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St Ann's Hospice Heald Green Good

Inspection Summary

Overall summary & rating


Updated 16 November 2016

St Ann’s Hospice provides in-patient hospice care and a day hospice from one site. It is part of a wider organisation with two other sites in the Greater Manchester area providing hospice care. The hospice holds condition specific clinics, has a bereavement support service, therapy services, a fundraising department and a team of volunteers all based on-site.

The service is a registered charity with a board of trustees. Day to day the service is run by an executive management team drawn from all departments within the hospice. There was a new chief executive who had been in post for several months who had been meeting with all staff and users of the service as part of their induction into the role.

There was a registered manager employed for this 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. The registered manager was experienced in providing palliative care and had joined the organisation within the last two years.

People and professionals spoke highly of the complementary therapies that were available to both people who used the service and relatives. The hospice provided family support, counselling and bereavement support and we saw the service helped people carry out specific wishes such as providing a Christmas party for someone with their family at the family’s request.

People told us that staff were caring, compassionate and listened to them. People we spoke with who received personal care felt the staff were knowledgeable, skilled and their care and support met their needs.

The service had recently introduced a new electronic recording tool called EMIS (Egton Medical Information System). Although this was still relatively new, staff we spoke with were positive about the training they had to support this new approach and stated it was, “useful and efficient.”

People’s health care needs were met by the in-house medical team. This included consultants, GP’s with a special interest in palliative care, an occupational therapy team, a physiotherapist, social worker, dietician and chaplain.

Care plans were personalised to include people’s wishes and views. People and relatives told us they were consulted about their care and treatment and that they regularly had the opportunity to speak to medical and nursing staff. Care plans were regularly reviewed in a multi-disciplinary framework. We observed staff caring for patients in a way that respected their individual choices and beliefs.

Staff recruitment processes were followed with the appropriate checks being carried out. There were sufficient staff on duty to meet people’s needs. The hospice had experienced some shortness of staff recently although this had not impacted detrimentally on the people using the service. The hospice had a bank of staff who they could contact if they needed additional staff. The registered manager told us they had recently tried to recruit additional nursing staff but felt the calibre of applicants wasn’t right. They were going to review their advert and recruitment process to try and attract further applicants. Staff and volunteers received a thorough induction and regular training to ensure they had the knowledge and skills to deliver high quality care and support.

Staff followed risk assessments and guidance in management plans when providing care and support for people in order to maintain people’s safety.

People were protected by the service’s approach to safeguarding and whistle blowing. People who used the service told us that they were safe, could raise concerns if they needed to and were listened to by staff. Staff were aware of safeguarding procedures, could describe what they would do if they thought somebody was being mistreated

Inspection areas



Updated 16 November 2016

The service was safe.

Checks of the building and equipment were completed to make sure it was safe.

Staff we spoke with could explain indicators of abuse and the action they would take to ensure people�s safety was maintained. This meant there were systems in place to protect people from the risk of harm and abuse.

On the day of our visit we saw staffing numbers and skills mix were sufficient to provide a good level of care to keep people safe. Robust recruitment procedures were in place to make sure staff were suitable to work with vulnerable adults.



Updated 16 November 2016

The service was effective.

People�s healthcare needs were carefully monitored and discussed with people who used the service and their family members.

Staff told us they felt supported by the service and had appropriate clinical supervision.

Staff of all levels had access to on-going training to meet the individual and diverse needs of the people they supported. Staff were trained to provide the specialist care people required.

People were assessed to identify risks associated with poor nutrition and hydration and spoke highly about the quality and choice of food.



Updated 16 November 2016

The service was caring.

People told us that staff were kind and compassionate at all times and treated everyone with dignity and respect.

The service provided emotional support to people, their family and friends via a team of dedicated counsellors, nurses and healthcare staff on an on-going basis.

People were supported spiritually. People were encouraged and supported to make decisions about their care and given time to make their own choices; this included their end of life care.



Updated 16 November 2016

The service was responsive.

People told us they felt confident they could express any concerns or complaints about the service they received.

People and their families were fully involved in assessing their needs and planning how their care should be given.

Staff delivered people�s care in a person-centred way, treating them as individuals and encouraging them to make choices about their daily lives.



Updated 16 November 2016

The service was well led.

The management team gave effective leadership and provided a clear strategy for the long term development of the service.

There were clear management structures and lines of accountability. Staff told us the service was well managed, that they were treated with respect and were actively involved in decision-making.

Systems were in place to monitor the quality of the service provided to ensure it was run in the best interest of people.

Staff and volunteers told us they felt part of a team and that management at all levels were accessible and approachable.