An unannounced inspection took place at St Joseph’s Hospice on 11 & 12 December 2017.At the previous inspection of 4, 5 & 7 July 2017 the provider was found to be inadequate and the service was placed in ‘special measures’ by CQC. We found breaches of regulations in all key questions we inspect (Is the service safe, effective, caring responsive and well led?).
The purpose of 'special measures' is to:
Ensure that providers found to be providing inadequate care significantly improve.
Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.
Services placed in 'special measures' are inspected within six months of the publication of the inspection report.
At this inspection we found improvements had been made. This meant the service was no longer rated inadequate and could be removed from 'special measures' by the Care Quality Commission (CQC).
Following the inspection in July 2017 we issued an urgent statutory notice requiring the provider not to admit any further people to St Joseph’s Hospice. The urgent statutory notice also required the provider to carry out a review of the quality assurance systems that were in place; the introduction of medicines management audits; the introduction of clinical compliance checks; appraisal of the individual competencies of all persons employed and also the directors at St Joseph’s Hospice and to issue a policy that is in accordance with the requirements of the Mental Capacity Act 2005 (MCA) in relation to the use of covert medication and administration of covert medication.
In light of the improvements we found at the December 2017 inspection we have now lifted this statutory notice which prevented people being admitted to the service. The provider had also complied with the other conditions of the urgent statutory notice.
We have revised the rating for the hospice following our inspection; however the service cannot be rated as ‘good’. To improve the rating to ‘good’ would require a longer track record of consistent good practice.
St Joseph’s Hospice provides care and support to terminally ill people and their families within the Liverpool and Sefton areas.The hospice provides care for people with progressive, degenerative conditions and for people with a brain injury. The hospice also provides end of life care and support to families of terminally ill patients. The hospice has accommodation and facilities for 29 people. At the time of our inspection 17 people were receiving a service at the hospice.
People in a hospice receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had 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 of the Health and Social Care Act 2008 and associated regulations about how the service is run.
At the inspection in July 2017 we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as medicines were not administered safely. We found concerns around the way some medicines were administered and recorded which placed people at high risk of harm. There were issues in the way some medicines were stored.
At this inspection reviewed the management of medicines. The hospice was working closely with external health professionals to improve the medicines arrangements in the hospice. We saw that people now received their medicines safely. Staff who had administered medicines had been trained and had their competencies checked. Storage conditions had improved. This breach of regulation had been met.
At the inspection in July 2017 we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as the hospice did not always support people to provide effective outcomes for their health and wellbeing, this included monitoring of pain.
At this inspection we saw staff completed care monitoring charts, for example, recording of people’s intake and output to help monitor people’s health and provide a care evaluation. Care records showed people’s plan of care was written in a way that reflected their wishes, preferences, needs and choices. This included reporting on medical conditions and formulating a plan of care for pain management. This breach of regulation had been met.
At the inspection in July 2017 we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as some food supplements were not administered in accordance with instructions.
At this inspection we found food supplements were given as prescribed in accordance with people’s nutritional assessment. This breach of regulation had been met.
At the inspection in July 2017 we found a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as staff were not supported through appraisal, supervision and the hospice's training programme.
At this inspection we saw staff received a good level of support and training. Staff had also had an annual appraisal. Staff told us they received good support from the registered manager and that they had access to a variety of training courses. This breach of regulation had been met.
At the inspection in July 2017 we found a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as when people were unable to consent, the principles of the Mental Capacity Act 2005 (MCA) were not always followed, in that an assessment of the person’s mental capacity was not made.
At this inspection we saw consent was sought from people around key decisions, including the administration of covert medication. This breach of regulation had been met.
At the inspection in July 2017 we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as there was a failure to maintain accurate and complete records of care and treatment for people and people’s care notes were taken to the dining room by staff for annotation. This room was used by relatives and confidential notes could be overlooked by relatives within this area.
At this inspection we saw confidential information was securely stored and staff made annotations to people’s notes in the office or nurses’ station. Staff were aware of how to main confidentiality and told us how this was respected. This breach of regulation had been met.
At the inspection in July 2017 we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as some of the systems for auditing the quality of the service needed further development and did not provide adequate monitoring of standards in the hospice. We found repeated failings with the service with the provider not able to meet statutory requirements.
At this inspection we found systems and processes for assuring the standards at the hospice were consistent and robust. We saw sight of the effectiveness of the improvements and also how the service was initiating further changes to support the development of the service. Clinical governance was well monitored and discussed at clinical governance meetings. We were assured by the measures taken. This breach of regulation had been met.
People who received in-patient care told us there were sufficient numbers of staff on duty to care for them. Staffing rotas evidenced staffing numbers and skill mix. People told us the staffing levels helped them feel safe and supported.
Staff had been checked when they were recruited to ensure they were suitable to work with vulnerable adults.
Staff had a good knowledge of safeguarding procedures. The hospice had reported actual or potential harm to the relevant local safeguarding authority and agreed protocols had been followed in terms of investigating. This helped to ensure any lessons could be learnt from and effective action taken. We had also been notified of safeguarded incidents in accordance with our statutory notifications.
A four week menu was in place and we saw people offered choice of well balanced meals. People told us the food was very good. People’s nutritional needs were assessed and recorded.
The environment and equipment was well maintained and subject to service contracts and safety checks. All areas seen were clean and kept hygienic.
Staff sought advice from external health and social care professionals at the appropriate time. This ensured people’s health was monitored effectively.
People who received in-patient care told us that staff were kind and caring and that they were treated with respect by staff. We saw good level of engagement between people receiving in-patient care and the staff. It was evident that the staff knew people and their relatives well.
Staff were aware of how to maintain people’s independence, taking in account current risks and how to manage these effectively.
People receiving in-patient care and their relatives had been involved with formulating the plan of care. We discussed ways of recording this in more detail to evidence their inclusion.
We saw good standards of privacy and dignity for people receiving in-patient care. This we evidenced by our observations, feedback from people receiving in-patient care, relatives and by looking at care records.
Social activities were arranged including holistic treatments suc