Archived: Woking Hospice

Updated 24 June 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection was carried out on 3 and 4 May 2016 and was unannounced. The inspection team consisted of two inspectors, a specialist nurse advisor and a pharmacist inspector.

The registered manager had completed a Provider Information Return prior to the visit. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We looked at all the information we have collected about the service. This included notifications the registered manager had sent us. A notification is information about important events which the service is required to tell us about by law.

We looked at the premises. We reviewed five sets of records that related to people’s care and examined four people’s medicines charts. We examined people’s assessments of needs and care plans and observed to check that their care and treatment was delivered consistently with these records. We consulted documentation that related to staff management and six staff recruitment files. We looked at records concerning the monitoring, safety and quality of the service and the activities programme. We observed a staff handover meeting and the arrangements for storage and the administration of medicines.

We spoke with three people who were in the inpatients unit and three of their relatives. We received telephone feedback from another relative following our visit. In total we spoke with seventeen members of staff. These included medical, nursing, and care staff, a physiotherapist and a counsellor. We also spoke with three members of the community team, the Practice Development Nurse, kitchen staff and some administrative staff. In addition, we spoke with four volunteers.

We spoke with the registered manager and the ward manager at length and spent some time talking with the medical director. We contacted twenty four professionals and organisations such as GP practices who had previous and current contact with the service and received four responses. CQC sent questionnaires to a range of individuals including people who use the service and their relatives. We received nineteen responses from people and five from their relatives. In addition, there were twelve completed questionnaires received from staff and four from community professionals. A selection of these responses has been incorporated into the body of the report.

Updated 24 June 2016

This inspection was carried out on 3 and 4 May 2016 by two inspectors, a specialist nurse adviser and a pharmacist inspector. It was an unannounced inspection.

Woking Hospice is a charitable organisation owned by Woking Hospice Trust. It is registered for provision of palliative care to adults over 18 years of age. It offers 10 in-patient beds and a further fifteen day care places. There is a Hospice Care at Home service which provides treatment, care and support for up to 300 people at any one time. The hospice adjoins a local NHS community hospital.

There was a manager in post 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 also managed the community services, the day hospice service on site and the sister hospice Sam Beare Hospice.

People were kept safe by staff who were trained in the safeguarding of adults and health and safety. They were able to fully describe their responsibilities with regard to keeping people in their care safe from all forms of abuse and harm. It was apparent from discussion with members of the management team that all health and safety issues were taken seriously to ensure people, staff and visitors to the service were kept as safe as possible. There were enough staff on duty to ensure people received safe care. People were given their medicines in the right amounts at the right times by properly trained staff. The recruitment process was robust and the service was as sure as possible that staff employed were suitable and safe to work with people who were cared for in the service.

People’s human and civil rights were upheld. The service had taken all necessary action to ensure they were working in a way which recognised and maintained people’s rights. The staff team understood the relevance of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS) and consent issues which related to the people in their care. The Mental Capacity Act 2005 legislation provides a legal framework that sets out how to act to support people who do not have capacity to make a specific decision. DoLS provides a lawful way to deprive someone of their liberty, provided it is in their own best interests or is necessary to keep them from harm. The registered manager and their predecessor had made the appropriate DoLS referrals to the Local Authority. Clear information about the service, the facilities, and how to complain was provided to people and their relatives. 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’s health and well-being needs were met. Staff had built strong relationships with people and they were knowledgeable and knew how to meet people’s needs. The service respected people’s views and encouraged them to make decisions and choices. Food was nutritious and of good quality. Staff were appropriately trained to meet the needs of people in their care. Staff knew each person well and understood how people may feel when they were unwell or approaching the end of their life. Overall, the service was responsive to people’s needs and was proactive when people’s needs changed.

People’s feedback was actively sought, encouraged and acted on. People and their relatives were overwhelmingly positive about the service they received. They told us they were satisfied with the staff approach and how the care and treatment was delivered. The staff approach was kind, compassionate and pro-active.

The environment was well designed, welcoming, well maintained and suited people’s needs.

The service was well managed. Meeting people’s needs was the priority for staff and the registered manager. The management team including members of the board were described by staff as supportive. Emphasis was placed on continuous improvement of the service. Comprehensive audits were carried on all aspects of the service to ensure that policies and procedures were being adhered to. When areas for improvement were identified, action was taken to ensure the quality of the service and care. The service worked effectively in partnership with other organisations.

No concerns were found at our last inspection in December 2013.