The Hospice of Our Lady and St John

Updated 3 June 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 24 March 2015 and was unannounced.

The inspection was carried out by one inspector and an Expert by Experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection we checked the information we held about the service and the service provider, and spoke with the local authority. No concerns had been raised and the service met the regulations we inspected against at their last inspection which took place on 23 June 2014.

During this inspection we observed how staff interacted with people and received care and treatment. We looked at how people were supported to join in therapy sessions of their choice and to have meals. We spent time in the Well-Being Centre.

We spoke with six people and the relatives of 3 people who used the service. We also spoke with the director of nursing, five care staff, one nurse, the chef, the chaplain, three volunteers and two housekeeping staff. We also spoke with a number of people using the 'wellbeing' centre.

We reviewed three care records, three medication records, eight staff files and records relating to the management of the service.

Updated 3 June 2015

The inspection took place on 24 March 2015 and was unannounced.

The Hospice of Our Lady and St John is known locally as Willen hospice. It provides up to 15 in-patient beds and out-patient care for adults who have complex needs and who are terminally ill.

There was a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People felt safe. They all had risk assessments in place, which were developed with input from the extended staff team.

Staff were aware of what they considered to be abuse and how to report this.

There were enough staff on duty, supported by volunteers, to ensure people were able to receive personalised care and support.

Effective recruitment processes were in place.

New staff were not allowed to start to work until provider mandatory induction and training had been completed.

Staff and volunteers attended a variety of training to enable them to support people using best practice techniques.

Medication was managed safely and processes in place ensured the handling and administration of medication was suitable.

People were supported to make decisions about their life and treatment plans. Staff were knowledgeable about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Capacity assessments had been carried out when required.

All of the food was freshly prepared, including home-made cakes, biscuits and ice cream. People were supported to eat and drink when required. People could ask for what they wanted to eat at any time.

Staff were very kind and caring.

There were health care professionals on site, including physiotherapists, and doctors, to support people’s health care needs.

We observed staff gaining consent to enter people’s rooms, before undertaking their therapy sessions and to enable inspectors to access confidential information.

People had up to date care/treatment plans, which they had been involved in developing.

The service had developed a 24/7 advice line for people, relatives and other healthcare professionals.

The service had a ‘wellbeing’ centre for people to use with support of therapists and health practitioners.

People’s privacy and dignity was respected at all times.

There was an effective complaints procedure in place, and lessons had been learned from past concerns.

People were complimentary about the registered manager and staff. It was obvious from our observations that staff, people who used the service and the management had good relationships.

We saw that effective quality monitoring systems were in place. A variety of audits were carried out and used to drive improvements.