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Inspection Summary


Overall summary & rating

Good

Updated 10 December 2016

We inspected The Prince of Wales Hospice on 03 and 04 October 2016. The first day of the inspection was unannounced, which meant the service did not know we were coming.

The hospice was last inspected in October 2013. We found it was compliant in all the aspects of care we inspected at that time.

The Prince of Wales Hospice provides specialist palliative care, including symptom control, respite, and end of life care for people with life limiting diseases and other progressive illnesses. The hospice is run by a registered charity which has a volunteer board of trustees. There are 14 inpatient beds and a day care service; care staff also provide a 24 hour/seven day a week advice line for people living in the community, carers and healthcare professionals. On the first day of our inspection there were six inpatients; two more were admitted on the second day.

The hospice is located in a residential area of Pontefract. The building is all on ground floor level. There is a car park and reception area to the front of the building, with separate areas for day care, inpatients and administrative activities. All inpatient bedrooms are ensuite and had French doors to allow patients to access a patio and garden area.

During summer 2016 the hospice had undergone significant refurbishment and improvement. At the time of our inspection this work was nearly complete, with nine inpatient beds available. The service planned to have the other five inpatient beds ready for admissions within the week following our inspection.

There was no registered manager in post. The last registered manager left in December 2015. A clinical services manager had been appointed in February 2016; they were in the process of applying to be registered manager. 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.

Medicines were managed and administered safely by staff. People told us they had access to pain-relieving medicines when they needed them. Staff were encouraged to report any medicines errors so lessons could be learned.

Risks to people had been assessed and managed appropriately. Regular safety checks had been completed on the building, facilities and equipment used to support people. We saw the hospice was clean.

People and their relatives told us there were sufficient care staff deployed to meet people’s needs. Our observations supported this.

Procedures for the recruitment of new staff at the hospice were updated shortly after our inspection to make them fully robust. A system was in place to ensure nursing staff had the correct professional registration.

Hospice staff could describe the forms of abuse people might be vulnerable to and told us they would report any concerns appropriately.

Staff received a comprehensive programme of induction and training. Annual appraisals were recorded but staff said supervisions had not been happening regularly. The clinical services manager was in the process of sourcing supervision training and improving their oversight of staff development.

Care staff members’ knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) was good. We saw capacity assessments and best interest decisions in people’s files. The service considered and documented whether care provided constituted a deprivation of people’s liberty.

Feedback about the food and drinks at the hospice from people and their relatives was extremely positive. The cook was knowledgeable about the nutritional needs of people receiving palliative and end of life care and could describe the needs of individual inpatients.

People had access to a team of healthcare professionals based at the hospice. People’s holistic healthcare needs were discussed d

Inspection areas

Safe

Good

Updated 10 December 2016

The service was safe.

Staff understood safeguarding principles and knew how to report concerns. Risks to people had been assessed and managed. Safety checks were made on the building, equipment and facilities.

Medicines were managed and administered safely.

Sufficient numbers of staff were deployed to meet people’s needs. Recruitment procedures were improved during the inspection to make them more robust.

Effective

Good

Updated 10 December 2016

The service was effective.

Records showed staff received the training they needed to support people effectively. Staff had annual appraisals and a new schedule of supervision was being implemented.

People and their relatives were very happy with the food and drinks served at the hospice. A multi-professional team of staff based at the hospice were available to support people’s holistic health needs.

The service assessed people’s mental capacity and made appropriate decisions in people’s best interests when they lacked capacity. There was a pragmatic approach to Deprivation of Liberty Safeguards.

Caring

Good

Updated 10 December 2016

The service was caring.

Staff respected people’s privacy and dignity and supported them to remain independent. People were involved in designing their care and support.

End of life care provided by the hospice was benchmarked against national standards and guidance to ensure it was up to date and evidence-based.

We observed warm and caring interactions between staff and people and their relatives. Staff knew about advocacy services and in what circumstances people might need to be referred.

Responsive

Good

Updated 10 December 2016

The service was responsive.

People’s care plans were person-centred. Daily records evidenced people were supported according to their assessed needs.

People using the service as inpatients had access to activities, either in the day care unit or their own rooms. Complementary therapies were available to people, their relatives and staff.

None of the people or relatives we spoke with had made a complaint and no formal complaints had been received by the service in 2016.

Well-led

Requires improvement

Updated 10 December 2016

The service was not always well-led.

There was no registered manager in post at the time of our inspection. The clinical services manager had applied to become the registered manager.

Three statutory notifications had not been made in 2016. We identified issues with audit at the service, although we were impressed by work undertaken to benchmark clinical practice against national guidance.

Considerable effort had been applied to teambuilding and improving communication across the organisation following staff changes at the start of 2016. Staff told us they were happy to work for the service.