Dorothy House Hospice Care

The inspection team included a lead inspector, pharmacist inspector, a nurse specialist and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

The provider is The Dorothy House Foundation Limited, a registered charity. It employs 430 staff and over 1200 volunteers. The service covers an area of 700 square miles and accepts people from Bath and North East Somerset (BANES), and parts of Wiltshire and Somerset.

Dorothy House Hospice is located in Winsley, just outside Bath and has just celebrated 40 years of providing care for local people. It is registered for 10 beds and provides specialist palliative and end of life care for adults, with life limiting illness or complex symptom management needs. At Dorothy House six people were being cared for at the inpatient unit when we visited. End of life care is for people who are considered to be in the last year of life. The service used referral criteria to identify people who would benefit from admission, and the average length of stay was 11 days. The inpatient unit provided 142 people with a compassionate and dignified death in the last year. People could access the service in a variety of ways, via referrals from local GP's and consultants in the NHS, or from people or family members/carers (with the person’s permission).

The inpatient unit had eight single rooms and one double room, with ensuite bathroom facilities. A restaurant was available and there were lots of quiet spaces for people and families to use. A wide variety of art and craft work, pictures and paintings were on display, which provided a calm and tranquil ambience throughout. A purpose built extension included a stunning chapel/spiritual space with lovely views over the beautifully landscaped grounds. There were ample car parking spaces, including disabled access spaces.

A hospice at home night sitting service provided care for people receiving end of life care at home and for two nights a week, so carers could have some rest. An Enhanced Discharge Service provided home care over 24 hours so people, who wanted end of life care at home, could be discharged from hospital at short notice.

A 24 hour advice line which offered people, relatives, hospital and community based professionals support and advice on palliative and end of life care. Day care services were offered at Winsley, which included social groups, activities, creative art therapy, complementary therapies and carer’s support groups. Two outreach centres, one at Trowbridge and the other at Peasedown St John provided a relaxed and informal drop-in and signposting service for anyone affected by a life-limiting illness, including family members and carers. The centres hosted group workshops and community groups, and had treatment rooms. Dorothy House nurse specialists were based at the outreach centres and visited people at home to support and provide pain management and symptom control and worked closely with local GP’s and community nurses.

Volunteer roles included administrative support to inpatient and day patient units, bereavement, complementary therapies, volunteer drivers, gardeners and retail services. They also offered befriending services to people and provided respite for carers.

The service had a registered manager who was the medical director. 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.

People, relatives and healthcare professionals consistently praised the excellent standards of care, treatment and support provided by hospice staff using words such as “excellent” and outstanding.”

An evidence based assessment tool helped people to self-report their physical, emotional, social and spiritual needs. This was completed at regular intervals to ensure outcomes that mattered to people were always met. People received effective end of life care because staff had link roles which championed best practice, for example, in skin care and prevention of pressure sores, falls prevention, nutrition and hydration and infection control.

The hospice had improved end of life care for people living with dementia. For example, through staff training and by making improvements to help people navigate their way around the environment. Specialist crockery and cutlery assisted people with cognitive difficulties to eat and drink independently. Hospice staff worked with a local mental health trust to support them to provide high quality end of life care for people with dementia. This meant people, with complex mental health needs, could remain in the specialist unit and receive end of life care from staff who knew and understood them.

Hospice staff worked with a dietician to develop an innovative nutrition assessment tool for people receiving palliative and end of life care. This enabled staff to support people at the end of their life to eat and drink what they wanted for as long as they wanted and recognise when the person was no longer well enough to do so. People had access to high quality food and drink, for as long as they were able and wished to. Excellent catering services met people's individual nutrition and hydration needs.

The hospice was doing outstanding work supporting children and young people facing bereavement and following the person’s death. They helped children and young people explore their feelings, prepare for what was going to happen and find ways to cope with the changes in their lives.

Staff went that extra mile for the people and families they supported. For example, arranging weddings at the hospice, supporting a person to make their peace with an estranged relative and arranging for a dying person to see their beloved horse again. The hospice used ‘Life Stories’ as a way of supporting people to leave personal messages, letters or keepsakes for those they loved and cared about and to create memoirs.

A volunteer ‘Companion Scheme’ provided people with opportunities to develop new friendships and gave carers the opportunity to have a break, so they could continue to support the person. To celebrate national carers’ week, staff arranged a cruise along the Kennet and Avon canal for carers, and offered practical support by caring for their loved one, so they could attend.

People received co-ordinated person centred care which responded to their changing needs through outstanding partnership working. For example, to improve equity of access to palliative care and end of life services for hard to reach groups such as homeless people and prisoners. A ‘Transitions Project,’ did innovative work to help young people with life limiting conditions to make the transition from children’s to adult end of life services at an earlier stage, by designing services with them to meet their needs.

A range of innovative activities and crafts were provided by the Creative Therapies Team, assisted by volunteers. ‘Creative keepsakes’ provided a personalised opportunity for any family to work together creatively to make beautiful works of art with their family. They developed a piece of art together that was meaningful to them such as a painting a pot, ceramics, making a plaster cast of hands.

People received co-ordinated, person centred care, when they used different services or moved between services such as the hospital, GP practice and hospice services. Hospice medical staff worked in the local NHS trust and community staff worked closely with GP’s, community nurses and other professionals and used the same electronic record system, so could communicate more effectively.

The service was committed to continuous improvement. For example, they reviewed and streamlined existing services to make them more accessible. To increase involvement of people in evaluating services and consult them in the development of new services, they commissioned Healthwatch Wiltshire to set up a user group to consult on service developments. They were developing clinics to offer people outpatient treatments nearer home in more relaxed hospice settings to meet people's needs and reduce hospital appointments.

People received consistently high quality care because the leadership team had high expectations of staff, and encouraged staff to take on new developments and innovate. For example, through projects to develop services for homeless people and prisoners and by extending their skills to offer more services to people. Staff increased the amount of time they could spend with spent more time with people through the use of ‘The Productive Ward’ programme. This supported staff teams to develop more efficient work systems and make improvements to the ward environment.

People received care at a time and pace convenient for them because there were enough skilled and experienced staff. Staff could spend time with each person offering them assistance, support, comfort and reassurance. People said staff made them feel safe and cared for. Staff knew how to recognise and report signs of potential abuse, and any concerns reported were investigated.

People received their medicines on time and in a safe way. All appropriate recruitment checks were completed to ensure fit and proper staff were employed. They were cared for in a clean and hygienic environment. Staff reduced the risks of cross infection for people through good hand hygiene, and regular cleaning.

People’s human and legal rights were respected because staff understood thei

We were informed the staff gained consent before they delivered care and treatment. One patient told us 'everything has been upfront and there was no pressure, the treatment I was offered I wanted.' The other patient said 'they explain things as they go along.' A relative reported 'they discuss what they need to do and ask 'how do you want to do it. There are no problems if XX refused, the implication of decisions would be explained.'

Patients knew the reasons for their admission to the in-patient unit. The two patients we spoke with told us the purpose of their referral to the in-patient unit and about the expected length of their stay. They told us about the personal support they received and how their care was monitored by the staff. The care action plans we looked at were brief and needed to be more detailed to follow good practice guidance.

The relatives of two people who used the Hospice at Home service told us staff recorded the care delivered to their family member. The relatives told us hospice staff used the district nurses' documentation to record the care and treatment they delivered. Relatives told us they had read the reports and one relative told us 'yes I read the file at times but rarely, I have so much confidence. Where it needs information is passed on.' The other relative we spoke with said 'yes I have read the file and reflects what has been done.' The member of staff in day to day charge of the Hospice at Home service told us care plans were to be developed in the near future.

Safe systems for medicine administration were in place. One person told us they had been asked if they wanted to self-administer their medicine. We saw where patients were considered safe to administer their medicines a competency assessment to ensure this had taken place. Another patient told us they had not been asked and told us 'It does seem daft because I was doing it before I arrived and I will be doing them when I go home.' Where patients had capacity but were not considered safe to self-administer their medicines the justification of this decision was not documented.

People told the staff were good and skilled to meet their needs. One patient told us 'jolly good bunch of staff very kind and helpful.' Another patient told us 'staff are brilliant and skilled.'

We saw the staff attended a combination of compulsory and essential training was provided to meet the values of the organisation and to meet the needs of the service users. For example health and safety, safeguarding adults equalities and diversity training.

People having respite care told us the staff were professional and skilled to meet their needs. We were told 'I have control of my care and I am cared for in the way I want' and 'My physiotherapist is helping me to walk before I go home.' The relative said the visits from the hospice at home service were important. We were told 'the staff are friendly but never loose their professionalism.'

People said they felt safe and they knew how to complain. We saw the 'Making a complaint' leaflet on display at Dorothy House. The relative told us they had a copy of this leaflet and were able to follow the procedure if they had a complaint.

The people we spoke with were receiving support from more than one provider and their comments confirmed their care was well coordinated. We were told information about their care was passed onto the appropriate social and healthcare professional. For example people had specialist palliative care nurses, social workers, community nurses, doctors and consultants involved in their care.