Fair Havens

Updated 14 April 2017

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 took place on 26 and 27 October 2016 and was announced.

We gave the provider notice of the inspection to ensure the correct people were available on the day of the inspection to speak with us.

The inspection was carried out by one inspector, a specialist advisor, an expert by experience and a member of the CQC medicines team. The specialist advisor was a specialist in end of life care and the expert by experience was a person who had personal experience of using and caring for someone who had used this type of service.

Before the inspection the provider completed a Provider Information Return (PIR). 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 checked the information we held about this service and the service provider. We also contacted the Local Authority. No concerns had been raised and the service met the regulations we inspected against at the last inspection which took place in June 2013.

During our inspection we observed how staff interacted with people who used the service.

We spoke with five people who used the service, three relatives, the manager, the CEO, the ward manager, the chaplain, the chef, the head of Human Resources (HR), a HR consultant, senior administrator, family support councillor, site support manager, three registered nurses, four Health Care Assistants (HCAs), a palliative care consultant and two trustees.

We reviewed five people’s care records, four medication records, four staff files and records relating to the management of the service, such as quality audits.

Updated 14 April 2017

This inspection took place 26 and 27 October 2016 and was announced.

Fair Havens is a ten bedded hospice for adults providing palliative medicine and nursing care on an inpatients and day care basis. Other services are co-ordinated from the establishment that include: Macmillan nurses, bereavement support, chaplaincy and home care services.

There was a registered manager in post. At the time of our inspection they were on long term leave and the service was being managed by a manager who was in the process of submitting their registration to CQC. They were supported by the Chief Executive Officer (CEO) and management team.

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 felt safe. Staff had received training to enable them to recognise signs and symptoms of abuse and how to report them. People had risk assessments in place to enable them to be as safe and independent as they could be.

Effective recruitment processes were in place and followed by the service to ensure staff employed were suitable to work with people who used the service. There were sufficient staff, with the correct skill mix, on duty to support people with their care and treatment needs.

Medicines were managed safely. The processes in place ensured that the administration and handling of medicines, including controlled medicines, was suitable for the people who used the service.

Staff and volunteers received a comprehensive induction process and on-going training. They were well supported by the manager and the management team. Staff had attended a variety of training to ensure they were able to provide care based on current practice when providing care and treatment for people.

Staff gained consent before supporting people or providing care and treatment. People were supported to make decisions about all aspects of their life; this was underpinned by the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff were knowledgeable of this guidance and correct processes were in place to protect people.

People were able to make choices about the food and drink they had, and staff gave support when required.

Staff provided care and support in a caring and meaningful way. They knew the people who used the service well. People and relatives, where appropriate, were involved in the planning of their care and support. People’s privacy and dignity was maintained at all times.

A complaints procedure was in place and accessible to all. People knew how to complain. Effective quality monitoring systems were in place. A variety of audits were carried out and used to drive improvement.