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Inspection Summary

Overall summary & rating


Updated 26 February 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

The inspection was announced. We told the provider two days before our visit that we would be coming.

St Wilfrid’s Hospice provided nursing care for people over the age of 18 living with a life limiting illness. The staff provided treatment and care for physical symptoms and helped people with addressing emotional, spiritual and social wellbeing. They also provided support to families and close friends during the illness and bereavement.

St Wilfrid’s hospice provided three distinct services. These included an ‘in patient unit’ which provided accommodation and had up to 20 bedrooms with en suite showers and toilets. ‘Wellbeing’ provided therapy and support to people who were able to come to the hospice and use its facilities.  People living at home received care, treatment and support from the ‘hospice at home’ team who were co-ordinated from the hospice.

There was a registered manager in post at the hospice.  A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People and their relatives told us that they felt safe when in the care of the hospice staff. Staff working for the hospice understood the needs of people and consulted with them throughout the care delivery. People and their families were involved in the planning of care and were treated with kindness and compassion with due regard to their privacy and dignity.  

Records showed that staff had received training on safeguarding vulnerable adults and the Mental Capacity Act 2005. Staff were able to tell us what they would do if they had any concerns and talked about when people were not able to make decisions for themselves. Meetings were held with relatives and health care professionals to make decisions in people’s best interest.

Staff were appropriately trained and skilled and provided care in a safe environment. They all received a thorough induction when they started work at the hospice and fully understood their roles and responsibilities, as well as the values and philosophy of the hospice. The staff had also completed additional training to ensure that the care provided to people was safe and effective to meet their needs.

St Wilfrid’s Hospice had the resources, that included skilled staff, facilities and equipment and well-established contacts with other health and social care professionals that ensured effective care delivery for people wherever they needed and wanted it. Feedback from all sources was used in a productive way to improve the service.

There was a strong management team which listened and supported the staff and volunteers working for the service. There was a clear clinical governance structure in place that involved staff at all levels to establish and maintain the best possible care for people.

Inspection areas



Updated 26 February 2015

The service is safe.

People who received a service from St Wilfrid’s Hospice felt safe and knew who to speak to if they had concerns.

Staff knew how to recognise and respond to abuse correctly. We saw that staff had been trained had guidance to follow and were supported by senior staff in the hospice when they raised any concern.

The hospice had effective systems to manage risks to people and staff, without restricting their independence. Staff managed people’s medicines safely and had the skills to work with medicines used in palliative care.

Staff spoken with and records showed us that the provider had ensured appropriate recruitment procedures were followed.



Updated 26 February 2015

The service is effective.

People and their families were involved in their care and were asked about their preferences and choices. People received care from staff that were trained to meet their individual needs.

Staff had good systems to help them manage any changes in people’s condition. They could also access appropriate health, social and medical support as soon as it was needed, even outside of normal working hours.

Staff monitored people’s nutritional needs and people had access to food that met their needs and preferences when they wanted it.



Updated 26 February 2015

The service is caring.  

People told us that staff were kind and compassionate at all times and treated everyone with dignity and respect. People’s views and preferences were central to the care provided, which was individual and took account of friends and family. 


The design of the hospice allowed for private space and people were supported spiritually, in accordance with their wishes.



Updated 26 February 2015

The service is responsive.

Staff communicated with other professionals to make sure that people were admitted and discharged in a coordinated way. Staff had established effective ways with people to enable them to express their views about their care, and future wishes.

Staffing arrangements ensured people received care and support when they needed it. A 24-hour telephone service ensured that patients and carers felt supported at all times. The hospice promoted family involvement and provided contact and facilities within the hospice to prevent social isolation.

Any feedback on the service was used to change and make improvements for the benefit of people and staff.



Updated 26 February 2015

The service is well-led

The culture of the hospice was open and supported staff in sharing their views. The registered manager and other senior staff provided exceptional and strong role models.

Clinical governance systems ensured that best practice standards were put in place and followed. Incidents and risks were monitored to make sure the care provided was safe and effective.