Archived: St Margaret's Somerset Hospice -Yeovil

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

This inspection was carried out on 22 August, 5 and 7 September and 6 October 2016 by one adult social care inspector, with a second inspector on 6 October, a pharmacist inspector, a bank inspector, a specialist advisor 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. This was an unannounced inspection on the first day.

A serious incident occurred at the end of 17 September 2016. A person using the service died as a result of fatal injuries sustained during a fire when the person was smoking whilst using an oxygen cylinder. The service clinical director informed us of the incident on 18 September 2016. We went back to the service on 6 October 2016 to make sure action had been taken by the service to reduce the risk of this happening again. We have rated safe, effective and well-led as requires improvement. This is because we found some failings in how the risk relating to smoking materials and oxygen use was managed and risk assessed. For example, there had been a lack of communication about the person’s smoking history and compliance to safe practice, two risk assessments directly linked to smoking risk had not been completed or reviewed and training did not contain adequate detail to ensure staff were aware of safe practices in this area.

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 Taunton and 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 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. 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 at the service to identify how it could improve. Where the need for improvement was identified, remedial action was taken to learn and 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 academy training centre based at the Taunton site 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 lymphedema 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 and a dedicated discharge co-ordinator. The day centre offered activities and support for people over 12 week sessions 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.

Other than in relation to smoking related risk, staff received 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.

Other than related to smoking risks, there was overall excellent communication and delivery using a multidisciplinary and holistic approach. People were 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.

Although two risk assessments for people who smoked were not completed on the patient electronic recording system, overall risk assessments were centred on the needs of the individual and 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 within the service.

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

Care and attention was paid to people's individual needs so that they received effective and appropriate treatment. Staff were trained to understand the specific needs of people requiring end-of-life care. Unexpected events were analysed and used as learning opportunities. The quality of treatment and care was closely monitored and the results of clinical audits were used to improve practice if necessary.

Staff were supported and managed effectively and were encouraged to up-date their skills and knowledge. Professional and organisational skills were regularly assessed and further development encouraged.

We spoke with staff, people who used the service and their relatives, looked at records and observed the care and support provided in the in-patient unit.

People told us that they were happy with the way they were cared for and said that they were respected and involved in their care. One person said 'the care here is excellent'. A relative of an individual being cared for told us that she felt 'completely included" in her relative's care.

We saw that staff were respectful, polite and caring and received good training. There was a relaxed and professional atmosphere throughout the service.

Staff told us they felt well supported in their roles and were able to access support from their managers and other staff when required.

Care plans reflected each person's needs and preferences. It was clear that the service did everything it could to ensure people who were at the end of their life had their care and treatment needs met.