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Inspection Summary


Overall summary & rating

Good

Updated 28 April 2017

Bury Hospice is a charity which provides a range of hospice services for adults with a life-limiting illness. The hospice is purpose built and provides accommodation on the Inpatient Unit for up to 12 patients. The hospice also has a Day Hospice and Hospice at Home service.

The hospice is purpose built and is situated in a residential area of Bury, not far from the town centre. The hospice is set in well-maintained gardens with adequate parking and clearly defined parking areas for disabled visitors.

Services are free to people, with Bury Hospice receiving some NHS funding and the remaining funds are achieved through fundraising and charitable donations.

There were six patients being cared for in the Inpatient Unit during our inspection, 20 patients being cared for in the community by the Hospice at Home service and 10 patients attending the Day Hospice.

We inspected Bury Hospice on the 21 and 28 March 2017. The first day of the inspection was unannounced. We last inspected Bury Hospice in April 2016 where we found there were several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the lack of audits on the quality and safety of the service, no formal staff supervision, incomplete training records and no business continuity plan in place to deal with emergencies that could arise and possibly affect the provision of care.

During this inspection we found that the service had met all the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The hospice had a manager registered with the Care Quality Commission (CQC) who was present during the second day of the inspection. A registered manager is a person who has registered with 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 and associated regulations about how the service is run.

We were assisted on the first inspection day by the hospice care team manager; a registered nurse with a wealth of nursing and palliative care experience.

The expressions of gratitude relayed to us demonstrated that patients and their families were cared for with the utmost compassion, kindness, dignity and respect. Patients spoke highly of the kindness and caring attitude of the staff. Patients told us they received the care they needed when they needed it and that staff were knowledgeable and committed. Visitors told us they were always made welcome.

Discussions with staff and visitors demonstrated to us that the staff recognised and considered the importance of caring for the needs of family members and friends. Patients were supported at the end of their life to have a comfortable, dignified and pain-free death. The nursing and medical staff showed they were highly skilled in pain and symptom control. The staff we spoke with had an in-depth knowledge of the care and support that patients required.

We saw that patients were assisted in a way that respected their dignity and privacy. We observed respectful, kindly and caring interactions between the staff, patients and visitors. The patients looked extremely well cared for and there was enough equipment available to ensure their safety, comfort and independence were protected.

The care records showed that patients were involved in the assessment of their needs. Their preferred place of care at all stages of their illness and the arrangements in the event of their death were documented. The care records we looked at showed that risks to the patient’s health and well-being had been identified, such as poor nutrition, the risk of developing pressure ulcers and the risk of falls. We saw care plans had been put into place to help reduce or eliminate the identified risks.

Suitable arrangements were in place to help safeguard patients from abuse. Policies and procedures for safeguarding patients from

Inspection areas

Safe

Good

Updated 28 April 2017

The service was safe.

Sufficient suitably qualified and competent staff who had been safely recruited were available at all times to meet patient’s needs.

The system for the management of medicines was safe and the care records showed that risks to the patient’s health and well-being had

been identified.

All areas of the hospice were secure, well maintained and accessible for people with limited mobility. In addition, good infection control procedures were in place; making it a safe environment.

Effective

Good

Updated 28 April 2017

The service was effective.

Staff were suitably supported and had undertaken the essential training necessary to enable them to do their work effectively and safely.

Staff were able to demonstrate their understanding of the principles of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

Patients were provided with a choice of suitable nutritious food and drink to ensure their health care needs were met.

Caring

Good

Updated 28 April 2017

The service was caring.

Patients and families spoke highly of the kindness and caring attitude of the staff. Patients were cared for with the utmost compassion, kindness, dignity and respect.

Patients were supported at the end of their life to have a comfortable, dignified and pain-free death. The nursing and medical staff showed they were highly skilled in pain and symptom control.

Visitors were made welcome and the staff recognised and considered the importance of caring for the needs of all family members and friends. The spiritual and pastoral support of patients and their families was considered and respected.

Responsive

Good

Updated 28 April 2017

The service was responsive.

The care records showed that patients were involved in the assessment of their needs. A patient’s preferred place of care at all stages of their illness and the arrangements in the event of their death were documented.

Staff were skilled in recognising when a patient was in the last days of life and were able to provide the appropriate care.

Suitable arrangements were in place for reporting and responding to any complaints or concerns.

Well-led

Good

Updated 28 April 2017

The service was well-led

The service had a registered manager in post.

Clear lines of accountability and effective methods of communication were in place to ensure patients and their families received the best possible service.

Systems were in place to monitor the quality of the service provided to help ensure that patients and their families received safe, effective care and support.

Checks on specific services

Hospice services for adults

Updated 22 May 2019

  • During our inspection we found that medicines, including controlled drugs and intravenous fluids were stored safely and in line with best practice guidance and organisational policy.
  • There was a culture of safety, assessing and responding to patient risk.
  • Staff felt able to speak out if they felt something was wrong or could be improved.
  • Managers supported staff to be open and honest, report incidents and put patient safety as a priority.

However,

  • There were gaps in some audit processes and in particular, there had not been a medicines management audit since March 2018.
  • Patients records were not stored in a way that prevented possible unauthorised access. The records’ trolley could not be locked due to a broken lock.
  • There was a lack of evidence of training and competency assessments for non-registered staff acting as second checker for controlled drugs.
  • Room temperatures where medicines were stored, were not monitored consistently.