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Inspection Summary

Overall summary & rating


Updated 22 December 2016

This inspection took place on 27 October 2016 and was announced.

Dr Kershaw’s Hospice provides care for people with life limiting illnesses through its inpatient unit, day care unit and hospice at home service.

There was a manager in place who had recently had their interview with the Care Quality Commission (CQC) to become the registered manager of the service. A registered manager is a person who has registered with the CQC 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.

People felt safe and had no concerns about their safety or wellbeing. Staff had received training in safeguarding vulnerable adults and were knowledgeable about recognising the signs of abuse and how to report and deal with them.

Staff received training and management support to perform their roles effectively and to deliver high quality care. Sufficient numbers of staff, with the right experience and skill mix were available to provide people with the support and care they needed.

Care plans and associated documentation were person centred and provided the details staff would require to provide effective support in accordance with the person’s needs and preferences. We saw care plans had been reviewed on a regular basis and that the reviews had involved the person and their relative(s) where appropriate. People consented to their care being provided.

We observed staff being kind, considerate and compassionate to people and also responding to requests for assistance quickly and in a sensitive manner. We also saw staff treat people and their visitors with respect and dignity and provide privacy where needed.

Medicines were handled safely and were stored, administered to people and disposed of following clear clinical guidance and in line with current regulations and guidance.

People were supported to receive end of life care. This care took account of the person’s wishes and needs and enabled them to achieve a dignified, private and pain free death. During this difficult time, the person, their family members and staff were offered and provided with bereavement support.

Contingency plans, including emergency procedures were in place for, fire, gas leak, water loss, electrical failure, loss of nursing support, major disaster and contained emergency contact numbers and details.

Inspection areas



Updated 22 December 2016

The service was safe.

People were supported and kept safe by sufficient numbers of staff to meet their assessed needs.

Medicines were stored, administered and recorded safely.

All grades of staff were recruited following a robust recruitment and selection process.



Updated 22 December 2016

The service was effective.

People consented to their care being provided.

Staff received appropriate training, regular supervision and an annual appraisal.

Pain management for people with a life limiting illness was an important part of the service provided by Dr Kershaw�s Hospice.



Updated 22 December 2016

The service was caring.

Staff knew people well and treated them with respect and kindness and maintained the person�s dignity at all times.

People were actively involved in their care.

Visitors were welcomed at any time and could stay as long as they wanted.



Updated 22 December 2016

The service was responsive.

People were involved in the development of their care plan.

A bereavement service was available which offered support to individuals and families who were facing life limiting illnesses or bereavement.

Care notes seen demonstrated that full consultation had taken place with one person and their next of kin before any decisions were taken to enter the hospice.



Updated 22 December 2016

The service was well-led.

Appropriate action had been taken regarding accidents and incidents.

Effective quality monitoring systems were in place.

Staff told us that the manager and management team were approachable and supportive.

The management team and staff worked in close partnership with other key organisations to help ensure a consistency of service could be provided to both people in the hospice and people in the community.