Archived: Fair Havens Hospice

Fair Havens is a ten bedded hospice for adults providing palliative medicine and nursing care on an inpatients and day care basis. Other services are co-ordinated from the establishment that include: Macmillan nurses, bereavement support, chaplaincy and home care services.

There was a registered manager in post. At the time of our inspection they were on long term leave and the service was being managed by a manager who was in the process of submitting their registration to CQC. They were supported by the Chief Executive Officer (CEO) and management team.

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.

People felt safe. Staff had received training to enable them to recognise signs and symptoms of abuse and how to report them. People had risk assessments in place to enable them to be as safe and independent as they could be.

Effective recruitment processes were in place and followed by the service to ensure staff employed were suitable to work with people who used the service. There were sufficient staff, with the correct skill mix, on duty to support people with their care and treatment needs.

Medicines were managed safely. The processes in place ensured that the administration and handling of medicines, including controlled medicines, was suitable for the people who used the service.

Staff and volunteers received a comprehensive induction process and on-going training. They were well supported by the manager and the management team. Staff had attended a variety of training to ensure they were able to provide care based on current practice when providing care and treatment for people.

Staff gained consent before supporting people or providing care and treatment. People were supported to make decisions about all aspects of their life; this was underpinned by the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff were knowledgeable of this guidance and correct processes were in place to protect people.

People were able to make choices about the food and drink they had, and staff gave support when required.

Staff provided care and support in a caring and meaningful way. They knew the people who used the service well. People and relatives, where appropriate, were involved in the planning of their care and support. People’s privacy and dignity was maintained at all times.

A complaints procedure was in place and accessible to all. People knew how to complain. Effective quality monitoring systems were in place. A variety of audits were carried out and used to drive improvement.

We considered if the service was safe and a specialist advisor accompanied our inspector at this inspection. We spoke with ten staff including nursing, cleaning, managers and maintenance staff. We found that whilst the premises were not purpose built, arrangements had been made to make people using the service comfortable during their stay. Staff told us that they were looking to develop a purpose built hospice locally.

During our visit we identified issues regarding fire and health and safety and we contacted other regulators for these areas for their consideration as to if they should take any regulatory action. We found that some infection control systems needed reviewing to ensure that people were not at risk. We found that the provider had systems in place for the monitoring and maintenance of equipment. We found that the provider had systems in place to ensure the service was well led and effective and to review reported issues and identify actions.

We saw that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. People experienced care, treatment and support that met their needs and protected their rights. Staff were supported appropriately and there were monitoring systems in place to regularly assess and monitor the quality of service that people receive.