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Severn Hospice Apley Site Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 July 2021

Severn Hospice Apley site is operated by Severn Hospice Limited. The service provides end of life care had 10 inpatient beds and provided services in the community.

The service is registered to provide the following regulated activities:

  • Diagnostic and screening.
  • Treatment of disease or injury.
  • Personal care.

Following this inspection, we told the provider that it must take some actions to comply with regulations. Following this inspection, we told the provider that it must take some action to comply with regulations. We also issued the provider with three requirement notices and a S29 warning notice.

Inspection areas

Safe

Inadequate

Updated 7 July 2021

Effective

Good

Updated 7 July 2021

Caring

Outstanding

Updated 7 July 2021

Responsive

Outstanding

Updated 7 July 2021

Well-led

Requires improvement

Updated 7 July 2021

Checks on specific services

Hospice services for adults

Requires improvement

Updated 7 July 2021

Our rating of this location went down. We rated it as requires improvement because:

  • Leaders did not operate effective governance processes throughout the service.
  • The service did not always ensure it followed current COVID-19 guidance in relation to retesting of patients.
  • The service did not always ensure it followed current COVID-19 guidance in relation to staff understanding of how many people could be in staff communal areas at any one time.
  • We found the risk register could be confusing due to the incorrect dates in columns.
  • Staff did not always receive the appropriate training for their role in line with the ‘Adult Safeguarding: Roles and Competencies for Health Care Staff, intercollegiate document (August 2018)’.
  • The service did not ensure that all documentation and risk assessments were completed regarding skin and wound care.
  • The service did not ensure that all documentation and risk assessments were completed and updated regarding the use of bedrails.
  • We found service did not have an Infection protection policy in place that related specifically to their service.
  • We found that the completion rate for mandatory training was low which meant staff may not have the skills or knowledge to complete their role effectively.

However:

  • We found that there was a sufficient stock of PPE and this was stored correctly. Staff were knowledgeable about personal protective equipment (PPE).
  • Ward areas were clean and had suitable furnishings which were clean and well-maintained.
  • The service had link Infection Prevention Control (IPC) nurses in place and IPC audits were completed identifying any actions that needed to be completed.
  • Staff knew how to identify incidents and report them. Incidents were also discussed in team meetings.
  • Staff told us that the senior managers were always visible.
  • We found that senior managers understood the hospice challenges and identified the required changes that had taken place during the pandemic.
  • Leaders had a clear leadership structure in place.