North Devon Hospice

The North Devon Hospice at Deer Park in Barnstaple provides a seven bed in-patient unit (called the bedded unit), a team of community nurse specialists (CNS), a range of day services and support groups and a hospice to home team. Deer Park is situated on the hillside above Barnstaple, has beautiful views and is surrounded by well-kept landscaped gardens. The area of North Devon covers 1000 squares miles of mainly rural countryside. They work closely with community hospital facilities and the local NHS Trust.

The hospice has an outreach centre in Holsworthy, known as The Long House. This opened in September 2015 and was a specially designed building in order to aid people’s sense of well-being. From here people can see their CNS, complementary therapist and attend therapeutic support groups. This addition of this outreach centre meant that people from the lower half of the North Devon area did not have to make long journeys up to Barnstable for their care, treatment and support.

Hospice services were provided for adults over the age of 18, with life-limiting illnesses and advanced progressive conditions. At the time of this inspection 80% of services were provided to people with a cancer diagnosis and 20% were to people with non cancer illnesses. Non cancer illnesses include motor neurone disease and other degenerative neurological conditions, pulmonary and cardiac disease.

Where people’s preferred place of care was their own home they were supported by the hospice to home team, the CNS and the local community district nurses. The hospice to home team helped people to stay at home longer or to die in their own home. The service also offered respite for family carers.

The staff team included the following: doctors, nurses, health care assistants, physiotherapist, occupational and complementary therapists, counsellors and volunteers. The various services provided by the hospice worked in conjunction with people’s own GP’s, community district nurses, and other health and social care professionals.

There was a registered manager 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. The director of care was the registered manager.

At the time of the inspection the bedded unit were looking after five people and the hospice to home team were providing support to about 20 people living in their own homes.

Both parts of the service provided end of life care in the last couple of weeks or during a time when they needed care and treatment for symptom control or help during an emotional or physical crisis. The service looked after people with a cancer diagnosis (80%) and non-cancer patients (20%) but the service aimed to increase the numbers of people they were able to support with non cancer conditions. From the bedded unit 20% of people were able to go home after a short stay and may return at a later date and 80% would die in the hospice. The hospice to home service was mainly provided for people nearing the very end of their life, however they may also support people and their families during a crisis.

The service was safe. All staff received safeguarding adults training. This meant they would be able to recognise if people and children they came into contact with were being harmed and would know what to do to report those concerns. Recruitment procedures were robust and ensured that only suitable staff were employed.

Training was undertaken by all staff who assisted people to move from one place to another including the use of equipment. Staff were trained how to use equipment correctly. Any risks to people’s health and welfare were identified during the assessment of care needs and were then well managed. The service had the appropriate procedures in place to protect people from being harmed.

Staffing numbers in the bedded unit were determined by the number of people who were receiving care and support and the complexity of their needs. The hospice to home team had a flexible workforce (bank staff) in order to be able to increase capacity and accommodate the demand for their service. The team endeavoured to always meet any referrals for a service and would pull out all the stops to support those in need.

The service was effective. There was a programme of mandatory training for all staff to complete and this prepared them for their job role. New staff had a comprehensive induction training programme to complete at the start of their employment and all other staff had a programme of refresher training. Additional training was arranged regarding clinical skills. This ensured the staff team had the required skills and qualities to provide a compassionate and caring service to people and their families.

People’s capacity to make decisions was continually assessed and where possible they were supported to make their own choices and decisions. Staff received training regarding the principles of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). Staff ensured consent was given prior to providing any care and support but worked within best interest principles where people could not provide this. Where people lacked the capacity to make decisions because of their condition or were unconscious they worked within assumed consent but checked with healthcare professionals and family members before providing care and support.

People in the bedded unit were provided with a well-balanced and nutritious diet. They were able to choose what they wanted to eat. There was a guide menu however alternatives were always prepared to meet people’s individual needs and preferences. Significant improvements had been made to the catering services since the last inspection. People were also given the choice of when they wanted to eat their meals; there was no set meal time. People in their own homes were assisted to eat and drink where this was required.

Health and social care professionals referred people to the hospice service when they needed in- patient care, and provided an overview of their medical and nursing care needs. The hospice to home service received referrals from the district nurses, GPs or clinical nurse specialists. Staff worked in partnership with healthcare professionals and families to be supportive and provide an effective service.

The service was very caring. All the staff teams had the necessary qualities and skills to provide sensitive and compassionate care and support to the people they were looking after. This care and support also extended to the person’s family and friends. It was evident the staff developed close working relationships with the people they looked after and their families. The staff went out of their way to meet people’s dying wishes and told us about several examples of how they had made a difference to the last few days/weeks of people’s lives. For example, they had arranged a third birthday party for a child whose mother was at the very end of their life and had arranged a Jamaican ‘sights and sounds’ experience for a Jamaican person who was dying. There were many examples of the staff going the extra mile and providing a person-centred service to each person and their family.

People received person centred care and as they moved between the different hospice services, the hospital and their GP, communication was coordinated. The hospice service provided ongoing bereavement support to families, adults and children for as long as was necessary. The service also referred families on to other relevant services where needed. All staff who worked for the hospice were emotionally well supported by their colleagues and the managers, evidencing this is a very caring service.

The service was responsive. The care and support needs for each person whether they were being looked after in the bedded unit, in their own home or attending for a treatment/counselling were provided with person-centred care. Regular reviews of people’s needs ensured their care plans were revised as often as necessary. People were always involved in making decisions about their care. The hospice to home team ensured that family carers were always supported in a way that was most beneficial to them.

The service was well led. There was a robust leadership and management structure in place and all the teams of different staff were passionate about providing a high quality service that was safe, effective, caring and met people’s needs. The measures in place to assess the quality and safety of the service ensured that when shortfalls were identified, that improvement actions were taken. Analysis of any events such as accidents, incidents and complaints meant any trends were identified and enabled the service to make changes and prevent a reoccurrence. There was a continual programme of audits in place to drive forward any service improvements needed.

Feedback from people and their families was used to measure how people felt about the care and support they received. This feedback was used to drive forward any improvements or to make changes to the service provided. One example was the provision of various support groups rather day hospice services.

North Devon Hospice headquarters is in Barnstaple, it is set on a hill and has beautiful views of the surrounding area and a well-kept themed garden. It provides a service for adults with life-limiting illnesses and advanced progressive conditions, such as, motor neurone disease. About 130 people were receiving a palliative care service across North Devon when we visited. The service includes an inpatient unit (known as the bedded unit) with seven beds, a day hospice at the same location and a newly built hospice outreach centre in Holsworthy, known as The Long House, which opened in September 2015. Most people receiving palliative and end of life care in North Devon preferred to remain at home and have support in the community, wherever possible. This was in line with national findings.

The day hospice in Barnstaple opened four days a week, and included a drop in service on Fridays. The Long House opened three days a week including a drop in service on Wednesdays. This new service provided a service closer to home for people in a very rural part of North Devon.

The hospice team included specialist palliative care medical and nursing staff, an occupational therapist, physiotherapist, a team of healthcare assistants and support staff. The hospice had a supportive care team, which included complementary therapists, counsellors, bereavement care, and a chaplain. A specialist community nursing palliative care team provided physical, emotional and social support for people thought to be in their last year of life and those close to them. They also provided specialist advice to GP’s, district nursing and other staff. Local GP’s and consultants in the NHS referred most people to hospice services, and a few people referred themselves. People accessed the service in a variety of ways, via the community nurse specialist, day hospice, bedded unit or the hospice to home team.

The hospice to home service is comprised of registered nurses and healthcare assistants, who provide personal care and support to people at home approaching the end of their life. Healthcare assistants in the hospice to home team were employed by the hospice but worked under the direction of the district nurses. District nurses assessed people’s individual needs and provided care plans to inform hospice to home staff about their care. The hospice to home service was available day and night, and was flexible. This meant it could respond to people’s rapidly changing needs and provided respite for carers. The team worked closely with Marie Curie, a charity for people with terminal illness, who also provided some night sitting services for people in the area.

The hospice had about 550 volunteers who were involved in all aspects of the service such as fund raising, working in the bedded unit, day hospice, in shops, and as volunteer drivers and gardeners. They offered befriending services to people and provided respite for carers. Some volunteers also had professional qualifications and offered counselling and complementary therapies.

The service had a registered manager, who is the director of care at North Devon Hospice. 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.

Staff supported people with poor appetites who needed help and encouragement to eat and drink. People praised the food available at the hospice, although some staff had concerns about people in the bedded unit being able to have food of a consistent standard whenever they wanted it during the day. Suggested reasons for this varied but included concerns about staffing levels in the kitchen, competing demands from the restaurant and a lack of staff training about preparing and presenting small amounts of nutritious food suitable for a person at the end of their life. There was ongoing work between departments to try and address this but further steps were needed.

People received their medicines on time and in a safe way, their pain relief and symptoms were well managed and they were kept comfortable. However, some improvements were needed in the prescription charts used and in assessing staff competencies in medicines management.

Comprehensive individual and environmental risks assessments were in place, which showed actions being taken to minimise risk. We identified some risks in relation to the use of convector heaters, which were hot to touch, and needed to be risk assessed.

People received effective care, based on evidence based practice, from staff that had the knowledge and skills needed to carry out their role. Staff had regular training and updating to maintain and increase their knowledge. However, greater clarity was needed about how the clinical competencies of staff were assessed and monitored to carry out their roles.

People had a high standard of end of life care which enabled them experience a comfortable, dignified and pain-free death. People and relatives consistently described amazing are from hospice staff. We received overwhelmingly positive feedback and comments about how staff treated people with the utmost kindness, dignity and respect. People described the hospice as a happy place, in which they felt supported and cared for. The service had received numerous compliments about the quality of care and the support staff provided. For example, one person said, "The minute you walk in the door everyone smiles, and immediately you feel comfortable." A relative said, “A hospice to most people means death, but it’s not, it’s a big comfort blanket, they wrap you up and make you feel better.”

Each person was supported to complete an advanced care plan which captured their wishes about their end of life care. This meant staff were able to carry out each person’s wishes, even when the person was no longer able to communicate them. The person and those important to them were involved in decisions about their care. Care plans gave detailed information about people’s needs and wishes and were reviewed and updated regularly.

The service worked in partnership with local health professionals to identify people likely to be in the last 12 months of life, so they could be offered hospice services. People and professionals had 24 hour access to specialist end of life care and treatment to manage their pain and physical symptoms from staff at the hospice.

There were sufficient numbers of suitably skilled staff on duty at all times to keep people safe, meet their needs and to provide skilled support. A robust recruitment process was in place to make sure people were cared for by suitable staff and volunteers.

People said they felt safe being at the hospice and steps were taken to protect them from potential abuse and avoidable harm. Staff were aware of potential signs of abuse and knew how to report concerns, and any concerns reported were investigated.

Staff understood their responsibilities in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty safeguards (DoLs). Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA.

People knew how to raise concerns and were confident any concerns raised would be listened and responded to. Any complaints received were thoroughly investigated and included following up any competency or attitudinal concerns about individual staff. Response letters sent were honest about any failings, they acknowledged and apologised where any deficiencies in care were identified and outlined actions being taken to improve.

The environment of the hospice was bright and welcoming, and was in good decorative order. It was clean and hygienic, with measures in place to prevent cross infection, such as good hand hygiene practices. All areas were well equipped and maintained, with good quality fabrics and furnishings.

People, relatives, staff and external professionals said the service was organised and well run. There was a culture of care, comfort and compassion for people and those important to them. Senior staff acted as role models to support staff to achieve high standards of care. Staff used local information to identify unmet needs and developed services to meet them. For example, the creation of a hospice to home team and the development of a hospice outreach centre in Holsworthy. Staff said they worked well as a team and felt supported and valued for their work.

There were a range of quality monitoring systems in place, which were well established. There was evidence of making continuous improvements in response to people’s feedback, the findings of audits, and of learning lessons through reflecting on practice, in response to feedback, complaints, accidents and incidents.

Care and attention was paid to people's individual needs so that they received effective and appropriate treatment. Staff were trained to understand the specific needs of people requiring end-of-life care. Unexpected events were analysed and used as learning opportunities. The quality of treatment and care was closely monitored and the results of clinical audits were used to improve practice if necessary.

Staff were supported and managed effectively and were encouraged to up-date their skills and knowledge. Professional and organisational skills were regularly assessed and further development encouraged.

We interviewed 14 staff including the acting chief executive, director of care, registered manager, human resources manager, palliative lead nurse specialist, a doctor, nurses, health care assistants, receptionist and counselling staff.

People were involved in all aspects of their care, consent was obtained and we were told 'they don't tell you what you should do. They ask you what would you like?' People said highly skilled staff had been recruited who understood and met their needs. People said the building was well maintained; for example one person commented 'it's like being in a first class hotel'. None of the people we spoke with had any concerns, but if they did they said it would be dealt with. One patient summed comments we had from people, 'I look forward to going there and every time I go I get a huge welcome'. The experiences families told us about were summed up in the comment 'They've taken a huge amount of pressure off us, you couldn't wish for a more caring place or staff'.