic and multidisciplinary way. Plans in regard to all aspects of their medical, emotional and spiritual needs were personalised and written in partnership with people. Staff delivered support to people according to their individual plans and worked together to meet people’s needs. This included overcoming barriers to enable people to have positive experiences near the end of their lives. There were some limitations with the use of the computer patient electronic recording system but this had been identified by the service and was being addressed and managed by a working group.
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 as per the Mental Capacity Act 2005 requirements.
People’s feedback was actively sought, encouraged and acted on. People and relatives were overwhelmingly positive about the service they received. They told us they were extremely satisfied about the staff approach and about how their care and treatment was delivered. Staff approach was kind, compassionate and pro-active.
People’s privacy was respected and people were assisted in a way that respected their dignity. Staff sought and respected people’s consent before they supported them. Staff pre-empted and responded to people’s individual needs and requirements and tailored support to suit them including sign posting to external services.
The environment was well designed, welcoming, well maintained and clean and suited people’s needs.