Zoe's Place Liverpool

We undertook a focused inspection on 19 December 2016 to check that the service had now met legal requirements. This report only covered our findings in relation to the specific area / breach of regulation and we found improvements had been made and the breaches of regulation had been met. While improvements had been made we did not revise the rating at this inspection. To improve the rating to 'Good' would require a longer term track record of consistent good practice.

At this announced comprehensive inspection of 20 & 21 September 2017 we found the breaches met and there was evidence of continued improvement and development within the hospice. We were therefore able to change the rating to ‘Good’.

Zoe's Place in Liverpool is part of the national organisation, Zoe's Place Trust. The hospice provides care and support for up to six children who have life limiting illnesses with special and complex needs to varying degrees. The service offers respite, palliative and terminal care to children aged from birth to five years. Families also receive support through the parent support network and sibling groups.

The organisation’s website states, 'Zoe's Place offers our parents and carers a chance to recharge their batteries or to spend time with their other children'. Registered children’s nurses and support staff (carers) look after the children during their stay. The organisational structure included a board of trustees and clinical lead manager who oversaw the three services, Zoe's Place Liverpool, Zoe's Place Coventry and Zoe's Place Middlesbrough.

The hospice offered an in-patient palliative and respite care to children up to the age of five who had life limiting or life-threatening conditions. There was also the provision of a day service from 10am to 6pm during the week and a sibling support group. Referrals to the service were made from families, health professionals, hospitals or by contacting the hospice direct. Referrals to the service were dealt with promptly and parents were provided with a minimum of two nights respite care each month for their child.

A registered manager was 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.’

Safeguarding policies and procedures were in place and discussions with staff confirmed their knowledge around child protection.

Each child had a personalised plan of care; any risks associated with their care were recorded and observations/checks completed in respect of their care and wellbeing. Risk assessments reported on actions to keep each child safe.

Care records we looked at detailed individual needs, preferences, likes and dislikes and play. Care records had been reviewed and evaluated on a regular basis.

The children at the hospice were of very young age and therefore consent to care and treatment was obtained from the parents. During our inspection we observed staff gaining assent from the children before carrying out care and treatment. Staff talked with children about day to day activities such as, what they would like for lunch, arts and crafts and also about the care they were providing to ensure their inclusion.

Parents informed us they were involved in all decisions round their child’s care and that the staff work closely with them.

Children received care and treatment from a multi-disciplinary staff team which included a registered manager, registered children's nurses, play leaders, local doctors, paediatric palliative care consultant, physiotherapist, health care assistants and ancillary staff. Advice from external health and social care professionals was sought at the appropriate time.

Medicines were administered safely to each child. The staff had implemented a clinical decision form for assessing medicines and feeds; this was completed if any risks were identified in respect of medicines prior to admission. Staff received medicine training and their competencies were checked to ensure they administered medicines safely.

Environmental risks assessments were in place and maintenance work of the building was completed. Safety checks of the premises and equipment were undertaken, including fire safety.

We found the premises to be clean and there was good adherence to infection control.

Recruitment was robust to ensure staff were suitable to work with children.

Sufficient numbers of skilled and experienced staff were employed. New staff received an induction and staff had access to a good training programme, including specific training to meet the clinical needs of the children they supported.

Play leaders oversaw a programme of social activities for the children staying at the hospice. The hospice offered good recreational facilities including a hydrotherapy pool, light sensory room and soft play area.

Staff told us they received supervision and good level of support from the management. Staff appraisals were also completed.

Mealtimes were family orientated with hospice staff and children eating together. Many of the children who attend the hospice are unable to eat or drink and therefore receive enteral feeding which is the delivery of nutritionally complete food via a tube directly into the stomach, duodenum or jejunum.

The staff team knew the children they were supporting in respect of their health and social care needs. Each child was allocated specific member of staff to oversee their care and treatment. Staff were able to provide us with details of each child’s care, treatment and tell us about the families. Staff approach with the children was warm, empathetic, respectful and sensitive.

Information was available regarding the hospice included care following the death of a child and a service user guide which provided information around the eligibility criteria, staffing, health and safety, care, accommodation, complaints and practical advice relating to respite visits.

Parents were provided with accommodation on the first floor of the building should they wish to stay overnight. Parents and staff had access to a chapel on the first floor of the building.

A complaints policy and procedure was in place and displayed for easy referral. Concerns and complaints were logged and investigated.

Feedback from parents regarding the care and treatment provided by the staff was sought. Satisfaction surveys sent out earlier this year were complimentary regarding the service provision.

Staff and parents told us the overall management of the hospice was good and the registered manager provided good leadership.

Quality assurance processes and systems were in place to monitor and improve the service. This included the completion of clinical and environmental audits. Where appropriate actions plans were drawn up and actioned completed in a timely manner. An external auditor undertook a review of the service as part of the governance arrangements for the hospice.

The hospice worked in partnership with other organisations at regional and national level and were keen to forge links with other hospice services to help monitor and develop the service provision.

After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection on 19 December 2016 to check that they had they now met legal requirements. This report only covers our findings in relation to the specific area / breach of regulation. This covered three questions we normally asked of services; whether they are 'safe', ‘responsive’ and ‘well led.’ The question 'was the service effective' and ‘was the service caring' were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Zoe’s Place Liverpool on our website at www.cqc.org.uk.

A registered manager was 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.

Zoe's Place in Liverpool is part of the national organisation, Zoe's Place Trust. The service provides care and support for up to six children who have life limiting illnesses with special and complex needs to varying degrees. The service offers respite, palliative and terminal care to children aged from birth to five years.

Families also receive support through the parent support network and sibling groups. The organisations' website states, 'Zoe's Place offers our parents and carers a chance to recharge their batteries or to spend time with their other children'. Registered children's nurses and support staff (carers) look after the children during their stay. The organisational structure included a board of trustees and clinical lead manager who oversaw the three services, Zoe's Place Liverpool, Zoe's Place Coventry and Zoe's Place Middlesbrough.

The hospice offered an in-patient palliative and respite care to children up to the age of five who had life limiting or life-threatening conditions. There was also the provision of a day service from 10am-6pm during the week and a sibling support group. Referrals to the service were made from families, health professionals, hospitals or by contacting the hospice direct. Referrals to the service were dealt with promptly and parents were provided with a minimum of two nights respite care each month for their child. At the time of the inspection the hospice was not providing end of life care. Three children were receiving in patient care during our visit with a further admission later that day.

At the previous inspection in August 2016 we found medicines were poorly managed and medicine practices at that time put children at risk. At this inspection we found improvements had been made. This included verifying what medication a child was taking before being admitted to the service, the administration of feeds via a stomach tube and lessons learned from medicines incidents being fully recorded and discussed with staff to minimise the risk of re-occurrence. This breach had been met.

At the last inspection we had concerns that the service was not following agreed local authority protocols for reporting allegations of abuse with the local authority or with us the Care Quality Commission (CQC). At this inspection our findings showed staff were aware of the safeguarding protocol to follow and on-going training was provided around the safeguarding of children. This breach had been met.

In respect of ensuring children’s safety, we found at the last inspection a lack of recorded safety checks for care and equipment. We found at this inspection that significant changes had been made to systems and records to improve the safety of the service. For example, a more detailed form had been introduced of observations checks required on each child throughout the day and overnight. For example, whether a child was asleep or awake, a record of their respiratory rate and use of oxygen and suction equipment. The observation charts were completed in detail to evidence the safety checks undertaken. This breach had been met.

We found at the previous inspection that children’s plan of care lacked detail or the information recorded was not in accordance with their current needs and treatment plan. At this inspection we saw improvements had been made. Care documents were now sufficiently detailed and inclusive of children’s needs. We saw this in respect of the care needs assessments and care records we viewed. This breach had been met.

In light of the overall concerns we had at the inspection in August 2016 we found the service’s overall governance arrangements were not robust to assure a safe effective service. At this inspection we found the overall management of the hospice had improved. We saw how changes had been made to ensure a more robust system was now in place to monitor how the service was operating and to drive forward improvements. The clinical governance framework was effective thus ensuring good standards of care. This breach had been met.

The registered manager appreciated that although significant improvements had been made, the changes made need time to embed and consideration needs to be applied to the future development of the service.

Feedback from staff was complimentary regarding the registered manager’s leadership and management of the hospice.

Zoe’s Place in Liverpool is part of the national organisation, Zoe’s Place Trust. The service provides care and support for up to six children who have life limiting illnesses with special and complex needs to varying degrees. The service offers respite, palliative and terminal care to children aged from birth to five years. Families also receive support through the parent support next work and sibling groups. The organisations’ website states, ‘Zoë’s Place offers our parents and carers a chance to recharge their batteries or to spend time with their other children’. Registered children’s nurses and support staff (carers) look after the children during their stay. The organisational structure included a board of trustees and clinical lead manager who oversaw the three services, Zoe’s Place Liverpool, Zoe’s Place Coventry and Zoe’s Place Middlesbrough.

There was 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’.

The hospice offered an in-patient palliative and respite care to children up to the age of five who had life-limiting or life-threatening conditions. There was also the provision of a day service from 10am-6pm during the week and a sibling support group. Referrals to the service were made from families, health professionals, hospitals or by contacting the hospice direct. Referrals to the service were dealt with promptly and parents were provided with a minimum of two nights respite care each month for their child. At the time of the inspection the hospice was not providing end of life care.

During our inspection we found a number of breaches in our regulations.

We looked to see if there were systems in place to ensure the proper and safe handling of medicines. We found medicines were poorly managed and current practices put people at risk.

Staff had a good knowledge of what constituted abuse and how they would report an alleged incident. Safeguarding policies and procedures were in place along with local authority guidelines for staff to follow. We found on inspection however that the safeguarding process had not always been followed to protect individuals from abuse. Incidents that affected children’s welfare had also not always been reported to us in accordance with our regulations. This showed a lack of governance over monitoring around risk.

Although systems were in place there appeared to be a fragmented approach in respect of identifying and controlling risks to children’s safety and concerns, reporting on incidents, lessons learnt and actions taken. This had the potential to place children at risk.

Children’s care files contained a number of documents relating to their assessment and care. We found a number of anomalies in respect of the care files we reviewed. Some care plans we saw described children’s care though these were not always consistent or inclusive of all care needs. Care plans had not always been reviewed on every visit to reflect current care. There was a risk therefore that the staff did not always have the information they needed to provide care and support to children in accordance with their individual need.

We saw a number of quality assurance systems and audits to monitor performance and to drive continuous improvement. The concerns we identified at our inspection had not been picked up by the current governance system and auditing arrangements. This meant the governance was not as robust as it could be to assure a safe effective service.

Children were supported by sufficient numbers of staff to provide care and support in accordance with individual need. We saw that children received care and treatment from a multi-disciplinary staff team which included a registered manager, registered children’s nurses, play leader, local doctors, paediatric palliative care consultant and a team of support staff (carers) and ancillary staff. Advice from health care professionals was sought at the appropriate time. Relatives told us the staffing numbers were good and the children received all the support they needed during their stay at the hospice.

The children at the hospice were of very young age and therefore consent to care and treatment was obtained from the parents. We saw evidence of consent forms completed by parents to ascertain their personal preferences, choices and wishes around their child’s care. Staff talked with children about day to day activities such as, what they would like for lunch, arts and craft, using the play area and also about their care they were providing to ensure their inclusion. Relatives told us their views were listened to and their wishes were recorded.

Children’s dietary needs were assessed and staff ensured meals were to their liking during their stay. Healthy meals were promoted with plenty of drinks and snacks at other times during the day.

The provision of family support was seen as an important part of the overall care. Parents told us how supportive the staff were of them and their siblings and they could contact staff at any time for advice. Parents said the support was ‘first class’.

During our inspection we saw that the hospice was very clean and subject to robust infection control measures.

Arrangements were in place for checking the environment to ensure it was safe. For example, health and safety audits were completed and contracts in place for services and equipment. This included fire prevention. Night time security arrangements at the hospice included the main gates being locked and use of intercom for entry. CCTV cameras monitored the grounds and hospice entrances.

Environmental risk assessments were completed in place for areas which included the pool side, lounge/play area and kitchen to help ensure they were safe for children and others. The service had a health and safety lead and a health and safety committee to oversee safe working practices.

The hospice provided suitable accommodation to meet children’s individual needs. The layout of the hospice meant children had plenty of space to relax and/or enjoy play time. The hospice grounds were easily accessible and children had the use of a hydrotherapy pool and light therapy room.

Parents were offered accommodation at the hospice able to stay at any time. Children who died at Zoe’s Place or who died elsewhere could use the ‘Snowdrop Suite’ at Zoe’s Place. This was a room where children who had died at the hospice or within the community or a local hospital could rest until their funeral.

Recruitment procedures were robust to ensure staff were suitable to work with vulnerable people.

Staff told us they were supported through induction, on-going training, supervision and appraisal. The formal training programme for staff included end of life qualifications as part of their professional development. The training records we saw confirmed this.

Staff were trained in the use of emergency equipment such as, oxygen and suction. Emergency medicine supplies and equipment were kept in close proximity to each child should they be needed in an emergency situation or to support a child if going to different areas of the hospice.

The service had an effective system for handling, recording and responding to complaints. The records we looked at showed how complaints were dealt with and responded to.

Our observations showed staff placed a high value on working closely with families and supporting them and their children in accordance with individual need. Parents told us they had close working relationships with the staff and knew their child was well cared for. They told us the staff were polite and showed genuine warm and interest in their child’s health.

There was a clear management structure and staff said they were supported by the management team.

You can see what action we told the provider to take at the back of this report.

Parents told us that staff treated them with respect, were excellent at communicating information, had a clear understanding of their child's needs and had involved them in care and treatment decisions. All the parents spoke positively about the care and treatment their child had received. Comments included, "Staff are outstanding, the facilities are great," and "The service is brilliant, we are really happy with the care," and "The staff are really dedicated."

Care files we reviewed contained information about each child's needs as well as the care and support they required. Care plans and risk assessments were up to date and had been regularly reviewed in partnership with parents. Prior to each respite stay an admission assessment was undertaken. This allowed parents to communicate any changes to their child's care and treatment. One parent told us, "They always have a handover, it's really thorough."

We found there were sufficient numbers of staff to meet the needs of the children who used the service. Parents told us that they saw the same regular staff and that staff understood the needs of their child. We observed staff providing care and support. They had a clear understanding of each child's needs and care and treatment was delivered in a respectful, warm and friendly manner. Staff were quick to respond to requests for help or support and did not appear rushed. Staff we spoke with had received training appropriate to their role and told us they had felt supported to access additional training to enhance their knowledge and skills.

Parents told us staff had always treated them politely and with respect and had involved them in the care and treatment of their children. They said at the beginning of each stay they had been asked to check information about their child's health and welfare to make sure it was current and up to date and any changes they reported had been updated in their child's care records.

Parents told us that staff had been good at communicating with them for example if their child had become unwell during their stay at Zo's Place or if staff had been unsure about something relating to the child's care, treatment or welfare.

Parents said they thought the staff were good at their jobs and they had no doubt that their child had always been well cared for by all staff.

Comments made by parents included:

'I have no criticism at all, my child loves staying there and the staff love him.'

'It is like home from home.'

'I am so happy with the care they give my child.'

'The manager and staff are fantastic I couldn't praise them enough.'

'I check everything is up to date at the beginning of my son stay at the hospice'.