Butterwick Hospice Stockton

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service was safe and has been rated good. The registered manager responded positively to the concerns raised following our last inspection and the conditions we imposed. We observed significant improvements to the service. It was evident the service now had a culture of safety and learning. Staff and leaders told us learning from complaints and incidents was now shared with teams during meetings, handovers and individual supervision. The service now provided care and treatment in a way which made patients feel safe, supported and listened to. We saw evidence that patients were treated with dignity and respect.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients felt supported and listened to. Patients and their families were encouraged to give feedback on their experience of care within the service. We saw evidence that staff and leaders acted on patient feedback.

Staff and leaders we spoke with told us safety was a priority. They described a culture of safety and learning, based on openness, transparency and learning from incidents. The service had now introduced the ‘Pearl’s of Wisdom’ bulletin, which captured key learning from incidents, and we saw these displayed for staff learning. Managers had introduced new processes, such as the freedom to speak up guardian, to encourage staff to feel supported to raise concerns. This meant staff felt confident to raise concerns without fear of retribution.

The service now managed safety incidents well and learned lessons from them. We reviewed 3 separate incidents and saw that they were investigated thoroughly. The incidents were appropriately investigated, reported and lessons learned resulted in changes that improved care for others.

Patients felt involved in decision making regarding their care. We saw an example of collaborative multidisciplinary team working to facilitate the complex discharge of a patient to another care service, in line with their needs, at that time. The patient and family were involved throughout. We saw evidence that the time and support provided by staff, resulted in a positive outcome for the patient.

Staff described a positive working partnership with the local NHS trust. Staff we spoke with told us they had good communication with internal and external colleagues, which enhanced the quality of care and support provided by the service. There was a strong awareness of the risks to people across their care journeys. The approach to identifying and managing risks was now proactive and effective.

Partners we spoke with told us senior leaders from the hospice were active members of the collective group, Hospices North East and North Cumbria. This provider collaborative was established by the 12 independent adult hospices within the local area. Collaborative working has resulted in the agreement of a common approach to the Patient Safety Incident Reporting Framework (PSIRF). There was a common plan and approach to reporting and learning from incidents to improve safety of pathways and transitions. The collaborative had strong links with the integrated care board and developed pathway and transition strategies together. We saw evidence of senior leaders’ involvement and contribution to a recent good practice conference, which was attended by staff and Trustees from all the hospices within the collaborative.

We saw evidence of a strong awareness of risk to patients, across their care journey. The approach to identifying and management of risk was proactive and effective. Ratified policies and procedures were in place, referenced to current best practice guidance. The effectiveness of relevant processes was monitored to keep people safe.

We saw evidence that patients and their carers felt able to approach staff if they had any safeguarding concerns.

We saw evidence of a strong understanding of safeguarding and how to take appropriate action. Staff gave us examples of when they had recognised and escalated safeguarding concerns. Training records we reviewed evidenced staff received the correct level of Safeguarding training for both adults and children. Staff demonstrated how they took immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way.

The service now ensured staff received Safeguarding training in line with intercollegiate guidance. There were improved systems, processes and practices to ensure people were protected from abuse and neglect. However, volunteers did not always receive the correct level of Safeguarding training. We reviewed the training spreadsheet for all volunteers and saw 3 staff had not undertaken any Safeguarding training. This meant we were concerned some volunteers may not know how to recognise and report abuse. Following our assessment, the service took immediate steps to arrange this training. The hospice had both Adult and Children’s Safeguarding policies, which were ratified and referenced to current best practice and intercollegiate guidance (2019). Safeguarding supervision and discussion took place routinely at monthly team meetings. Monthly audits were completed to monitor attendance and completion. We found 94% compliance as of April 2024. Safeguarding concerns were discussed and recorded during each shift handover and recorded appropriately. New starter induction packs included a section to record Safeguarding policies and procedures had been discussed. Safeguarding information was clearly displayed on the ward notice boards.

We saw evidence that patients were provided with the appropriate equipment for their assessed needs, such as airflow mattresses and routine monitoring for positioning. We reviewed 3 patient records. Known risks were assessed with patients and their carers prior to admission and patients were assessed again by both nursing and medical staff at the point of admission. We saw that these assessments were fully completed. In addition, we saw risk assessments were in place for aspects of fundamental care such as falls, tissue viability and nutrition. However, we reviewed the ‘Care of the Dying Patient’ document and saw limited personalisation within care plans. It was evident care delivered met individual need, but this was not reflected within the completed document.

Staff we spoke with demonstrated how they assessed risks, such as falls and skin integrity. These were person-centred, and staff understood them. Staff we spoke with told us patients were involved in the completion of care plans and risk assessments, as far as possible.

The service now had clearly defined ceilings of care to ensure services and facilities were appropriate and met patient's individual needs. We saw effective systems to assess, monitor and mitigate the risks, relating to the health, safety and welfare of service users. Staff were able to articulate care of the deteriorating patient, however these processes were not formalised with a service policy. The shift handover and safety huddle documentation provided detailed information about patients, including how patients had been throughout the shift, what was important to them, and additional specific needs such as, if feeling anxious, the steps to take to help them relax. In addition, we saw emergency health care plans were in place for patients as appropriate. Staff we spoke with were now clear what the ceiling of care was when admitting patients. For example, which patients would not be suitable for admission. Admission documentation detailed the aim for each admission to be patient centred. We saw evidence that all decisions and plans were made following full discussion with the patient and or next of kin (if applicable) to ensure patient autonomy and empowerment.

The hospice was purpose built and had suitable and sufficient day and inpatient services facilities. Patients could reach call bells and staff responded quickly when called. We saw evidence that patients reported they felt safe on the ward.

Staff we spoke with told us they had sufficient equipment to carry out their duties. Staff accessed emergency equipment, including an anaphylaxis kit and an emergency grab bag on the ward and weekly checks were completed and recorded. If concerns were identified they were reported and acted upon quickly. Staff explained they would dial 999 to convey patients to hospital in the event of a serious clinical emergency.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were appropriately trained to use equipment. Staff managed clinical waste well. For example, sharps waste bins were assembled and labelled correctly. All portable equipment seen had an up-to-date portable appliance testing sticker. Equipment used by staff, such as hoists, and syringe drivers were in date for their maintenance checks. All sharps waste bins seen were appropriately assembled and labelled. All medical gasses including oxygen cylinders, were safely stored and secured. All items subject to the control of substances hazardous to health regulations (COSHH) were safely stored in a locked cupboard, within a locked room. All fire extinguisher appliances inspected were signposted and serviced within an appropriate timescale. Fire exits and corridors were clear of obstructions. The service had a fire evacuation plan and conducted annual fire evacuation drills. Access to restricted areas such as administration and storage areas, was controlled.

There were systems for recording the service and planned preventive maintenance of equipment, identified through a central log and equipment compliance stickers, which indicated the dates tests were due. Environmental audits we saw, had been completed and showed full compliance.

We reviewed the most recent copy of the patient survey and saw feedback was positive, for example, patients and families reported staff made them feel safe and thought they were competent in their roles.

The service provided mandatory training in key skills to all staff and made sure everyone completed it. Managers monitored mandatory training and staff compliance on a training matrix. In addition, registered nurses were provided with 3 clinical competency training modules. These were Medication, Syringe Drivers and Verification of Death. We saw staff were fully compliant with the training that had been identified for their role. We saw evidence that all staff had opportunities to learn, and poor performance was managed appropriately. Leaders took staff feedback seriously, for example, we reviewed a small number of staff concerns, which related to alleged poor practice. We found these were managed effectively and ensured patients were kept safe. Staff received the support they needed to deliver safe care. For example, managers supported nursing staff to develop through performance appraisal and clinical supervision of their work. Clinical staff appraisals from May 2024 audit, showed 91% completion. In addition, staff accessed clinical supervision sessions from the local NHS trust’s specialist nurses. This was offered on a regular basis recorded within monthly audit figures. The audit figures for May 2024 showed 85% compliance rate.

The service had enough nursing, allied healthcare professional and support staff to keep patients safe. There was a service level agreement (SLA), with the local NHS trust, to ensure consistent staffing numbers. Staff rotas were planned to ensure there was at least 1 member of staff who was appropriately trained in providing specialist support, when required. A nurse practitioner supported medical staff as a non-medical prescriber (NMP). The service had enough medical staff with the right qualifications, skills, and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service was nurse led, however the SLA with the local NHS trust meant specialist palliative care consultants provided 4 half day sessions across the Monday to Friday period, dependent on the service need. Specialist palliative care advice could always be accessed via a dedicated team between 9am and 5pm Monday to Sunday (including bank holidays). Consultant on call arrangements were in place to cover 5pm to 9am Monday to Friday, and for 24 hours Saturday and Sunday (including bank holidays). There was also additional opportunity for hospice clinicians to discuss patients at the specialist level palliative care multidisciplinary meeting, which was held weekly. Systems were now in place, to ensure professional registration checks for both nursing and medical staff were completed. We saw full compliance in the records we reviewed. In addition, training requirements by job role were now clearly defined and managers monitored compliance, to ensure staff were appropriately skilled and competent in their roles. The service had appropriate recruitment policies and we saw the service carried out disclosure and barring service (DBS) checks for all staff. Audit figures in May 2024 demonstrated 100% compliance rates. This included DBS checks for volunteers.

Service users we spoke with had no concerns regarding cleanliness and handwashing.

The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

All staff we saw had bare arms, below the elbow, in accordance with National Institute of Health and Care Excellence (NICE) guidance and the service’s own policy. We saw they accessed ample supplies of personal protective equipment and handwashing supplies. We saw handwashing technique posters clearly displayed in accordance with NHS England ‘5 moments’ guidance.

Staff accessed up to date Infection Prevention and Control (IPC) policies. IPC audits were completed and reported every month and included, for example, hand hygiene, uniform compliance and environment audit. Audit data for January and February 2024 provided by the service showed high compliance.

We saw evidence that patients were appropriately involved in decisions about their medicines. Patients were involved with assessments and reviews about the level of support they needed to manage their medicines safely, ensuring their preferences were included. This was clearly documented in their care plan.

Staff we spoke with described clear arrangements which ensured medicines were appropriately prescribed prior to patient transfer to the hospice. We saw appropriate stock levels of medicines that were routinely used. Staff we spoke with had completed Non-medical Prescriber training. The service had a service level agreement with the local pharmacy to provide support and advice.

All clinic rooms and medicines fridges were clean and staff were able to access all appropriate equipment. Medicines were stored, managed and dispensed in line with national guidance, including the management of controlled medicines. Staff had access to relevant patient medicines documentation, including information on patient allergies.

Medicines policies we reviewed referenced best practice guidance, including medicines administered through syringe driver. Staff accessed accurate, up-to-date information about people’s medicines, when they moved between health and care settings in accordance with local policy and national guidance. There were appropriate arrangements for the safe management, use and oversight of controlled medicines. For example, a stock rotation and expiry date check was completed weekly and fridge temperatures were monitored and recorded daily.