19 July 2018
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 planned 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 took place on 9, 10 and 12 April 2018. The first day of the inspection was unannounced. The inspection team consisted of two inspectors, a pharmacist inspector, two specialist advisors in palliative care and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
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.
During the inspection we spent time on the inpatient unit (IPU), the day centre and we visited two people receiving support in their own home. We spoke with five people on the IPU; two people using the day centre and two people receiving support at home. We also spoke with two people by telephone following the site visit. We spoke with 10 relatives either within the IPU or in their own home during visits or by phone. We also spoke with 31 members of staff and two volunteers. This included the registered manager, clinical director, consultant, two doctors, eight nursing staff, two Clinical Nurse Specialist (CNS), the lead IPU nurse infection control lead, tissue viability lead, the human resources coordinator, two learning and development leads, the head chef, cleaning staff, volunteer coordinator, lead therapist; occupational therapist, members of the spiritual care team, the estates manager and maintenance personnel.
We looked at six sets of records that related to people’s care on the IPU. We also attended a multidisciplinary team meeting (MDT). We sampled the services’ policies and procedures; quality audits, quality assurance reports and minutes of meetings.
We contacted commissioners and other professionals who worked with the hospice. We received a response from one commissioner and five community partners. For example, community nurses, care home managers, community health and wellbeing lead and palliative care nurse specialist.
19 July 2018
This comprehensive inspection took place on 9, 10 and 12 April 2018. The first day was unannounced.
We previously inspected the service on 22 August; 5 and 7 September 2016 and 6 October 2016. At the last inspection the service was rated as ‘requires improvement’ overall and requires improvement in three key questions; safe; effective and well-led. One breach of regulation was found at the last inspection relating to regulation 12, safe care and treatment. This was because people who used the service and others were not always protected against the risks associated with smoking and oxygen use.
Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe; effective and well-led to at least good.” At this inspection we found the provider had followed their action plan and improvements had been made to ensure people were safe when using oxygen.
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. They provide a service for people with a range of conditions including cancer. Services include an inpatient unit (IPU) with 12 beds in Yeovil. This means the hospice are able to prioritise beds for those people with more complex symptom control or end of life care needs.
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.
Most people are able to remain in their own home, supported by the community services. There are five community teams supporting people across Somerset, bringing the benefits of hospice care to those who can remain at home. 3800 people are supported across the Somerset community per year with an average of 300 on the community caseload at any one time.
The Sunflower Centre provides support for people who are well enough to live at home but would like the specialist support that St. Margaret’s can offer during the day. The centre at Yeovil is open Monday to Wednesday from 9.30am to 4.30pm and provides emotional, spiritual and social support, symptom control and management, as well as a range of complementary therapies. Practical advice on nutrition, rehabilitation, finance and benefits is also available. Carers are welcome to attend as well.
Other services include physiotherapy and lymphoedema clinics. (Lymphoedema is a chronic long term condition that causes swelling in body tissues. It can be a primary or secondary condition). Bereavement and counselling service were also offered to people and their relatives or friends.
The service provides specialist advice and input, symptom control and liaison with healthcare professionals. The hospice has a 24 hour out of hour’s advice line and central referral centre (CRC). One person reported , “It has been a great support to me…”
There was a registered manager in post; who was also the governance director 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 2008 and associated Regulations about how the service is run.
There is a second St Margaret’s Hospice in Taunton which is rated outstanding. The two services work very 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 was clear about their local demographic meaning 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.
People, relatives and healthcare professionals consistently praised the high standards of care, treatment and support provided by the hospice. Comments included, “We have had invaluable support from wonderful staff” and “All the staff I saw were highly experienced, extremely kind and gave me excellent advice; I couldn't ask for more”.
The service was well managed. There was an open and transparent culture. This was evident from the incident reporting process and complaints process and how the service had responded to serious incidents. The senior management team demonstrated an excellent knowledge of the duty of candour. This was also evident when reviewing complaints and concerns.
There were robust systems in place to obtain feedback from people, their families and friends, staff and other health and social care professionals about the hospice. Feedback was overwhelmingly positive about this service.
The hospice played a leading role in promoting end of life care within the local community and developed strong links with many community groups. The service worked collaboratively with other professionals and organisations to improve end of life care within the county. Hospice staff worked closely with the local NHS Trust, GP’s and community nurses when people moved between different services to ensure the transition was as seamless as possible.
Over the last two years, the provider has conducted a ‘Fit for Future’ review to help identify and plan a sustainable model for the future provision of services provided by St. Margaret's Hospice across Somerset. They engaged with the local community to improve public understanding and the ongoing development of the hospice.
The hospice participated with various research projects and used evidence-based practice and nationally recognised benchmarking tools to promote and sustain outstanding care.
Staff worked in a highly personalised and holistic way to deliver outstanding care to people. Staff had developed exceptionally positive caring and compassionate relationships with people. People were treated with sensitivity, dignity and respect. People said the staff were exceptionally compassionate, meeting their physical, emotional and spiritual needs. People’s comments included, “The place is fantastic. Not at all how I imagined a hospice to be…” and “The staff are outstanding in every way. We trust them….” The occupational therapists and social workers at the hospice had won the Somerset County Council ‘Care and Respect’ team award for their contribution to excellent patient care.
Support for relatives and friends was an important part of the service provided. Relatives and friends had access to complimentary therapy, counselling and bereavement services. Relatives reported the positive benefits of these services. Comments included, “I received excellent bereavement counselling….very sensitive and understanding. My sessions were very enjoyable as it helped me to become strong inside…”
The service had a strong person centred culture and staff went the ‘extra mile’ for the people and families they supported. The whole team worked to fulfil people’s last wishes where possible. For example, arranging weddings and blessings at the hospice; and special celebrations and outings.
People’s emotional and spiritual needs were met by the excellent spiritual care, led by a spiritual care co-ordinator. The spiritual care co-ordinator explained the holistic model of spirituality which was not based on religion alone, but included the philosophy of mind, body and spirit. A ‘sanctuary space’ offered a neutral spiritual space, which was open to all. This quiet, peaceful space had small multi-faith symbols discreetly available to those who wished to use them for prayer or worship.
People were remembered and celebrated. An ornate celebration tree had been installed in the reception area which enabled relatives and friends to remember and celebrate their loved one. Each leaf had the name of a person cared for by the hospice team or the celebration of a special event for someone. One relative said, “I think this is a lovely touch and a way to remember people.”
Without exception, the people we spoke with said they felt safe at the hospice or when using the community services at home. One person said, “I feel absolutely safe here. They attend to every detail…” and “The Staff make me feel very safe here, they spend time with me without rushing me…”
People received effective care and treatment based on best practice delivered by a highly skilled multi-disciplinary team. Staff received excellent training and support to ensure they had the knowledge, skills and competencies needed to support people’s complex needs. Without exception, people and their relatives spoke very highly of staff and their experiences of the care and treatment they received, both on the in-patient unit and in the community.
Supportive suggestions and interventions by staff enhanced people’s sense of wellbeing and quality of life. People had access to the multidisciplinary team in order to meet their health and care needs. For example, occupational therapists, physiotherapists, counsellors, nurse specialists, clinicians and spiritual support. There was a focus on people’s rehabilitation and the promotion of their independence, led by the therapy team. People, including those living in their own home, were provided with equipment and adaptations in a timely way and taught techniques to help manage their symptoms to make life easier. People valued this support and described p