Pilgrims Hospice Thanet

There was a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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. The registered manager was also the director of nursing and care services.

At our last inspection on June 2016, we found that medicines were not properly and safely managed; staff had not received the appropriate supervision to enable them to carry out their roles; we issued two requirement notices in relation to these two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found that the service was not always effective in protecting staff from rude and bullying behaviour. The registered provider sent an action plan to us detailing the improvements they would make. They confirmed they would be meeting the requirements of the regulations by October 2016 and that new systems would be embedded and sustained over time. They kept us informed of their progress.

This inspection was carried out on 15 and 16 June 2017 to follow up on compliance with these notices and check whether new systems were embedded in practice. At this inspection we found that the registered provider had met the requirements detailed in the requirement notices and had made significant improvements to medicines management, the support provided to staff and the culture of the service.

Staff knew how to recognise signs of abuse and how to raise an alert if they had any concerns in regard to people’s safety. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm.

Improvements had been made in regard to the management of medicines. People received medicines that were stored, documented, administered and disposed of appropriately by competent staff.

People received care from staff who were appropriately supported, skilled and appropriately trained. All staff received regular one to one supervision sessions to support them in their role. There were members of staff who took the lead in a speciality, offering guidance to other staff so people could be confident about staff particular expertise. There were sufficient staff on duty to meet people’s needs across the service. Robust recruitment systems ensured staff were suitable to work with people.

People were fully involved in the planning and review of their care, treatment and support while in the Inpatient Unit (IPU) and while receiving support in the community. Staff delivered care and support to people according to their individual plans.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to hospices. A system was in place to submit appropriate applications to restrict people’s freedom when necessary after the least restrictive options were considered, in accordance with the Mental Capacity Act 2005 requirements.

The staff provided meals that were in sufficient quantity and met people’s needs and choices. People were very complimentary about the food provided and told us they enjoyed their meal times. Staff knew about and provided for people’s dietary preferences, restrictions and reduced appetite.

Staff knew each person well and understood how people may feel when they were unwell or approached the end of their life. They responded to people’s individual communication needs and treated them with genuine kindness and respect.

Staff were caring, empathetic and compassionate. Staff approach was kind and pro-active; they were skilled at giving people the information and explanations they needed in a sensitive manner.

Clear information about the service, the facilities, and how to complain was provided to people and visitors. People’s privacy was respected and people were assisted in a way that respected their dignity. Staff sought and respected people’s consent or refusal before they supported them.

People and relatives told us they were very satisfied about the staff approach and about how their care and treatment was delivered. People’s feedback was sought, valued and acted on.

A robust quality assurance system was implemented and embedded in practice. A range of audits and checks were carried out throughout the service to identify how the service could improve and action was planned and taken as a result.

The inspection took place on 15, 16 and 17 June and was unannounced. Pilgrims Hospice Thanet is one of three hospice locations for the provider, Pilgrims Hospices in East Kent. The hospice offers specialist palliative care, advice and clinical support for adults with life limiting illness and their families. They deliver physical, emotional and holistic care through a multi-disciplinary team of nurses, doctors, counsellors, social workers, occupational therapists, physiotherapists, spiritual leaders and a range of volunteers. The location has a day centre and capacity for 18 in-patients. At the time of our inspection up to 12 people were using the service as in patients. The community team provide services for people in their own homes and at an outreach clinic in Deal. There is a Rapid Response Service that provides personal care to people in the community and is available on the same day it is needed. Support groups for carers are available and there is a 24 hour advice. The service was providing services to 349 people in the community and in the hospice at the time of the inspection.

A registered manager was in post. 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.

Safe systems were in place for the ordering and administration of medicines. However, medicines which had passed their expiry date were stored with current medicines. This was not safe practice. Guidance was not in place for the use of prescribed creams nor if people were able to self-administer their medicines.

The service had not followed its policy in providing staff with regular supervision which offers staff support and learning to help with their development. Opportunities for staff to reflect on their practice and to learn what they were doing well and what they could improve in supporting people, had not been formalised throughout the service.

There had been a lack of consistency in leadership at the service and not all staff had not been protected from bullying and harassment. The staff team had not felt valued, listened to or supported for a number of years. Even though some staff morale was low, all staff continued to give a high standard of care for people who used the service. The new management team was aware of staff’s feelings and that it took a long time to change the culture of a service. They had put in a range of initiatives to engage with staff.

Staff understood how to safeguard adults and children and this was central to the running of the service. Staff received training in safeguarding and demonstrated they knew how to recognise and report potential abuse.

Potential risks to people had been assessed and action and guidance was in place which identified how they could be minimised. Environmental and health and safety checks were carried out to ensure that the environment was safe and that equipment was in good working order. There were systems in place to review accidents and incidents and to identify any patterns or trends. The service was clean and infection control guidance was followed to help minimise the spread of any infection if it should occur.

Checks were carried out on all staff at the service, to ensure that they were fit and suitable for their role. Staffing levels were flexible so staff could support people in the part of the service where there was the greatest need.

New staff received a comprehensive induction and were provided with the training necessary to their roles. This included specialist training in bereavement and end of life care to make sure that they had the right knowledge and skills to meet people’s needs effectively.

People’s health, medical, nutritional and hydration needs were assessed and closely monitored. Their changing needs were effectively communicated within the multi-disciplinary team and with other professionals so that everyone involved in their care was knowledgeable about their needs.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes, hospitals and hospices are called the Deprivation of Liberty Safeguards (DoLS). The service understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).

The service provided a relaxed, comfortable and clean environment. There were a range of areas available for people and their visitors to sit and a large area for day patients to undertake activities.

Staff were kind, compassionate and caring and spent time listening and talking to people in a way that they understood. Supporting people’s family members was key to the service and they received support before and after the death of their loved one through counselling, bereavement counselling and carers groups. People also benefitted from spiritual support and complimentary therapies being available.

People’s individual wishes with regards to their care were recorded and the staff team advocated for people when necessary to ensure these were met. People and family members were involved in planning their care and treatment and care plans were personalised.

People’s needs were thoroughly assessed before and at the time of being admitted to the service. The service could immediately respond to people’s nursing and care needs to ensure they died in their preferred place.

People were supported to maintain their mobility and to manage their symptoms through exercise and breathlessness management. The day hospice offered a range of activities and information sessions and promoted conversation in a comfortable environment.

The service had built links with the local community through offering services and fundraising events. People were able to make their views known and knew how to make a complaint or raise a concern. When complaints had been received, these had been investigated so that lessons were learned to improve the service.

The service had a clear management structure and lines of accountability. There was a programme of clinical governance and audit to identify and take action to address any shortfalls. Research and education was undertaken to help improve the care offered for people at the end of their lives.

We found two breaches of the Health and Social Care Act 2008 (Regulated activities 2014). You can see what action we told the provider to take at the back of the full version of the report.

People told us that the staff were attentive to their needs. One relative told us "they really can't do enough for you.'

The manager and staff took care to ensure that people's views were taken into account.

We spoke to two patients and three relatives of patients. All the people we spoke to said that they were happy with the care given and none had any concerns. One told us that "you can't fault the treatment."