care quality commission - prospect hospice … · 2020. 6. 21. · prospect hospice is operated by...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Requires improvement –––

Are services caring? Good –––

Are services responsive? Requires improvement –––

Are services well-led? Requires improvement –––

PrProspectospect HospicHospiceeQuality Report

Moormead RoadWroughtonSwindonWiltshireSN4 8BYTel: 01793 813335Website: www.prospect-hospice.net

Date of inspection visit: 25 to 26 June 2019Date of publication: 05/09/2019

1 Prospect Hospice Quality Report 05/09/2019

Letter from the Chief Inspector of Hospitals

Our rating of this service went down. We rated it as Requires improvement overall.

We found the following issues the service provider needs to improve:

• Staff completed, but did not always update risk assessments for each patient to identify, remove or minimise risks.Nursing staff did not always keep detailed records of patients’ care and treatment. Records were not always clear,up-to-date or easily available to all staff providing care.

• The service did not always have enough nursing staff with the right qualifications, skills, training and experience tokeep patients safe from avoidable harm and to provide the right care and treatment in the community clinical nursespecialist team.

• Staff did not manage prescription documents, in line with the provider’s policy. NHS prescription stationery usagewas not tracked as required by national guidance.

• Staff recognised and reported incidents and near misses. Managers investigated incidents but did not always sharelessons learned with the whole team and the wider service.

• The service did not provide care and treatment based on national guidance and evidence-based practice. Managersdid not always check to make sure staff followed guidance.

• Staff did not monitor the effectiveness of care and treatment as there was no participation in relevant qualityimprovement initiatives. Staff did not always document their assessment of patients regularly to manage their pain.They did give additional pain relief to ease pain.

• The service did not always plan and provide care in a way that met the needs of local people and the communitiesserved. Nor was the service inclusive and did not always record patients’ individual needs and preferences. Waitingtimes from referral to achievement of preferred place of care and death were not documented in line with goodpractice.

• There was no overarching governance system to systematically improve service quality or safeguard high standardsof care. The service did not have embedded systems to fully identify risks, with clear plans to eliminate or reducethem. The service did not always collect, analyse, manage and use information well to support all its activities.

• Some staff did not always feel respected, supported and valued. The culture did not always encourage opennesswithin the organisation.

However, we also found the following areas of good practice:

• The Chief Executive Officer was clear on the organisational priorities and, with the senior leadership team, hadidentified ways of working to improve the position of the service. It was recognised that work was still needed toimprove the culture and ensuring the service was a good place to work.

• Managers at all levels in the service had the right skills and abilities to run a service providing good-qualitysustainable care. There were new members of the senior leadership team.

• The service provided mandatory training in key skills to all staff and ensured most staff completed it. This was animprovement from the last inspection in August 2018.

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staffhad training on how to recognise and report abuse, and they knew how to apply it. This was an improvement on thelast inspection in August 2018.

• The hospice was designed to meet the needs of families and relatives of patients.• The service-generally controlled infection risk well. They used control measures to prevent the spread of infection

before and after the patient died. They kept equipment and the premises visibly clean. This was an improvement onthe last inspection in August 2018.

Summary of findings


• Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supportedeach other to provide good care and communicated effectively with other agencies. Key services were availableseven days a week to support timely patient care. Staff gave patients practical support to help them live well untilthey died.

• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of theirindividual needs. They provided emotional support to patients, families and carers to minimise their distress. Theyalso understood patients’ personal, cultural and religious needs.

• We saw a committed team who wanted to work well together, inclusively for the benefit of people using the service.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that itshould make other improvements. Details are at the end of the report.

Ted BakerChief Inspector of Hospitals

Overall summary

Prospect Hospice is operated by Prospect HospiceLimited. The service provides community and inpatienthospice care. The inpatient service is registered as a16-bedded facility which provides respite care, symptomcontrol and care for 12 patients at the very end of life.

During this inspection we inspected the inpatient unitand their community services.

Prospect@Home provides hands-on care in the patients’home, night and day. It has a team of nurses, nursingassistants and specially-trained home support volunteerswho work alongside the patient’s own GP, communitynurses and others involved in a patient’s care. It providescoordinated care, designed and delivered to meet thewishes of patients who wish to be supported at home.The Prospect clinical nurse specialist team arecommunity based and offer care and support to peoplein their homes. This team supports patients and theirfamily soon after diagnosis and for as long as they areneeded. They also have nurses dedicated to supportingpatients who live in care homes, working alongside carestaff to support and care for the patient.

Within the past 20 months the hospice has beeninspected three times. The hospice was inspected in

February 2018, at that inspection we issued a warningnotice warning notice for Regulation 17: GoodGovernance. Another inspection took place in August2018 which was a focused inspection to review theprovider's actions in respect of the warning notice. Whilesome improvements had been made, these were notenough to provide full assurance. As a result we imposedconditions upon the provider's registration whichincluded monthly risk and health and safety reports. Forthe most recent inspection, we inspected this serviceusing our comprehensive inspection methodology. Wecarried out this unannounced inspection on 25 and 26June 2019.

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do so,we rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Hospiceservices foradults

Requires improvement –––We rated this service overall as requiresimprovement. Safe, effective responsive, andwell-led require improvement. Caring was good.

Summary of findings


Contents

PageSummary of this inspectionBackground to Prospect Hospice 7

Our inspection team 7

Information about Prospect Hospice 7

The five questions we ask about services and what we found 9

Detailed findings from this inspectionOverview of ratings 12

Outstanding practice 34

Areas for improvement 34

Action we have told the provider to take 35

Summary of findings


Prospect Hospice

Services we looked atHospice services for adults

ProspectHospice

Requires improvement –––


Background to Prospect Hospice

Prospect Hospice is operated by Prospect HospiceLimited. The service opened in 1980. It offers communityand hospice care and services the communities ofSwindon, Marlborough and North Wiltshire. Theorganisation is a charity, of which 70% is funded by thelocal community through fundraising. Of its income, 30%is provided by statutory organisations such as the localNHS acute trust and the local Clinical CommissioningGroup.

The hospice has not had a registered manager in postsince November 2018. At the time of the inspection, anew manager had been appointed and had applied toCQC to be considered for registration. There was a newChief Executive Officer in post, and they were aware oftheir responsibility to register with us.

Our inspection team

The team that inspected the service comprised of aninspection manager, two CQC inspectors, an assistant

inspector, a pharmacy inspector, and one specialistadvisor with expertise in adult hospice care. Theinspection was overseen by Mary Cridge, Head of HospitalInspection.

Information about Prospect Hospice

The inpatient service is registered as a 16-bedded facilitywhich provides respite care, symptom control and carefor 12 patients at the very end of life. There are sevenindividual patient rooms and two four-bedded male andfemale bays. Since December 2017, when a review of bedoccupancy and staffing took place, staffing levels hadbeen set to provide cover for 12 out of the total 16 beds.

At the time of our inspection in August 2018, we had beeninformed that only six inpatient beds were in use. At thisinspection the hospice now provided care for 12 patientswith 11 inpatients at the time of the inspection. We weretold that staffing levels could be increased if more than 12patients were assessed as requiring admission or ifpatient acuity rose significantly.

The service also included community services,Prospect@Home (end of life care delivered in patients’homes by a team), clinical specialist nurses and a singlepoint of access team. The provider employed a team ofclinical nurse specialists working within a local acutetrust identifying end of life patients suitable for care in thecommunity. A clinical nurse specialist was also employedby the provider to provide expertise to local nursing/carehomes for end of life care.

The hospice had 134 admissions between August 2018and June 2019, 291 patients on the community clinicalnurse specialist caseload and an average of 20 patientson the Prospect@Home caseload.

This was an unannounced (they did not know we werecoming) comprehensive inspection of the hospice,Prospect@Home and the clinical nurse specialist teams.During the inspection, we visited the inpatient unit,Prospect@Home team (a team working in thecommunity) and the clinical nurse specialist team. Wespoke with 37 members of staff including; nursespecialists, registered nurses, health care assistants,volunteers, reception staff, medical staff, clinical leads,the chief executive, members of the senior leadershipteam and trustees. We reviewed eight sets of patients’records. We spoke with four patients and two relatives.We observed the care and treatment of patients in theinpatient unit, day therapy unit and in two patients’homes. We also looked at and analysed data about theorganisation and information provided by the provider.

The hospice has one inpatient ward and is registered toprovide the following regulated activities:

Summaryofthisinspection

Summary of this inspection


• Diagnostics and screening• Treatment of disease, disorder and injury• Transport services, triage and medical advice provided

remotely

Track record on safety from April 2018 – June 2019

• No never events• 45 Clinical incidents with no serious injuries• From June 2018 to May 2019, there had been three

incidences of hospice acquired MRSA and twoincidences of hospice acquired Clostridium difficile.

The provider received 29 complaints of which two wereconcerned with clinical care.

Services accredited by a national body:

Their education services retained the quality assurancestandard in March 2019 of the education body Council forAwards in Care, Health and Education, NCFE/ CACHE(NCFE CACHE provides qualifications for those who careand educate).

Services provided at the hospice under service levelagreement:

• Clinical and non-clinical waste removal• Interpreting services• Grounds maintenance• Laundry• Maintenance of medical equipment• RMO provision




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Our rating of safe went down. We rated it as Requiresimprovement because:

• Staff completed, but did not always update risk assessments foreach patient to minimise risks.

• Managers regularly reviewed staffing levels and skill mix,however, they did not always ensure there were enough staff inthe clinical specialist nursing team.

• Nursing staff did not always keep detailed records of patients’care and treatment. Records were not always clear, up-to-dateor easily available to all staff providing care.

• Staff did not manage prescription documents in line with theprovider’s policy. NHS prescription stationery use was nottracked as required by national guidance.

• Staff recognised and reported incidents and near misses.Managers investigated incidents but did not share lessonslearned with the whole team and the wider service.

However:

• The service provided mandatory training in key skills to all staffand made sure most staff completed it. This was animprovement from the last inspection in August 2018.

• Staff understood how to protect patients from abuse and theservice worked well with other agencies to do so. Staff hadtraining on how to recognise and report abuse and they knewhow to apply it. This was an improvement on the lastinspection in August 2018.

• The service, on the whole, controlled infection risk well. Theyused control measures to prevent the spread of infection beforeand after a patient died. They kept equipment and thepremises visibly clean. This was an improvement on the lastinspection in August 2018.


Are services effective?Our rating of effective went down. We rated it as Requiresimprovement because:

• The service did not provide care and treatment based onnational guidance and evidence-based practice. Managers didnot always check to make sure staff followed guidance.

• Staff did not always document their assessment of patientsregularly to manage their pain. Patients did not raise concernabout this and were provided with pain relief when required.





• Staff did not fully monitor the effectiveness of care andtreatment as there was no participation in relevant qualityimprovement initiatives. They could not assure themselveswhere improvements were required to achieve good outcomesfor patients.

• The service did not ensure records of training evidenced thatstaff were competent for their roles in the community clinicalnurse specialist team.

However:

• Doctors, nurses and other healthcare professionals workedtogether as a team to benefit patients. They supported eachother to provide good care and communicated effectively withother agencies.

• Key services were available seven days a week to supporttimely patient care.

• The service made adjustments for patients’ religious andcultural needs.

• Staff gave patients practical and emotional support to helpthem live well until they died.

• Staff supported patients to make informed decisions abouttheir care and treatment. They knew how to support patientswho lacked capacity to make their own decisions or wereexperiencing mental ill health.

Are services caring?Our rating of caring stayed the same. We rated it as Good because:

• Staff treated patients with compassion and kindness, respectedtheir privacy and dignity, and took account of their individualneeds.

• Staff provided emotional support to patients, families andcarers to minimise their distress. They understood patients’personal, cultural and religious needs.

• Staff supported and involved patients, families and carers tounderstand their condition and make decisions about theircare and treatment.

Good –––

Are services responsive?Our rating of responsive went down. We rated it as Requiresimprovement because:

• The service did not always plan and provide care in a way thatmet the needs of local people and the communities served.

• The service did not always take account and record patients’individual needs and preferences.





• Waiting times from referral to achievement of preferred place ofcare and death were not documented in line with goodpractice.

However:

• The hospice was designed to meet the needs of families andrelatives of patients.

• Patients could usually access the specialist palliative careservice when they needed it.

• The service treated concerns and complaints seriously,investigated them and shared lessons learned with all staff.

Are services well-led?Our rating of well-led went down. We rated it as Requiresimprovement because:

• The service had a vision for what it wanted to achieve, however,this was under review with plans for future development withthe whole staff team.

• Some staff did not always feel respected, supported andvalued. The culture did not always encourage, openness withinthe organisation. However, this had improved since our lastinspection and the senior leadership and staff had worked hardto support staff and recognised this was an area for continuedsupport.

• The service did not have overarching governance systems tosystematically improve service quality or safeguarded highstandards of care.

• The service did not have imbedded systems to identify risks, oran overarching plan to identity, eliminate or reduce them, andcope with both the expected and unexpected.

• The service did not always collect, analyse, manage and useinformation well to support all its activities.

However:

• Managers at all levels in the service had the right skills andabilities to run a service providing high-quality sustainable careand there were new members of the senior leadership team.

• Trustees were visible and involved.• Staff told us they really enjoyed working in the hospice.• Leaders and staff actively and openly engaged with patients,

staff, equality groups, the public and local organisations to planand manage services.





Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Hospice services foradults

Requiresimprovement

Requiresimprovement Good Requires

improvementRequires

improvementRequires

improvement

Overall Requiresimprovement

Requiresimprovement Good Requires

improvementRequires

improvementRequires

improvement

Notes

Detailed findings from this inspection


Safe Requires improvement –––

Effective Requires improvement –––

Caring Good –––

Responsive Requires improvement –––

Well-led Requires improvement –––

Are hospice services for adults safe?


Our rating of safe went down. We rated it as requiresimprovement.

Mandatory trainingThe service provided mandatory training in keyskills to all staff and ensured most staff hadcompleted it. At our inspection in August 2018 we foundcompliance with mandatory training for staff was poor. Atthis inspection we found mandatory training had beencompleted by most staff including volunteers. All trainingand development was overseen by the educationmanager. A system had been introduced so that allmandatory training could be recorded, and reminderswere sent to staff when training was due. All managerscould access the electronic system to monitor progress oftheir staff training. Staff told us that more mandatorytraining courses were available since the last inspection.

The provider did not set a target for completion ofmandatory training, but rated completion levels incategories, such as red (not achieved), amber (nearlyachieved) and green (achieved). Mandatory trainingincluded, manual handling, basic life support andinfection control. The provider confirmed that as of June2019 the e-learning modules in the inpatient unit hadachieved 87.6% compliance and Prospect@Home staffhad a compliance of 93.1%. The inpatient unit showed93% of nurses and health care assistants had completedall areas of mandatory training.

There were also 19 core competency training modulesavailable that were also rated. This included safeguarding

adults and child protection, nurse led swallowassessments, syringe drivers, wound care and leg ulcermanagement. Of these modules 75% of nurses hadcompleted and 78% of health care assistants hadcompleted them. The Prospect@Home nurse team hadcompleted 62% of the modules and the health careassistants had completed 79% of the training. Trainingcompletion for volunteers was recorded at 100%completion.

There was a structured vetting and orientationprocess for agency nurses which was completedwhen they started work at the hospice. At ourprevious inspection in August 2018, we found a newsystem had been introduced to ensure agency nurseswere appropriately vetted and provided with orientationbefore commencing their shift. When we looked throughrecords we found the process was not being followedconsistently. At this inspection we found an improvementwith agency staff orientation checklists showing agencynurses were vetted and provided with orientation to theunit before commencing their shift.

SafeguardingStaff understood how to protect patients from abuseand the service worked well with other agencies todo so. Staff had training on how to recognise and reportabuse, and they knew how to apply it. At our inspection inAugust 2018 we found staff understanding ofsafeguarding poor, so we could not be assured thatvulnerable people were protected from abuse. At thisinspection staff could articulate what safeguarding was,and their duties to report and support patients at risk.Staff told us training in safeguarding had improved as thiswas now face to face rather than online training and wasoffered to volunteers as well as employed staff.

Hospiceservicesforadults

Hospice services for adults



Safeguarding link nurses had been identified for each ofthe hospice teams. Staff we spoke with were aware of thehospice’s point of contact for safeguarding and wereaware of the safeguarding policy. This had been issued inJanuary 2019 and was due for review in November 2021.

Staff knew how to identify safeguarding risks andwere made aware of safeguarding risks alreadyknown. Staff told us that usually any patient at risk ofharm had been identified prior to admission. However,they were clear how to identify safeguarding risksincluding financial abuse, and controlled drug misuse.Staff could give us an example of when a patient hadraised concerns about another patient. Both patients hadbeen managed appropriately with support offered.

Cleanliness, infection control and hygieneStaff used recognised infection control measuresand were clear on their responsibilities in relation tothis. There was a clear infection control policy to guidestaff and direct practice. Staff kept the equipment and thepremises clean. They used control measures to preventthe spread of infection. At our inspection in August 2018we found systems and processes to prevent and protectpeople from healthcare-associated infection were noteffective and did not keep people safe. At this inspectionwe found infection control measures had improved. Staffwe spoke to knew the isolation procedure for patientswho had infections.

We found staff were bare below the elbow in line withprovider policy. This promoted effective hand washingand prevented long sleeves from touching patients,therefore reducing the risk of spreading infection.

Safety and safeguarding systems, processes andpractices were recently developed but not fullyimplemented. At our inspection in August 2018, wefound the infection and control policy had been out ofdate and did not reflect current best practice. At thisinspection we found a new infection control policy hadbeen issued on January 2019, for review in November2021.

It included a standard operating procedure (SoP) for careof a patient with Methicillin-resistant Staphylococcusaureus but hospice acquired Clostridium difficile was aseparate SoP sent after the inspection”.

The policy stated a schedule of regular audit would beundertaken or arranged by the infection control linknurses bi-monthly to cover public areas, inpatient areas,clinical rooms, bathrooms, dirty utility and the domesticrooms. There was also six-monthly audits for the kitchensand handling of linen with annual audits for waste ofdisposal, sharps, patient equipment, hand hygiene,personal protective equipment and clinical practices. Theannual results were going to be made known to theinfection prevention lead and reported to the Board ofTrustees through the Patient Services Committee. Thiswould then be fedback into the Hospice quality and auditcycle. However, not all of these audits appeared on theaudit schedule and annual audits had not yet beenundertaken.

The provider monitored infection levels. The providerwas monitoring infection control practices of hygieneaudits to establish staff compliance. From June 2018 toMay 2019, there had been three incidences of hospiceacquired Methicillin-resistant Staphylococcus aureus(MRSA), and two incidences of hospice acquiredClostridium difficile (C.Diff).

Hand hygiene audits were completed monthly to assesscompliance with National Institute of Health and CareExcellence (NICE) Quality Statement 61 (Statement 3). Thehand hygiene audit for May 2019 showed that 13 separateobservations had been completed and all seen had beenfully completed.

Staff took precautions to protect people fromhealthcare-associated infections. Hand sanitiser gelwas available in all clinical areas we visited. Eachindividual area had hand cleaning facilities for staff,patients and relatives. We saw staff and relatives usingthe hand gel or washing their hands. This was in line withthe National Institute of Health and Care Excellence(NICE) Quality statement 61, (statement three).

Cleanliness, infection control and hygiene wereobserved being managed. A cleaning audit wasundertaken monthly. The outcomes for May 2019cleaning audit had been added to an ongoing action planand the resulting actions delegated and monitored forimprovement.

An infection prevention audit report dated June 2019 wasshared with the inspection team. This showed infectionprevention compliance at 97% overall. This covered 16





areas, of which 12 areas received a score of 100%. Theseincluded: clinical practice; clinical equipment; sharps andwaste management and pressure sore management andchronic wound care. The clinical environment scored93%; hand hygiene scored 95%, urinary cathetermanagement scored 94%, and governance anddocumentary evidence scored 87%. It was not clearwhether targets had been set for these areas, and actionsfor improvement were not included within the report. Theorganisation advised us following the inspection anaction plan was in progress.

Clinical waste was managed safely andappropriately. We saw clinical waste was separatedfrom regular waste into the correct colour coded bags inseparate bins. This prevented the spread of crossinfection. Clinical and domestic waste was stored in largebins in a locked compound on site before being collectedweekly. There had been no audit of clinical wasteundertaken at the time of our inspection.

The provider had a process to care for the body of adeceased person. The hospice did not have a mortuarybut had a cold room to store the deceased person untilthe undertakers arrived. The cold room had goodinfection control procedures. The provider also had aviewing room for relatives situated next door to the coldroom. The hospice provided personal protectiveequipment for funeral directors to use when collectingthe deceased.

Environment and equipmentThe service had suitable premises and equipmentand looked after them well. At our inspection in August2018 we found some equipment on the inpatient unit hadnot been properly maintained. We also foundconsumable items for use in emergency situationssignificantly out of date. Prior to this unannouncedinspection, and part of their conditions of registration, theprovider sent us copies of their audits of emergencyequipment included in their emergency bag. Theseaudits were for March 2019 and they were completed infull. At this inspection we found that all consumableitems for use in emergency situations were within daterange. We also checked the dates and checks onresuscitation trolley equipment, the emergency grab bagsand blood spillage kits. We found all were within date. Atthis inspection we found resuscitation equipment waschecked daily and was consistently completed.

Sharp instruments were disposed of safely. Theservice provided safe sharp bins to dispose of sharpinstruments. We found these to be used to a safe leveland not overfilled.

Equipment was safe, ready to use and storedappropriately. Equipment was serviced and checked inaccordance with manufacturers’ and local requirements.Safety testing stickers showed the equipment had beentested in the last year. This was carried out by an outsidecontractor. However, the provider did not have acomplete asset register of all equipment on the premises.

Changes had been made to the environment. Wenoted at our previous inspection that some aspects of thefacilities did not always keep people safe. There werecarpets in some clinical areas which was a risk of crossinfection. At this inspection, in clinical areas, carpets hadbeen replaced with vinyl flooring which meant it waseasily cleaned. The provider told us of their plans toeventually replace all carpets.

Assessing and responding to patient riskThe initial admission assessment for inpatientrespite patients were not always completed withinthe timescales set by the service. All patients had aninitial assessment and risks were prioritised and actionstaken. We found safe assessments of patients planningan inpatient respite visit were not consistentlycompleted. An inpatient respite audit was completedduring January 2019 to March 2019 which looked at theprocess leading up to respite admission and included thesupport provided by different services patients receivedduring their admission. The audit explored the phase ofillness for all 13 planned respite admissions leading up totheir respite stay. The report concluded three of thepatients had deteriorated prior to being admitted, and ithad been identified that they were to be physically seenwithin five days prior to their planned admission. Onlythree out of the nine admissions had been physicallyseen within five days prior to their admission. Thisshortfall was an area recognised by the service and theyhad plans for this to be reviewed further.

There was effective assessment, action planning andreview for community patients which wasunderstood by the patient and their family andsupported patient choice. We visited two patients intheir own home with the clinical nurse specialist. We





observed patients treated with compassion and dignity.They allowed time for the patients and relatives to askquestions and to listen to their concerns. Advanced careplanning and preferred place of death were bothdiscussed.

Staff did not always assess and respond to patientrisks and these were not always recorded correctly.During our inspection in August 2018, we found that riskassessments were not always carried out for patients. Atthis inspection we found this had only slightly improved.The provider was trialling an inpatient risk assessmentbooklet. Of the seven sets of patient notes we reviewed,five had this document completed correctly. The twoother sets of notes just had risk assessments completed.However, we identified three patients who requiredregular pressure ulcer risk assessments, but these werenot recorded. This meant patients may not be receivingthe right level of intervention to reduce the risk of apressure ulcer. Four patients with specific care plans forpain had poorly completed or no pain assessmentsdocumented. This meant patients trends/types of painwould not be identified and staff did not have clear painassessments to follow. Patient records, including riskassessments, had been audited recently but the auditconcentrated on grammar, spelling and not quality issuesfor example, timely completion of risk assessments.

Patients at risk and in need of mental health supportwere supported. The provider had a clinicalpsychologist who visited the hospice once a week forinpatients and held outpatient clinics. The provider alsohad a service level agreement with a local mental healthNHS trust to refer the patients with mental health needswith the consent of the patient and their GP. The providercould also access an inpatient mental health facility at alocal NHS acute trust. If a patient was already assigned acommunity psychiatric nurse, they were welcome tocome into the hospice to see the patient during their stay.

Staff shared key information to keep patients safewhen handing over their care to others. On theinpatient unit, a pre-recorded handover of patients careand support needs was completed at each shift change.They focused on the holistic needs of each patient suchas clinical condition, comorbidities, ongoing assessmentsof the patients’ needs as their condition changed andupdating of family member involvement. After thehandover there was a safety briefing which informed staff

of particular risks faced by the patients, for example, highrisk of developing pressure ulcers or the risk of falling. Thenursing team used the handover process to plan theirwork for the day and to discuss any possible dischargesor new admissions.

Managers regularly reviewed staffing levels and skillmix, however, they did not always ensure there wereenough staff. At our previous inspection there was noset staffing establishment in the inpatient unit. The seniorteam told us that a staffing structure had been agreedand baseline staffing was being established. At thisinspection, the core staffing numbers had beenestablished for up to 12 patients. The provider was usinga ‘Dependency to Acuity’ tool to aid professionaljudgement about staffing levels. This measured theintensity of nursing care required which in turn,influenced the number of nurses on a shift according topatients’ needs. When we cross referenced the staffingnumbers to the acuity score from 28 May 2019 to 4 June2019, we found all the shifts had an acuity score whichadvised another registered nurse. An extra registerednurse had only been provided for one shift. Staff told us,despite the acuity score recommending anotherregistered nurse, it was difficult to convince seniormanagement to increase staffing. Some staff told us theyfelt the acuity scoring was a ‘paper exercise’. However, onreviewing the staff roster of 540 shifts, from January 2019to June 2019 for the Inpatient unit, there were elevenoccasions when staffing fell below the prescribed threeregistered nurses in the daytime and one occasion atnight. The organisation assured us that this onlyrepresented two percent of shifts. We found there wereno specific patient safety incidents relating to thoseoccasions of reduced numbers of registered nurses.

Staff told us that they felt the duty roster was not alwaysfair and duties were changed at short or no notice.Contracts were being changed following consultationwith staff to internal rotation to include night duty.

At our previous inspection, there remained insufficientoversight of the employment of agency staff and a lack ofassurance about their level of competence. At thisinspection we found most vacant shifts were coveredwhen possible by substantive or bank staff. All agencystaff undertook an introduction tour and completed asafety checklist.





Medical staffingThe service did not always provide assurance thatthey have enough medical staff to keep people safefrom avoidable harm and to provide the right careand treatment. There were risks to the organisation notbeing able to provide consistent medical cover. Duringour previous inspection, we identified there was only onelocum doctor available four days a week. In the absenceof a consultant, two rotational GP trainees could accesstelephone advice from a neighbouring hospice or thelocal acute hospital.

At this inspection we found the locum consultant was stillin post although the provider was actively recruiting apermanent consultant and a medical director. There werefive speciality doctors who worked one or two days eachto cover the service, including weekends. There was alsoa rotational post for first year GP trainees who worked atthe hospice for three months at a time. Telephonemedical advice out of hours was provided by the locumconsultant or a consultant at another local hospice.

The provider held information which recorded reasons forpatients not being admitted to the inpatient unit. On 12occasions between August 2018 – June 2019, the reasonthe provider had given for not admitting patients wasrecorded as ‘not enough medical staff’. When we spokewith the provider about this they told us that they hadrecognised that this data needed further investigation asthey believed there had never been a situation whenthere was not medical staff on duty. After the inspection,the provider examined the issue of admissions duringweekends. They told us they ensured there were alwayssufficient medical staff on duty to meet people’s needs byprioritising admissions during the week and care ofexisting patients at weekends.

In the rotas from August 2018 to June 2019, there wasalways one doctor minimum and usually up to three, inthe inpatient unit, during the day time. It was dependenton the medical needs of the other patients on the unitwhether a second patient could be admitted when onlyone doctor was on the rota, as at weekends.

Nurse staffingThe service did not always have enough nursingstaff working in the community to keep patients safefrom avoidable harm and to provide the right careand treatment. At our inspection in February 2018 we

found staffing levels had been assessed and were beingmonitored daily, but they did not always ensure theywere flexible and sufficient to meet patient's individualneeds. The inpatient unit also had a high number ofvacancies. At our inspection in August 2018 we foundthere were many occasions where staffing on theinpatient unit left the ward potentially unsafe. At thisinspection we found the provider had improved staffingon the inpatient unit.

However, the clinical nurse specialists working in thecommunity had a high level of short and long termsickness and two full time vacancies. This meant thatband five registered nurses in the community had theirown caseload when they should have been supportingthe community nurse specialists. The band five registerednurses should not have had their own caseload, eventhough this was a developmental post, without theoversight and support from a clinical nurse specialist.

RecordsNursing staff did not always keep appropriaterecords of patients’ care and treatment. Recordswere not always clear, up-to-date and available toall staff providing care. We reviewed seven sets ofrecords paper and their corresponding electronic notes.We found the care plans for both paper and electroniccopies to be brief, vague and not individualised. Careplans were pre-printed, with the patients namepopulated onto the care plan but these care plan lackeddetail of the patient’s individual needs and wishes. Somecare plans were in paper form and a few (not all) were onthe electronic system. Staff told us this led to them beingconfused about where they documented the patientscare.

The provider had a ‘personalised care plan informationbooklet’ which was given to patients for their informationabout what they could expect to be recorded within theircare plan. It had been recorded electronically for themedical and nursing staff to know this informationbooklet had been handed out to patients. This was alsodocumented on the handover sheet. Following theinspection, the chief executive told us this booklet waspart of a cross-organisational initiative to promotecontinuity of care across care settings. This was createdas part of implementation of the ‘Five Priorities for Care ofthe Dying Person’ (2014).





Evaluation of care given to patients was usually recordedon the electronic system. A member of staff told us theythought the provider was going back to be completelypaper based system. The mixture of recording was atemporary solution until moving to a complete electronicsystem but was confusing for staff. The organisation wasin the process of improving the paper care planningdocuments before transferring all records to an electronicsystem. However, of the seven sets of notes we reviewed,only one had a comprehensive assessment andevaluation on the electronic system. We found littleevaluation of care on either system. For example, onepatient was admitted with pain had a basic pre-printedcare plan for pain. We found there was no evaluation ofregular pain relief given and no mention of effectivenessof pain relief given for breakthrough pain.

We also found gaps in documented care called‘intentional rounding’. This was to ensure patients wereseen regularly for pressure area care, to be offered a drinkor the toilet. We found in three of the seven sets of notes,gaps of six hours and one intentional rounding chart wasblank at 3pm in the afternoon. We could not be assuredthat patients were receiving the care they required. Webrought this to the attention of the Director of Services tobe rectified.

After the inspection, the chief executive told us they hadstarted a project to improve the paper care plans,overseen by a dedicated nurse.

Medical staff kept appropriate records of patients’clinical care and treatment. All clinical notes weredocumented on the electronic system. All notes wereclear, concise and had a clear medical management planfor each patient. It was clear that patients had beenconsulted about their wishes and expectations. Aspeciality doctor had devised a series of prompts forjunior staff when clerking patients. Medical and nursingstaff jointly admitted patients onto the inpatient unit.Allergies were discussed with patients on admission andwere noted in their records and on prescription charts.

There was good management of paper records. Wefound that staff of various disciplines recordedinformation into the patients’ records. We found thatinformation was recorded in a contemporaneous way

and staff signed, dated and timed their entries andrecorded their designation or role. Notes we reviewedwere neat and legible and detailed the care the patienthad received well. This was in line with good practice.

Prescription charts and records relating to medicineswere of a good standard. We did not see anyunauthorised omissions on the medicines charts wechecked. The patient’s allergy status was recorded on allmedicine’s charts reviewed.

Patient records and information were storedsecurely. We found paper-based records to be storedsecurely in a locked office. We found all computers lockedand accessed by appropriate staff.

MedicinesThe provider had systems for the safe storage,administration, prescribing and disposal ofmedicines. However, not all staff administeringmedicines had undertaken the services requiredtraining and had been assessed as competent.Patients received the right medicines at the right dose atthe right time. At our inspection in February 2018 wefound medicines management was not always safe. Weissued a requirement notice for areas of concern. Theprovider sent us an action plan which said they hadaddressed the shortfalls. At this inspection we found staffstored and managed all medicines and prescribingdocuments in line with the provider’s policy.

There were suitable arrangements for ordering andstoring controlled drugs with a check of balancecompleted by two nurses daily. Stock medicines werestored securely with access restricted to registerednursing staff.

Medicines including emergency medicines and medicalgases were stored securely and within theirrecommended temperature ranges. There were systemsto monitor medicine expiry dates

In the day therapy unit, patients were assessed for thesupport they needed to administer their own medicines.There was a registered nurse in day therapy to supportpatients with administration of medicines if required,including medical gas therapy.





Medicines related stationary was not managedsafely and securely in line with guidance. We foundmedicines related stationery was not tracked as requiredby national guidance issued by NHS Counter FraudAuthority Management

Medicine incidents and errors were recorded on theincident reporting system. Medicine errors werediscussed at the monthly risk and information meeting. Amedicines errors report was extracted from the incidentreporting system. In 2018-19, 71 medicines errors hadbeen reported. The provider had recently changed thereflective tool used for staff, both medical and nursing,after a medicine error. This was to increase the level ofscrutiny for medicine errors. We were given an examplehow changes had been made to staff practice followingsome recent incidents.

Training and competency assessment of all staffhandling medicines was not always undertaken.Registered nursing staff were expected to complete anonline medicines management module. However, todate, only 46% of registered staff had completed this.Healthcare assistants did not administer medicines in theinpatient unit but applied topical creams and ointments.The registered nurse signed for the administration but didnot actually usually administer it. This was highlighted ina recently independent report, commissioned by theprovider, into administration of medicines.

The provider had pharmacy input. Support wasavailable from a local acute trust pharmacist. The acutetrust was contracted to provide medicines with out ofhours support also provided. Additional pharmacysupport was provided by a local pharmacy threemornings a week.

Medicines reconciliation was carried out by a trainedand competent healthcare professional. We reviewedseven inpatient prescription charts. We found allprescription charts had been reviewed by a pharmacist,there were no gaps in administration, ‘as necessary’medicines were prescribed and administered, and thepatient’s allergy status was recorded.

IncidentsThere had been some improvement in the reportingand investigating of incidents, however furtherimprovements were required to build on this. At ourinspection in February 2018 we found staff were not

always supported to understand what constituted anincident. At our August 2018 inspection we found therewas no formal incident investigation process to ensurethat learning from incidents were identified andcascaded to staff to improve patient safety.

At this inspection staff told us there was an incident bookheld on reception, and information in relation toincidents were also held electronically. They told us of anexample where a patient was injured getting out of theircar, and this had led to training and learning on manualhandling techniques. However, volunteers we spoke withtold us they were not involved with incident reportingand therefore we could be assured that all whosupported patients were aware of, or supported to, reportincidents, when required, for investigation.

There was a formal paper-based incident reportingsystem, training for the investigation process and aclinical incident log to monitor incidents. The provider'sincident policy had an incident grading matrix to classifyincidents into none/near miss, low, medium, high anddeath. However, the incident log did not document thegrade of risk of the incident. This meant that potentiallyserious incidents could be missed.

We saw there were databases and spreadsheets availablefor staff to record incidents and actions taken. However,there was variation across the organisation in the use ofthese. We found the corporate incident report did notcontain any learning shared, and this was replicated inother departments. However, the single point of accessteam had recorded lessons learned. From this we couldsee team reflection had taken place following incidents,actions taken and integrated into practice.

Staff received training to undertake investigations,however, lessons learned were not always shared. InNovember and December 2018, 18 senior staff hadreceived training for root cause analysis. However, ourreview of actions following a root cause analysis foundlessons learned from investigations had not always beenshared with the whole team and the wider service.

In team minutes there was limited mention of incidents.For example, we reviewed the incident log and comparedthe incidents that had occurred and whether they werementioned in the limited amount of meeting minutessupplied to us; they were not. Also, the lessons learned,and dissemination of lessons learned were not





consistently completed or recorded on the incident log.Staff told us they did not receive feedback from incidentsin their team meetings or safety briefings therefore,learning from incidents was not consistently used todevelop learning. For example, an inpatient falls audithad been completed to learn from and preventrecurrence of falls. The audit was of ten responses anddemonstrated higher times in relation to shift patterns,the highest levels of falls were on Mondays at aroundbreakfast, lunchtime and bedtime. There was noevidence provided that would demonstrate theinformation was used to inform staff, staffing levels orwork plans.

From April 2018 – June 2019 there had been no NeverEvents and 45 clinical incidents with no serious injuries.

Are hospice services for adults effective?(for example, treatment is effective)


Our rating of effective went down. We rated it as requiresimprovement.

Evidence-based care and treatmentThe service did not always provide care andtreatment based on national guidance and evidenceof its effectiveness. Advance care planning was aprocess that enabled individuals to make plans abouttheir future health care. Advance care plans providedirection to healthcare professionals when a person maynot be able to either make and/or communicate theirown healthcare choices.

The provider cannot be fully assured that care,treatment and support was always delivered in linewith legislation, standards and evidence-basedguidance, including NICE and other expertprofessional bodies. We requested, but did not receive,evidence that national guidance was incorporated intosystems, processes and policies. For example, the ‘Fivepriorities for care of the dying person’; National Institutefor Health and Care Excellence (NICE) Quality Statement(QS) 144 Care of dying adults in the last days of life(March, 2017); NICE National Guidance 31 Care of dyingadults in the last days of life (December, 2015), NICE QS13End of life care for adults (November, 2011) and

Ambitions for Palliative and End of Life Care, a nationalframework for local action 2015-2020. When we spoke tosenior members of staff they were not aware of the fivepriorities for care of the dying person and told us theythought these were a good idea and something theywould look into.

As there was no audit process or outcomes in relation tothe care of the dying, we could not be assured nationalguidance was being used effectively to manage patients’care in the last days and hours of life. We also found thatpatients did not have a clear personalised care planwhich reflected their complex needs and wishes.

Not all patients cared for by the hospice hadAdvance Care Plan to which the hospice had accessto. The advanced care plans could be completed with theGP, District Nurse or the hospice. We found that advancecare planning documentation was not always completed.This meant patients care needs and preferences at theend of their life may not be met by the staff.

Of the seven sets of notes we reviewed, only two patientshad advanced care plans.

Nutrition and hydrationAlthough the service was committed to providinggood quality meals, we found the individualnutritional and special needs of patients were notalways identified and recorded. In order to supportpatients, the service used special feeding and hydrationtechniques when necessary. An inpatient nutritionalaudit was completed in March 2019, but there was noevidence the information was used to tailor meals toindividual needs. The audit was of six patients andincluded patients who needed assistance with eating anddrinking. There were minimal actions recorded from theaudit and there was no follow up date to review andensure the actions identified from the audit had beencompleted. The provider had not collected any feedbackfrom patients about the quality and choice of meals anddrinks available.

The general menu offered to patients had a very limitedselection and did not meet the needs of patients who forexample, had a sore mouth or difficulty in swallowingfood. There was no evidence that soft diets for patientswere considered and fortified foods for patients with poornutritional intake were not available. There was noprovision made for patients with special needs. For





example, some patients may benefit from finger foodsbeing available throughout the day. The provider wasaware that this was an area for improvement. A new linknurse had been appointed and was keen to improvenutrition for patients. They had arranged a meeting withthe dietitian and chef to look at issues such as fortifiedand soft options of food for patients.

The kitchen was locked at night and night staff hadaccess to the keys. Staff could prepare soup, sandwichesand drinks for the patients if required.

Hydration was managed according to patientwishes. Following assessment of a patient, and if thepatient wanted or had planned for, intravenous orsubcutaneous fluids could be prescribed andadministered.

Pain reliefStaff did not always record that they regularlyassessed and monitored patients to see if they werein pain. The provider used a pain score to assess thelevel of pain. Patients were asked to grade the pain theyexperienced on a scale of one to ten. We found there wasno recorded evaluation of the effectiveness of pain reliefgiven, including when given for breakthrough pain.However, patients we spoke to were positive about theway their pain was managed. We observed staff askingpatients about their level pain on medicine rounds.

We observed the clinical specialist nurses talking topatients about pain management and symptom control.

Staff prescribed and administered pain reliefaccurately. Anticipatory medicines were prescribed forpatients on the inpatient unit and ‘just in case’ medicinesin the community for symptom control. This meantpatients would not have to wait for medicines to beprescribed when experiencing a symptom for the firsttime. For example, medicine for nausea and stronger painrelief. We found anticipatory medicines were prescribedand given as needed.

The provider was also improving the safe use oftranscutaneous electrical nerve stimulation (TENS),which is a method of pain relief involving the use of amild electrical current, through improved competency forregistered nurses and consent from patients.

Patient outcomesManagers did not always monitor the effectivenessof care and treatment to use findings to improvethem. A patient discharge audit had been undertakenbetween January and March 2019. This audit looked atthe average length of stay for discharged patients,geographical location, eligibility for funding, level ofsupport required to help individuals manage afterdischarge and whether they had a mental capacityassessment. The data collected was used to implementactions and improve outcomes for the next quarter. Thiswas the first audit and we were told this would be used tomeasure against future audits.

There was no participation in relevant qualityimprovement initiatives. There was no programme ofmultidisciplinary audits to check care and treatment wasbeing provided in accordance with national guidelines.For example, patient outcomes against the ambitions ofthe Five priorities for care of the dying person. Seniormembers of staff we spoke with about this told us theywere unaware of such an audit, it was something theywere interested in, and it would be something they wouldlook into.

An audit of records was undertaken in December 2018 toassess compliance recently. However, the auditconcentrated on grammar, spelling and not quality issuesfor example, timely completion of risk assessments andevaluation of care given. Staff members we spoke withconfirmed there was further work to do to capture theright data to improve patient outcomes.

The provider used outcome measures such as theoutcome assessment and complexitycollaborative(OACC) for patient care. However, they didnot evaluate results to understand the breadth of theservice being provided. Monitoring patient outcomes wasimportant to know if the care given is what the personand their family wanted and to ensure it was the mostappropriate care possible and how it made a positivedifference to their lives. The provider did not participatein the National Audit of Care at the End of Life (NACEL).The provider told us they were considering registering tobe part of the audit.

The organisation held monthly quality improvementand clinical audit meetings. These were attended by allclinical leads and a senior manager. We found minutes of





these meetings which covered what audits were due, andensuring tools were ready to complete audits. We sawaudit papers, with action plans, but these plans had notimescales or responsible person. We found results ofaudits were not discussed at the meetings, and actionplans were not followed through or monitored. We foundno evidence that audits were used to improve outcomesfor patients.

Competent staffThe service did not always record the training andsupervision undertaken to demonstrate staff werecompetent for their roles. At our focused inspection inFebruary 2018 we found staff did not receive role-specifictraining on a consistent basis. Most staff had notundertaken refresher training on role specificcompetencies. Following that 2018 inspection, theprovider had acted to address the gaps in staff training.Staff told us that whilst they had benefitted from thetraining they had felt overwhelmed with the extra training.

At this inspection we had concerns about the records ofeducation and skills undertaken by the clinical nursespecialists (CNSs) working in the community. Staff told usthere was a competency framework for them and thatthey had completed this. However, when we reviewed theprovider's training records, none of the CNSs had anyrecords documenting further education undertaken, suchas degree or master’s level degree in the field of end of lifecare. A bank CNS had a level two certificate in end of lifecare. The service had six non-medical prescribers andtwo were undertaking the course; this was also notdocumented.

The CNS team were experiencing high levels of short- andlong-term sickness and also had two full time vacancies.Band five staff nurses in the community, who supportedthe CNSs, had their own caseload as demand for serviceswas so high. A senior member of staff told us that staffwere very experienced and trained to an appropriatelevel, but we could find no documented evidence of fulltraining undertaken. Also, we were unable to establishwho had oversight of the competency framework and itscompletion. The provider had identified that band fiveregistered nurses should not have their own caseload.

However, band five registered nurses had caseloads andwe were concerned whether they received thesupervision support they required as the provider couldnot provide evidence of this.

There was a structured induction programme thatall staff and volunteers completed when theystarted work at the hospice. At the last inspection inAugust 2018, we found the provider did not ensure therewas an induction programme which prepared all staff fortheir roles. At this inspection we found an improvementas all new staff, including volunteers, received aninduction programme and this was documented. Staffand volunteers told us they had undergone acomprehensive induction and had felt well supported.

Staff received clinical supervision/one-to-onemeetings on a regular basis. Following the August 2018inspection, we issued a requirement notice for theirprovider to address these shortfalls. The action plan wereceived following this inspection said they hadaddressed these areas of concern. At this inspection wefound staff were receiving some clinical supervision. Thematron received clinical supervision from the clinicalpsychologist every six to eight weeks.

Therapy staff we spoke with told us they had yearlyappraisals and one-to-ones with their manager. Staff hadbeen asked to identify goals they wanted to achieve bythe end of the financial year. At the time of the inspectioneach member of therapy staff had been asked to createtimelines and milestones to help ensure goals could bemet. Staff also told us they had access to additionaltraining modules, such as medicines management.

Nursing professional registration was recorded on thetraining records. We found six registered nurses whosecurrent professional registration was not recorded by theprovider. However, assurances were received post theinspection, that all registered nurses had a valid andcurrent registration to practice.

Volunteers, where required were trained andsupported for the role they undertook. During ourinspection we spoke to six volunteers, two clinical andfour non-clinical staff. They had received an inductionthrough the provider which they felt had prepared themwell for the role. The volunteers spoke very positivelyabout their experiences in working for the provider and





told us they felt like part of the wider team, and furthertold us that communication was good from managers.Volunteers also had a quarterly meeting, and this was anopen forum to discuss any issues.

Multidisciplinary workingStaff of different kinds worked together as a team tobenefit patients. Doctors, nurses and other healthcareprofessionals supported each other to provide good care.

Effective multidisciplinary working was evident. We foundgood multi-disciplinary working between thedepartments. Staff delivered and reviewed care in acoordinated way. Staff felt confident in seeking supportfrom members of the department. Nursing staff spokevery positively about the volunteers who attended tohelp with patients in the inpatient unit and in the daytherapies rooms and supported the carers café.

Information was shared with the patients GP ondischarge. Discharge letters were automatically sent tothe patients GP when discharged from department. Ifpatients were part of a follow up clinic then a letter wouldbe sent to the patients GP. This information would also beshared with social or care workers where appropriate.

There was a clear process for the transfer of carefrom hospital to the hospice. The provider had a teambased at the local hospital which covered most end of lifepatients. They had clear pathways to aid them to ensurepatients were sent to local hospices where appropriate.

Seven-day servicesThere were services available 24 hours a day withenough access to support patient care.

Nurses and medical staff provided cover 24-hours-a-day,seven days-a-week. This was either on site or on-call.Junior and middle-grade doctors told us the consultantswere always accessible and gave them good support andwould attend during on calls as required. Cover was alsoavailable from clinical nurse specialists, Prospect@Homeand therapy team staff.

Pharmacy services were available either in thedepartment, accessible by telephone or on call. Staff toldus should they need specific medicines, not stocked inthe department, the pharmacy arrangement with thelocal acute trust responded in a timely way.

Health promotionThe hospice offered support to people to live welluntil the end of their life, through self-management,reablement and appropriate therapies. The service’stherapy team included physiotherapists andoccupational therapists, as well as offering access to alymphoedema nurse five days a week and a dietitian oneday a week. The purpose of the day therapy unit was tohelp patients stay independent, feel supported and buildconfidence in readiness for the challenges they may faceahead.

The unit offered an ‘open programme’ to new patients. Itoffered a range of courses designed to help patients copebetter with their illness. Developed by the therapy team, itwas designed to give practical advice and information tobuild skills and confidence. This was an eight-weekcourse, with subjects including: living withbreathlessness; managing fatigue; managing stress;nutrition workshop; adapted Tai Chi and a sleepworkshop. Staff gave us examples of changes made to theprogramme following patient feedback. For example,patients told staff that the session on fatigue was toolong, so adjustments were made to reduce the length ofthe session.

The unit also offered a 16-week course, designed to helpsupport patients through their illness, to maintainindependence and to boost sense of wellbeing. Thisincluded taking part in some of therapeutic and socialactivities, to help to lift each patient’s confidence andself-esteem, and reduce stress and anxiety. The therapiesteam worked with patients to set goals together.

Consent, Mental Capacity Act and Deprivation ofLiberty (DoLS)

Staff understood how and when to assess whether apatient had the capacity to make decisions abouttheir care. They followed the service policy andprocedures when a patient could not give consent.

The Prospect team based at the local acute hospitalclearly understood the requirements for patients toconsent to their care. All patients referred to their servicehad to be consented by the NHS hospital staff before theycould be referred to the service. Consent of patients wasclearly identified on the notice board in the locked roomwhere staff were based. We reviewed all the inpatients





treatment escalation and resuscitation plans. We foundthey were generally well completed and mental capacitywas always considered and reasons for decisions welldocumented.

The hospice had identified two recent incidents whereDoLS forms had not been completed, both in May 2019.Following these incidents, the organisation notified thelocal clinical commissioning group. The organisationprovided mandatory on-line training to staff and furthermandatory face to face sessions had been arranged totake place in the week following the inspection. Plans forimproved paperwork were underway, and we were toldthat new flowcharts were being added to the policywhich would then be recirculated.

Staff understood their roles and responsibilitiesunder the Mental Health Act 1983 and the MentalCapacity Act 2005. They knew how to support patientsexperiencing mental ill health and those who lacked thecapacity to make decisions about their care.

A patient discharge audit was completed from January toMarch 2019 which included a review of mental capacityassessments. The report concluded there had beensignificant improvement in acknowledgment of mentalcapacity and appropriate capacity assessments had beencarried out. Patients who were assessed as lackingcapacity had a best interests meetings and were involvedin decisions about their care and treatment. There was anaction plan to continue to monitor and gatherinformation on best interest meetings and DoLsoutcomes for patients as part of the next cycle of auditsto ensure correct processes were being followed.

Are hospice services for adults caring?

Good –––

Our rating of caring stayed the same. We rated it as good.

Compassionate careStaff cared for patients with compassion. Weobserved all staff introduce themselves and explain whothey were and their role. The tone of voice used was oneof respect and care and an understanding of both thepatients and relative’s situation. Patients we spoke withall spoke positively about the care they had received.

Patients felt staff gave them the care they needed, and weobserved staff treating patients with empathy andkindness. Staff took the time to interact with people whouse the service and those close to them in a respectfuland considerate manner.

Feedback from four patients and relatives confirmed thatstaff treated them well, with kindness, dignity and respectby all staff. The provider conducted patient experiencesurveys. The latest survey showed a satisfaction rate forthe inpatient unit was 94%, Prospect@Home 100%,complimentary therapy 99%, day hospice 95%, clinicalnurse specialists 96%, Occupational Therapy 87% andPhysiotherapy 98%.

Staff understood and respected the personal,cultural, social and religious needs of people andtook these into account in the way they deliveredservices. The provider ensured care after death, whichincluded honouring spiritual and cultural wishes of thedeceased person and their family and carers. Patientswere asked if they had any spiritual or religious needsand we saw this documented in the care plans. Staffundertook online learning for spiritual needs of patientsand their families. The provider also had a spiritualco-ordinator who had good links with local churches andfaith leaders. The inpatient unit had a multi-faith roomcalled the ‘Quiet Space’. This room was well furnishedand had copies of different religious texts for patients andrelatives to use. There was also access to the viewingroom where relatives could spend private time with theirdeceased relative. The provider also had a designatedfamily room where private discussions could be held withrelatives.

The service honoured people’s wishes for organ andtissue donation. A speciality doctor had compiled atissue donation flow chart for the hospice and thecommunity. This contained the eligibility and exclusioncriteria for donation. Patients and relatives were asked fortheir opinion on donation when being admitted by thedoctor.

Emotional supportStaff provided emotional support to patients,families and carers to minimise their distress. Theyunderstood patients’ personal, cultural and religiousneeds. Emotional support was provided by all staff topatients and relatives. We saw staff sitting with patients





and families providing explanations, listening andsupporting patients and relatives. We observedcomprehensive assessments conducted in a very caring,considerate manner. They ensured they understood theinformation and were given the opportunity to answerany questions.

People were given appropriate and timely supportand information to cope emotionally with their care,treatment or condition. Staff said that whereappropriate they referred or signposted patient's andrelatives to other community services, including supportgroups and voluntary agencies, for emotional and mentalhealth support with their care.

Patients could be referred to the clinical psychologistwho visited the hospice for support. We observed staffdemonstrated a non-judgemental attitude whensupporting patients with a mental health issue. Theyshowed understanding about their condition and talkedto them with respect.

Understanding and involvement of patients andthose close to them

Staff involved patients and those close to them indecisions about their care and treatment. Patientsand relatives were given opportunities to ask questionsand staff gave them time to do this. We observed staffasking questions and waiting for the answers. Staffoffered options and were able to discuss the patientscare with them. Relatives and carers were given timelysupport and a space to have discussions. Patients carers,advocates and representatives including family membersand friends were identified, welcomed, and treated asimportant partners in the delivery of their care.

Staff involved people who used services and thoseclose to them in planning and making shareddecisions about their care and treatment. Weobserved many examples of how staff included patientsand those close to them in making decisions about theircare. For example, medical staff encouraged patients andthose close to them in be involved in decisions abouttheir care. Medical staff said that it was about “what wasimportant” to patients and about patients taking“ownership” of their care.

Are hospice services for adultsresponsive to people’s needs?(for example, to feedback?)


Our rating of responsive went down. We rated it asrequires improvement.

Service delivery to meet the needs of local people.The service did not always plan and provide care in away that met the needs of local people and thecommunities served. At our focused inspection inFebruary 2018 we found patients did not always havetheir individual needs met as admissions to the unit wereregularly delayed. This was due to issues with staffing. Weissued a requirement notice for the provider to addressthis issue. The action plan we received following theinspection said this was addressed. At our August 2018inspection we found patients were still being delayedadmission to the hospice due to staffing.

At this inspection we found between August 2018 andJune 2019, 190 patients were added to the waiting list ofwhich 151 were actually admitted. Of these 114 patientswere admitted within one day and the average waitingtime to be admitted was 1.3 days with the longest wait ofthree days. Delayed admissions affected 63 patients, 22due to shortage of medical and/or nursing staff, 30 due tothe inpatient unit being full and eight patients weremedically delayed. In total, 39 patients were removedfrom the waiting list for varied reasons including thepatient declining admission, being admitted to the localacute hospital and patients who died at home. Althoughpatients were still experiencing delays, this was animprovement on the inspection in August 2018. At thetime of our inspection, only one patient was waiting foradmission.

The service worked with others in localorganisations to plan care. The provider workedclosely with the local clinical commissioning group, thelocal acute trust, a local independent pharmacist, socialservices and their own teams to plan care for patients.The provider employed a team of clinical nurse





specialists who worked within a local acute trust Theirrole was to identify patients who would benefit frompalliative care, either in the community or in the hospiceadmission and support their discharge from hospital.

The hospice was designed to meet the needs offamilies and relatives of patients. The hospiceprovided accommodation for families and relatives ofpatients. They had two purpose-built lodges in thegardens. These were well furnished, and relatives told usthey helped them to be near to their loved ones. Relativeswere also allowed to stay by the patient’s bedside ifrequested.

The hospice also had a cafeteria run by volunteers. Allfood was cooked in the hospice kitchens and wasavailable to families, relatives, staff and visitors. Thehospice also provided hot and cold drinks for relativeswho could help themselves.

Staff had access to translation services to helppatients with communication. Staff told us how theycould access translation services when required.

Meeting people’s individual needsThe service and its environment took account ofpatients’ individual needs. Corridors and doors werewide enough for wheelchair access. All bathrooms haddisabled facilities, including the lodge accommodationprovided for families. Staff were able to accessinterpreters for patients whose first language was notEnglish. This could be arranged through an externalcompany over the telephone.

People’s privacy and dignity were respected, includingduring physical or intimate care in nearly all areas wevisited. Staff pulled curtains and doors were shut whenundertaking care. A member of staff was observedattending to the personal hygiene needs of an end of lifepatient. They answered the call button immediately andspoke to the patient in a discrete and quiet manner. Thecurtains were drawn round the patient to ensure privacyand dignity.

All the rooms and bays in the inpatient unit looked outonto the gardens. Patients could be wheeled out, on theirbeds if needed, to enjoy the outdoors. Parasols and suncream were provided for the patients. The gardens hadwheelchair friendly paths and there was also aremembrance area where relatives could lay

commemorative stones in memory of their loved ones.This part of the garden could be accessed from the side ofthe hospice so that relatives did not have to pass throughthe hospice.

The inpatient unit had a large conservatory called thegarden room. There was a large television on the wall andpatients and relatives were encouraged to use the room.It had been used for family parties, weddings and aconfirmation.

Nurse call bells and emergency call bells were availablein areas where patients were left alone, such as toiletsand changing areas. The staff carried bleeps in theirpockets to alert them to the needs of the patients andthere was a panel at the nurse’s station which had anaudible alarm. We found they were answered quickly.

The provider had ‘Pets as Therapy’ dogs who visited theunit once a week. Relatives were also able to bring inpatients’ pets.

The provider had a network of volunteers who supportedpatients and relatives at home. They did not providepersonal care but provided support and companionshipto patients and relatives.

The service made adjustments for patients’ religious,cultural and other preferences. The provider's chef hadworked with a local Hindu community group whoshowed them how to cook Hindu vegetarian food. Theyalso catered for Halal and Kosher diets.

The provider was not fully engaged in patientspreferred place of death. The provider was able toproduce basic information on whether a patient had diedin their preferred place of death. However, it was notpossible to see if patients wishes had been met, and inmany cases the patient’s preferred place of death wasunknown and had not been obtained or recorded in theirnotes. The data given to us recorded that from August2018 to June 2019 showed 62% of patients had died intheir preferred place of death, 10% had not, but whetherthe patient had died in their preferred place of death wasunknown for 24% of patients. After the inspection, theprovider told us it was neither compulsory, nor possibleto obtain this information all of the time. The reasonsgiven were the organisation was not the only providerresponsible for obtaining this data and it was sometimesnot possible to obtain it.





Access to care at the right timePeople could access the service when they needed it.The service had a ‘single point of contact’ (SPOC) teamwhich began in May 2017. Their role was to ensure thatpatients referred to the service received the right at theright time, in the right place. At the time of the inspectionthere were three band six nurses employed in the SPOCteam (an increase of one staff member since April 2019),and three administrators. The team told us thatpreviously all patients had been referred to the clinicalnurse specialists, and this meant that there could bedelays in providing care to patients.

The SPOC team accepted and managed all patientreferrals from the community (from patients, families, andhealthcare professionals). The team ensured referredpatients meet the referral criteria and had consented tothe care. They contacted each patient or carer and to findout what the expectations were of the patient. For allimmediate referrals, where the patient was imminentlydying, patients or their carers or families were contactedwithin 24 hours. For urgent referrals, patients, families orcarers were contacted within 48 hours, and routinereferrals were contacted within three to five days. Dataprovided by the organisation showed that all immediatereferrals were dealt with on time.

The provider had effective processes to manageadmission to the service. The provider had anadmission policy which aimed to facilitate admission andsafe discharge of patients. The local commissioninggroup had commissioned the provider to provide a‘single point of contact’ to the provider's services. Onweek days, a daily bed meeting was held in the inpatientunit (IPU) which included the IPU nurse in charge, IPUcoordinator, specialist doctor on duty, a nominatedclinical nurse specialist (CNS) based at the local acutetrust and a CNS from the community team. Bedoccupancy, staffing, skill mix and current patientdependency levels were reviewed, and potentialadmissions planned accordingly. At the weekends,potential admissions were discussed between the doctorand CNS on call in agreement with the IPU nurse incharge.

The provider was in charge of its admission list. Patientswere prioritised at the bed meeting through jointconsultation and as a multidisciplinary decision. Thelocal acute trust funded two beds within the inpatientunit for their patients if they needed palliative care.

Learning from complaints and concernsThe service treated concerns and complaintsseriously, investigated them and learned lessonsfrom the results, and shared these with all staff. Theprovider had 29 complaints from June 2018-19 of whichthree were about clinical care received. Staff worked tomanage concerns before they became formal complaints.Learning from complaints was a standing agenda item fordiscussion at governance meetings, team meetings and,if safety related, during safety briefings.

Complaints were investigated and used to improve theservice. Formal complaints were investigated by seniorstaff. Staff told us they received feedback to anycomplaints they were involved with.

Patients were encouraged to report concerns about theircare and treatment and provide feedback. None of thepatients we spoke to felt they had cause to complain. Theprovider website also had a section on how to complain.

Patients were encouraged to report concerns about theircare and treatment and provide feedback. For example,patients told day therapy unit staff that the open sessionon fatigue was too long, so adjustments were made toreduce the length of the session. Patients also suggestedan adapted Tai Chi session, which now forms part of the‘open programme’ on the unit.

Are hospice services for adults well-led?


Our rating of well-led went down. We rated it as requiresimprovement.

LeadershipManagers at all levels in the service had the rightskills and abilities to run a service providinghigh-quality sustainable care, and there were newmembers of the senior leadership team. Boardassurance was in its infancy. At previous inspectionswe found the senior leadership team were not always





visible or supportive and a number of senior leadershipposts were vacant. Trustees were not fully involved anddid not provide adequate challenge or hold the seniorleadership team to account.

At this inspection, we found the hospice was led by achief executive officer (CEO) supported by a new team offive directors covering a range of portfolios includingpatient service, patient services/inpatient unit, familysupport team, therapy service, a community nursingteam and organisational change. A new director forgovernance and quality was due to start in July 2019. Theservice was not clinically led by a medical director as theorganisation had found it difficult to recruit. Clinical staffwere in post such as a matron and the inpatient had aclinical lead. As a charity, the chief executive wasaccountable to a board of trustees led by the chair. Therewere 13 trustees on the board, from a mixture ofbackgrounds.

The hospice has not had a registered manager in postsince prior to the last inspection in August 2018. Theregistered manager de-registered with CQC in November2018. The CEO also left the service and hadsimultaneously held the role as nominated individual. Atthe time of this inspection and report there were noregistered persons. However, the provider had recentlyappointed to the CEO post and this person was aware oftheir responsibility to register as the nominatedindividual. The provider also now had a registeredmanager in post who was in the process of registeringwith us. Since our last inspection a matron, a clinical anddeputy clinical lead had been appointed to oversee theinpatient unit.

The new CEO had maintained regular contact with CQCsince their appointment in September 2018. Theyprovided regular updates on senior appointments, inaddition to sending monthly progress reports, as requiredby the conditions of registration. Staff told us that seniorleaders were visible and approachable. All staff told usthere was improved support and engagement from theexecutive team, including the chief executive.

There has been a positive step change since our lastinspection, with the new leadership team having the keyingredients and commitment to develop a performingteam. The CEO, trustees and the senior leadership team

have identified areas of improvement and haverecognised that there are still a number of areas fordevelopment and improvement and are working todevelop and strengthen these areas.

The most current staff survey had been conducted inJune 2018. The staff survey used by the hospice was asurvey recommended for this service type. The 2018survey reported that 87% of staff were clear about whatwas expected of them, 50% of staff felt appreciated and athird of staff didn’t feel there were opportunities forcareer and personal development. A staff survey for 2019was in progress at the time of this inspection.

The CEO has initiated a monthly update newsletter tostaff in order to aid communication and staff engagementand feedback. We saw a committed team who wanted towork well together, inclusively for the benefit of peopleusing the service.

We found the quality assurance and governanceframeworks were not yet fully developed and that workwas in progress to support the development of this andthe board assurance framework and the underpinningassociated dashboards. We saw positive changes in theorganisation and the board since our last inspection. Theboard were working together more cohesively as a groupand there was a feeling of ‘being on a journey’. We sawwhat we felt, was a step change at the service. However, itwas important that enough time and attention to qualityimprovement and board governance and developmentwas given.

People that we saw at differing levels within teams told usthat they were on board with the journey of improvementand we were also told that although difficult for somestaff, they had recognised that changes were needed.Staff were keen to be involved in quality and safetydevelopment and improvement to provide the stabilityand assurance required to take the service forward.

Trustees were striving to meet their governanceresponsibilities and have a good understanding ofquality and safety of care. Since our last inspection theprovider has appointed a director for organisationalchange who was on a fixed term contact and a director ofgovernance and quality assurance who was taking up thepost in July 2019

Also, since our last inspection the trustees had been moreengaged with staff, participating in culture workshops





and undertaking trustee buddy visits to departments,these visited were recorded, and feedback to developand improve services had been provided. In July 2019 thecurrent chair of the board, who had served the maximumterm permitted, stepped down and an experiencedreplacement had been identified.

The leadership team were highly visible in thehospice. Some members of staff told us they felt well-ledand connected. They said they felt they were able toescalate issues which would be dealt with, they wererespected and listened to. They told us the team had‘gelled and really turned around and was unrecognisablefrom last year’ and that the disconnect between staff andthe senior management team had now gone.

The clinical leads wrote bi-weekly reports of issues forescalation to the executive team. This process waspopular with the clinical leads as a good channel ofcommunication.

Vision and strategyThe service had a vision for what it wanted toachiever, this was under review and developmentwith the whole staff team. At our inspection inFebruary 2018 we found the provider had a clear set ofvalues which staff were expected to demonstrate but itwas unclear if staff were always demonstrating them.

The hospice had a mission statement and a set ofvalues. These were currently under review. Three “YourProspect” workshops have taken place and were wellattended with almost 150 staff, including trusteesattending with some clinical staff attending in their owntime. We were told that staff engagement looking at theorganisation's culture, mission, values and underpinningbehaviours has been high and the output from theworkshops will be brought together and reviewed at thestaff forum. We were told the next steps were to look atembedding the values with staff, incorporating thesewithin 1:1 meetings and linking these into individual’sannual performance reviews.

At this inspection we found the provider was working withthe whole staff team through a serious of staff workshops,staff forums and culture work to review the organisationvision and mission. As part of this work there were plansto develop organisational values and behaviours. Thiswork was very much in the early stages and the seniorleadership team were committed to developing a strategy

to underpin this. Staff were engaged in the strategy workand were being consulted for their views, further workwas planned for consultation with people who use theservice, their carers and other external stakeholders. Thestrategy should align to local plans in the wider healthand social care

Structures, processes and systems of accountabilityto support the delivery of the strategy and goodquality, sustainable services were at different stagesthroughout the organisation. We found teams hadused the Care Quality Commission’s key lines of enquiryto underpin its governance. For example, in meetings andminutes and staff one-to-one meetings were structuredunder: safe, effective, caring, responsive and well-led.Staff told us that this had helped them identify gaps intheir processes, for example requiring some updatedstatements of purpose.

CultureManagers across the service promoted a positiveculture that aimed to support and value staff, therehas been improvement, however, this was still anarea for improvement. At our inspection in August 2018we found managers did not promote a positive culturethat supported and valued staff. Staff on the inpatientunit felt unsupported by the senior management teamand the trustees. Staff morale was mixed. We found thatstaff complaints and grievances had not beeninvestigated in a timely way. At this inspection we foundstaff at all levels were committed to ensuring patient carewas safe, however, staff satisfaction was variable. Theorganisation had worked to improve the culture andsome staff told us that since our last inspection theculture had improved. After the inspection, the providertold us they had identified an equality and diversity leadwho been given an 18-month project to includeembedding of the work on culture within theorganisation. The culture workshops had helped and thatthe organisation were on an improvement journey,however, some staff told us they felt undervalued andbelieved that there was lack of recognition of their inputand impact and were emotionally upset in sharing theirexperiences with us. Additionally, we heard from somestaff of a poor culture around speaking up with a fear ofthe outcome of doing so. Generally, staff gave us a clearmessage that they wanted to be involved in decisionsthat affected them.





The culture did not always encourage, openness theorganisation. Staff were aware of the Freedom to SpeakUp Guardian role. There were three new guardians andthe CEO had also been identified as a point of contact forpeople to raise concerns to. We spoke to staff withinthese roles who were clear on their role andresponsibilities and had worked to develop the speak uppolicy, staff training and development and to publicisethe purpose and function of the role. We found that somestaff did not know who the guardians were and althoughthey welcomed this process some staff told us that theywould not speak up for fear of reprisal and the lack ofconfidence that their issues would be listened to. TheFreedom to Speak up policy and procedure wasapproved for issue by the board in April 2019. Someconsideration should be given to this policy as the tittle‘The Freedom to Speak up policy ‘as this could bemisleading for staff. Contained within the policy wasreference to ‘protected disclosure’ which directed staffwho wished to make a whistle blowing concern to anexternal body or legal representative, but the policy didnot cover what a protected disclosure was and how thiscould be raised within the organisation.

Since our last inspection the staff forum had beenreviewed and refreshed with new membership, the groupmet monthly, issues covered included staff safety,well-being and communication. Information containedwithin the minutes of these meetings showed that stafffelt that feedback within the organisation was mixed, allgave positive feedback on the structure and pace of the‘Your Prospect days’, however, some people indicatedthat information was not getting to them from the staffforum.

Not all staff felt supported, respected and valued.During the inspection we looked at the analysis of staffwho had left the organisation. From January 2018 to May2019 88 members of staff had left. Of those, 24 had hadexit interviews. Nine members of staff had been unhappywhen they left, with issues around ethos andmanagement in the organisation; heavy workload, issueswith managers and work-related stress. The analysis hadbeen reported to the board, and an action plan waspresented, although this could not be provided at thetime of the inspection. Staff we spoke with told us that

going forward all exit interviews would be face to face andcarried out by a member of the human resources team,with the aim to have accurate and timely information toreport upon.

Staff told us they really enjoyed working in thehospice. The volunteers we spoke with told us howproud they were to work for the organisation and feltvalued by both employed staff and patients. Volunteerswere invited to bi-annual meetings which functionedsimilarly to a staff forum. A lunch had also been organisedfor the volunteers, as well as occasional evenings out.Volunteers told us they felt valued and were thanked atthe end of each shift. They told us they were not taken forgranted.

On the whole there were cooperative, supportive andappreciative relationships among staff. However, teamstended to work in silos and more work could beundertaken to ensure staff and teams workedcollaboratively, in order to share responsibility andresolve conflict quickly and constructively.

Daily handovers took place on the inpatient unit,attended by nursing team. In addition to discussing eachpatient, staff would share education on symptommanagement and any changes in patient medicines.

The hospice care team managers held monthly staffmeetings to share information from the senior managersmeetings; however, these were not well attended, andmanagers were considering how they could improveattendance levels.

Equality and diversity were promoted within and beyondthe organisation. Staff, including those with particularprotected characteristics under the Equality Act, told usthey were treated equitably.

Measures were taken to protect safety of staff whoworked alone and as part of dispersed teams in thecommunity. Staff told us they felt well supported andwere clear on their roles and responsivities as well astheir own personal safety. The provider has a loneworking policy which staff were aware of.

GovernanceAlthough the will was there and the intent at thispoint in time the service did not have overarchinggovernance systems to systematically improveservice quality or safeguarded high standards of





care. At the inspection undertaken in February 2018 wefound there were quality assurance and clinicalgovernance systems, but they were not always effectiveand were not in a format which drove continuousimprovement. Following that inspection, we issued theprovider with a warning notice to make improvements.The warning notice contained information of ourconcerns. Following the inspection in February 2018 theprovider sent us an improvement plan detailing that theyhad addressed all areas of concern. At our inspection inAugust 2018 we found the warning notice had not beenmet and we judged the provider had not made progressat sufficient pace. The improvement plan was notsupported by sound evidence and we found someassurances provided by the organisation were factuallyinaccurate. Following that inspection, we addedconditions to their registration and these included theprovider sending us information every month todemonstrate they were monitoring elements of theservices being provided to make sure patients were safe.

At this inspection we found the board assuranceframework (BAF) was planned by the organisation to beintroduced in September 2019. At a strategic planningevent with the board of trustees held in May 2019, timewas spent working through the BAF and discussing whenthe organisational and departmental strategies would bereviewed. Utilisation of the trustee’s skill set were alsoreviewed and evaluated at this event. At the time of thisinspection we were shown a BAF prototype and some ofthe underpinning performance dashboards but cannotcomment on the quality or accuracy of these as thesewere still under development. Although improved, therecontinues to be a lack of managerial oversight of the risksto quality and safety and a lack of scrutiny and challengeat the top of the organisation.

To support the governance, monitoring and qualityinsight, work was needed to produce an integratedperformance report which was sufficiently detailed,accessible, and that clearly identifies where there may bevariations and/or a need for change or improvement.

To support governance, risk oversight and qualityassurance, the organisation should consider producingdata which could provide intelligent insight andforecasting for the future and to drive service and boardimprovement decisions.

We were concerned that care plans were not personcentered, were not holistic and did not involve the personto whom the care was provided. Staff told us recordswere confusing and that both paper and electronicsystems were used, and they were not always assuredthey were recording patient care and treatment in thecorrect place.

The service did not undertake any end of life or care ofthe dying audit focusing on the quality and outcomes ofcare experienced by those using the service and thereforecannot be assured of the quality of the service or thatpatient’s wishes were known and respected.

The provider sent us regular notifications, as required bythe regulations. People's care records were kept securelyand confidentially, and in accordance with the legislativerequirements. All record systems relevant to the runningof the service were well organised and reviewed regularly.

Managing risks, issues and performanceThe service did not have embedded systems to fullyidentify risks, plan to eliminate or reduce them, andcope with both the expected and unexpected. At ourinspection in August 2018 we found patient safety, qualityand sustainability did not receive sufficient coverage inthe organisation’s board meetings, where the focus wason reputational risk and risks to income generation.

At this inspection we found that there was a prototypeboard assurance framework however, systems had notbeen fully established and operated effectively to ensurefull assurance and oversight.

Governance was still considered by the provider as a‘work in progress’ the board assurance framework wasstill under development. The clinical audit plan did notaccurately reflect work and was not given sufficientpriority and pace. Quality Improvement was lacking, anda system had not been established. This meant that thesenior leadership team were not able to assess, monitorand improve the quality and safety of the servicesprovided.

Risk registers were used in each department, at patientservices level to review and monitor risk. This was ascore-based system and escalation was made by themanagement team as required, however, the risksrecorded on the department risk register did not reflectthe concerns staff and managers told us about, concernsover culture within the organisation is an example of this.





Although the board assurance framework was still in itsinfancy we saw evidence that the risk register was part ofthe agenda for all board of trustee’s meetings. It was alsodiscussed risk at safety compliance committee meetings,which were held every two months.

Any member of staff could report an incident; forms wereavailable on the hospice Intranet and completed onpaper. Incidents were investigated by the hospice careteam manager or head of clinical services. Feedback wasgiven individually.

At our last inspection, undertaken in August 2018 wefound that the service did not manage patient safetyincidents well. There was no formal incident investigationprocess to ensure that learning from incidents wasidentified and cascaded to staff to improve patient safety.Since our last inspection the risk register identifies areasfor improving patient safety, such as a falls assessmentand screening tool which are being introduced

Pharmacy support was available from the local NHS Trustand a local pharmacist has been commissioned by theprovider since our last inspection to oversee medicinesmanagement.

Feedback from people who used the service and thepublic was collated via an online survey; ‘I want greatcare’. Feedback was extremely complimentary andpositive about the care and service provided by staff.

The hospice had a positive and collaborative relationshipwith the local clinical commissioning group and attendeda monthly contract meeting with commissioners todiscuss performance and funding.

Records we looked at during inspection showed that riskassessments were completed upon admission but notalways reviewed at suitable intervals during a patient’sstay in the hospice. Care plans and risk reductionmeasures were implemented as appropriate where riskswere identified. This included risks of falls, pressureulcers, nutritional deficiency. We had noted on threepatients records required regular pressure ulcer riskassessments, but these were not recorded. This meantpatients may not be receiving the right level ofintervention to reduce risk. We also found the nutritionalneeds of patients were not always met. Patientsnutritional needs had been audited in March 2019 butthere was no evidence that this was used to provider thenutritional support needed.

Individual risk for people using the service was discussedat handovers and multidisciplinary meetings. Weobserved a nursing hand over during our inspection andfound that risk for people within the inpatient unit washighlighted effectively.

There was at least one doctor on site in the hospice eachday with a consultant on site four days a week. Theconsultant was available ‘on-call’ when not on site andcould provide advice and support to the staff bytelephone. The doctors worked to the local NHS hospitalpalliative care formulary.

At the time of our inspection there was not a holisticunderstanding of performance with performanceindicators and measures, which sufficiently covered andintegrates people’s views with information on safety andquality. The provider is aware of this, a lead for qualityimprovement had been appointed and part of their rolewill be to work with others in order to develop a system inwhich tools and information are developed to identifyand measure areas for improvement.

Managing informationThe service did not always collect, analyse, manageand use information well to support all its activities.At our inspection in February 2018 we found the inpatientunit did not have effective recording and datamanagement systems. Information from investigationsand complaints were not always acted on or used to drivequality across the service. At this inspection we looked atthe records seven patients that were being cared for asinpatients at the hospice at the time of our inspection.We found nursing records were not always keptappropriately. Records were not always clear, up-to-dateand available to all staff providing care. Care plans werebrief, vague, not individualised and were a confusing mixof paper and electronic records. Both electronic andpaper notes were stored securely. We also checked tworecords of patients being supported by the Communitynursing team. We found that record keeping was of agood standard. Notes were comprehensive, completeand included important information; there were no looseleaves.

Information needed to deliver effective care andtreatment were well organised. Treatment protocolsand guidelines were either included in proformas oreasily accessible from the trust’s intranet site.





EngagementLeaders and staff actively and openly engaged withpeople who used the service. They collaborated withpartner organisations to help improve services forpatients. At our inspection in August 2018 we found thatalthough the former chief executive and trustees hadarranged a series of visits to engage with staff on theinpatient unit, many staff continued to feel unsupportedby the senior management team, who, they said, werenot visible leaders. At this inspection we found the servicewas taking steps to improve staff engagement. Inresponse to our previous concerns about staff moraleand dissatisfaction with management.

The service engaged well with patients, volunteers andthe public and local organisations to plan and manageappropriate services and collaborated with partneragencies effectively.

The unit held regular coffee mornings throughout theyear which allowed former patients to stay in touch withstaff and other patients who had been discharged.

Employees completed an annual staff survey. The resultsof the 2018 survey were generally positive with staff

answering positively to questions asking if the service’svision, mission and valued mattered to them, that therole the worked in was as they expected it to be and theircolleagues were committed to doing quality work.

The service ran a patient survey for service users to givetheir feedback about their experience, we saw the resultsfrom these feedbacks were overwhelmingly positive.

There was regular communication with staff via 1;1 andannual appraisal meetings, individual team meetings, theCEO monthly updates, the intranet page and staff forum.

The service had an on-line facility for people to providefeedback about the service, there also was a feedbackbox for written feedback and also the service had an IPADin the reception area for people to have their say and tohave methods to help improve the quality of the existingservices and be involved in the discussion about thedevelopment of future services.

The service met regularly with the local ClinicalCommissioning Group who reviewed and oversaw theorganisation's improvement plan.





Areas for improvement

Action the provider MUST take to improve

• Ensure care plans are person centered, holistic andinvolve the person to whom the care was providedto. Staff told us that patient care records wereconfusing and that both paper and electronicsystems were used, and they were not alwaysassured they were recording patient care andtreatment in the correct place. (Regulation 12 (1) (2)(d))

• Ensure quality improvement principles and practicesare developed and ensuring they are given pace andprioritisation and must be cascaded and embeddedwithin the organisation to ensure they are effectiveand are in a format which drive continuousimprovement. (Regulation 17 (1) (2) (a))

Action the provider SHOULD take to improve

• Check risk assessments are kept under review foreach patient to identify, remove or minimise risks.

• Have an appropriate level of nursing staff with theright qualifications, skills, training and experience tokeep patients safe from avoidable harm.

• Resolve the confusion about paper and electronicsystems for recording nursing notes.

• Check all staff involved in incident reporting are clearon their role and responsibility and are clear on thereporting process and that there is a process ofoversight monitoring evidencing lessons learnt toavoid, where possible, reoccurrence of incidents.

• Manage prescription stationary line with theprovider’s policy and national guidance.

• Share and document lessons learned from patientsafety incidents with the whole team and the widerservice.

• Provide evidence that care and treatment deliveredis based on national guidance and evidence-basedpractice. The nutritional needs, wishes and choicesof people are known and provided to meetindividual need.

• Check staff always document pain assessments ofpatients.

• Monitor the effectiveness of care and treatment andparticipate in relevant quality improvementinitiatives. Care should be planned and delivered in away that met the needs of local people and thecommunities served.

• Check training records demonstrate that all staff arecompetent for their roles.

• Continue to improve waiting times from referral toachievement of preferred place of care and deathand document to be in line with good practice.

• Continue work on culture within the organisation tomake sure staff feel respected, supported andvalued. Also, continue to work on the culture toencourage, openness within the organisation.

• Give consideration to there being clear recordedinformation for staff on how to raise concerns safely.

• Align the organisational vision and strategy to localplans in the wider health and social care economy,and identify how have services been planned tomeet the needs of the relevant population and be inline with national recommendations and direction oftravel for hospice care.

• Review board meetings to provide scrutiny and aclear audit trail of the discussions that take placeand the key decisions made.

• Look to produce an integrated performance reportwhich is sufficiently detailed, accessible, and clearlyidentifies where there may be variations and/or aneed for change or improvement.

• Have a system for producing data which can provideintelligent insight and forecasting for the future andto drive service and board improvement decisions.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Diagnostic and screening procedures

Transport services, triage and medical advice providedremotely

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

The provider must ensure care plans are personcentered, holistic and involve the person to whom thecare was provided to. Staff told us that patient carerecords were confusing and that both paper andelectronic systems were used, and they were not alwaysassured they were recording patient care and treatmentin the correct place. (Regulation 12 (1) (2) (d))

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Diagnostic and screening procedures

Transport services, triage and medical advice providedremotely

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

The provider must ensure quality improvementprinciples and practices are developed and ensuringthey are given pace and prioritisation and must becascaded and embedded within the organisation toensure they are effective and are in a format which drivecontinuous improvement.

Regulation 17 (1) (2) (a)

Regulation

This section is primarily information for the provider

Enforcement actionsEnforcementactions


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