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Inspection Summary

Overall summary & rating


Updated 7 July 2016

This inspection took place on 28 April 2016 and was unannounced.

Peace Hospice is registered to provide specialist palliative care, advice and clinical support for adults with life limiting illness and their families .They deliver physical, emotional, spiritual and holistic care through teams of nurses, doctors, counsellors and other professionals including therapists. The service provides care for people through an ‘In-Patient Unit’, Day Service, `Out- Patient Care` and `Community Outreach Team`. The out -patient services included rehabilitation, wellbeing, bereavement and counselling support. The community outreach team consisted of a single point of referral for `Hospice at Home` service and `Herts Neighbours` service which reached out to people in the community and provided a range of services offered by volunteers employed by the hospice. `Herts Neighbours ‘service did not include an activity regulated by the Care Quality Commission (CQC).

At the time of the inspection there were six people using the inpatient service and 60 people using hospice at home services. The day services called `Starlight Centre` offered a range of services to people recently diagnosed with life limiting conditions, their carers and families. The service provided specialist advice, courses, complimentary therapy sessions and clinics and aimed to empower people to be in control of their condition and achieve what was important to them. The Starlight Centre also offered counselling and bereavement service through teams of volunteers and contracted accredited counsellors to people and family carers.

Peace Hospice had a registered manager in post. 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.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risks to people`s well-being were assessed by staff daily and the majority had measures in place to mitigate risks and keep people safe. Hospice at home staff communicated any risks to people`s health and well-being to health and social care professionals involved in peoples` care in the community. They followed up and reviewed risks regularly to ensure these were appropriately managed and mitigated.

People were at the heart of the service and were fully involved in the planning and review of their care, treatment and support. People told us they were fully involved in setting their priorities for care. Care plans in regard to all aspects of people`s medical, emotional and spiritual needs were personalised and written in partnership with people. Staff delivered support to people respecting their wishes and preferences.

Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced. Staff reported any concerns so that these could be reviewed and discussed to identify if lessons could be learnt to reduce the likelihood of reoccurrence.

Recruitment procedures were robust and ensured that staff working at the service were qualified and skilled to meet people`s complex needs. There were sufficient numbers of staff to ensure people received support when they needed it.

The service operated a 24 hour medical and duty manager on-call system for all the services offered by the hospice to ensure people received the same support and advice during the day as during the night. People using the inpatient service had their medical needs met by a team of doctors employed by the hospice.

People who used the Starlight Centre told us that this service enabled them to meet people with similar conditions and helped them prepare for the future. People told us that staff understood

Inspection areas



Updated 7 July 2016

The service was safe.

Staff had been trained to recognise and respond to any actual or potential abuse. The service had developed systems for reporting and monitoring allegations of abuse.

Potential risks to people were assessed and measures put in place to reduce risks. Accidents and incidents were analysed and learning was shared amongst staff to prevent reoccurrence.

There were sufficient numbers of staff with the appropriate skills and knowledge to meet people`s needs at all times.

People received their medicines from staff who were trained and qualified in safe administration of medicines and the use of specialist equipment to ensure people received their medicines in time and safely.



Updated 7 July 2016

The service was effective.

People received support and care from a staff team who were trained to meet their needs. Training was well managed by a dedicated team within the service. Staff were encouraged to develop their knowledge and skills.

Staff were aware of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People were involved in making decisions about all aspects of their treatment and care.

People were supported to eat and drink and maintain a balanced diet. People were able to choose from a varied menu, which included a range of specialist drinks for those with a reduced appetite.

People�s health needs were carefully monitored by nursing staff and if people`s health required, appropriate referrals were made to other professionals.



Updated 7 July 2016

The service was very caring. People�s and their relative�s feedback about the caring approach of the service and staff was overwhelmingly positive.

Staff showed kindness and knew how to show empathy when people faced challenging situations. People valued their relationship with the staff team who often performed beyond the scope of their duties and helped people achieve their last wishes.

The service was very flexible and responded quickly to people�s changing needs or wishes. Staff communicated effectively with people and treated them with kindness, compassion and respect.

People were consulted about and fully involved in their care and treatment. The service provided outstanding end of life care and people were enabled to experience a comfortable, dignified and pain-free death.



Updated 7 July 2016

The service was responsive.

People and their families were fully involved in assessing and reviewing their needs and planning how their care should be provided, which included their wishes and priorities regarding their end of life care and preferred place of death.

The service provided person-centred care based on best practice and focussed on continuous improvement. Staff understood and anticipated people`s needs which enhanced the quality of the care people received.

The service encouraged people with life limiting conditions and their family�s early involvement in the hospice by organising diverse activity groups part of the Starlight service and complimentary therapies.

People�s families were offered bereavement support and counselling as long as they needed it.

The provider had a positive approach to using complaints and concerns to improve the quality of the service and this was closely monitored by the management team.



Updated 7 July 2016

The service was well-led.

The service promoted a positive and open culture and provided a range of opportunities for people who used the service, their relatives and people from the wider community to comment and influence the quality of service provided.

The Board of Trustees, the Chief Executive and the Registered Manager were implementing a new management structure in the hospice and re-organising services to ensure they offered a long term sustainable service.

The service worked in partnership with other organisations to ensure they followed best practice and provided a high quality service.

There were robust auditing systems in place to ensure the quality of the service was constantly monitored and actions were in place to constantly drive improvement.