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Inspection Summary


Overall summary & rating

Good

Updated 22 May 2019

Bury Hospice is registered charitable organisation providing hospice services, the service has 12 inpatient beds, however they were only commissioned for and so used eight beds. They also had a day hospice which people attended during the day only and were not admitted as inpatient.

We inspected this service as a response to concerns raised about the storage and administration of controlled drugs and medicines. We carried out an unannounced inspection on 27 February 2019. We did not rate this service at this inspection.

In order to respond specifically to the concerns raised to us we only looked at some aspects of the safe and well led domains. Specifically, we looked at the following key lines of enquiry; in ‘safe’ we looked at incident reporting, medicines management, records and assessing and responding to risk. In ‘well-led’ we looked at culture, governance and monitoring risk in relation to medicines management. Throughout the inspection, we took account of what people told us, what we found on inspection, and what staff told us.

During the inspection, we visited the inpatient ward and day hospice unit. We spoke with ten members of staff including registered nurses, health care assistants, medical staff and senior managers. We spoke with two patients. During our inspection, we reviewed all four sets of notes for inpatients (there were only four inpatients at the hospice at the time of inspection) and one patient record on the day hospice unit.

We found good practice in relation to medicines management:

  • 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 and reducing risk to patients.
  • 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.

We found areas of practice that could be improved in relation to medicines management:

  • 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 reduced the chances of unauthorised access. The records trolley could not be locked due to the malfunctioning of the 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.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)

Inspection areas

Safe

Good

Updated 22 May 2019

  • NOT RATED

We found the following areas of good practice:

  • 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 and assessing and responding to risk to patients.

However, we also found the following issues that the service provider needs to improve:

  • 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 the malfunctioning of the 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.

Effective

Good

Updated 22 May 2019

Caring

Good

Updated 22 May 2019

Responsive

Good

Updated 22 May 2019

Well-led

Good

Updated 22 May 2019

  • NOT RATED

We found the following areas of good practice:

  • 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 to put patient safety as a priority.
  • The service had effective governance systems in place to ensure accountability and support the delivery of the service.
  • There were effective processes in place to manage current and future risks, which were regularly reviewed.

However,

  • There were some lapses in audit processes; there had not been a medicines management audit since March 2018.
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.