Zoe's Place Middlesbrough

Zoe’s Place Middlesbrough was operated by Zoe’s Place Trust, which was a registered charity, that also operated from two other locations. The service provided palliative, respite and end of life care to babies and infants aged from birth to five years, who were suffering from life-limiting or life-threatening conditions.

Opening in 2004, Zoe’s Place Middlesbrough was situated in a largely residential area occupying a converted leased building, (formerly a convent), that was wheelchair accessible and with ample off-street parking. The public reception was managed by volunteer staff with adequate seating and toilet facilities. The hospice had its own entrance which was managed by clinical staff.

The service provided respite care for the families of the babies and young children up to five years old. As part of this wrap around service, staff could offer therapy, bereavement support, (including use of private accommodation so the family could stay with their child for as long as they needed), plus support groups for the wider family.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on 6 November 2019. Unknown to us, the service was closed on this day. We re-visited on 12 November 2019 to speak to more staff and parents/carers. To gain their feedback, we also spoke, over the phone, with parents/carers.

To get to the heart of patients’ experiences of care and treatment, we asked the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rated services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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

Services we rate

We had previously rated this service in August 2014. At that time the service was rated outstanding overall with outstanding in the domains of effective, caring, and responsive, with safe and well-led rated as good.

At this inspection the rating went down. We rated it as Good overall.

We found good practice in relation to children and young people care:

• The service provided mandatory training in key skills to all staff and made sure everyone completed it.

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

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

• The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.

• Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.

• The service had enough staff with the right qualifications, skills, training and experience to keep babies and children safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.

• Staff kept detailed records of babies and children’s care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.

• The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave children, young people and their families honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.

• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for babies and children’s religious, cultural and other needs.

• Staff assessed and monitored babies and children regularly to see if they were in pain and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.

• All those responsible for delivering care worked together as a team to benefit patients. They supported each other to provide good care and communicated effectively with other agencies.

• Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.

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

• Staff supported and involved children, young people and their families to understand their condition and make decisions about their care and treatment. They ensured a family centred approach.

• The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.

• The service was inclusive and took account of children, young people and their families' individual needs and preferences. Staff made reasonable adjustments to help babies and children access services. They coordinated care with other services and providers.

• People could access the service when they needed it and received the right care in a timely way.

• It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.

• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where babies and children, their families and staff could raise concerns without fear.

• Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.

• All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation.

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

• The leadership at the service had not set any key performance indicators, for example, mandatory training targets, which meant it was difficult for the leadership and staff to effectively monitor performance and drive improvement.

• National recommendations, such as the inter collegiate guidance for safeguarding, required staff dealing with adults and children to be trained to a certain safeguarding level depending on the role staff had. We found clinical and volunteer staff were not trained to the appropriate level for adult safeguarding and for volunteer staff, children safeguarding.

• The environment should be free of ligature risks and risks of crushing by door hinges. However, we found examples of such risks when inspecting the environment.

• Good governance required that staff were guided by policy on how to use their risk registers, that risk registers were aligned between the local and trustee register, and that all registers reflected actual risks posed to the service. We found the local risk register and trustee risk register were not aligned and did not reflect the actual risks posed to the service. The risk management policy failed to guide staff on using the registers to record risk, its escalation, or monitoring.

• To ensure staff and users of the service knew they were following the latest guidance, notices, policies and procedures that were displayed should have had a current version control. We found version control was not displayed on notices we saw or, when it was, they were not current.

• To assess and address risks to health, policies should set out what staff should do if faced with a deteriorating child. We found staff had no written policy to follow for the deteriorating child.

• A clinical audit programme was one way to ensure that staff were using the latest evidence-based practice. We found the service did not operate a clinical audit programme.

• To support staff in identifying parents or carers who may not have had the necessary mental capacity to consent to treatment provided to their baby or child, staff should be trained in mental capacity and consent. We found staff were not trained in mental capacity and consent.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected the service. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals (North)