St Wilfrid's Hospice

Updated 26 February 2015

The inspection team consisted of one inspector, a specialist advisor who worked in a senior position within a hospice, a pharmacist inspector 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 expert for this inspection had experience of a relative who had used hospice services.

At the time of our inspection St Wilfrid’s Hospice had seven people staying in the ‘in patient unit’  a further ten people were attending ‘wellbeing’, and the hospice at home had over 100 people on their contact list. The registered manager told us that although the hospice had 20 beds they currently only used 11. The additional beds were being phased in as the hospice established itself and recruited the required staff and volunteers to do so effectively.

During the visit, we spoke with fourteen people. We were also able to talk to nine relatives and friends who were visiting people within the ‘in patient unit.’ Following the inspection visits we contacted three people who were receiving a service from the ‘hospice at home’ team.

We spoke with nine staff, including the registered manager, and seven volunteers.

We observed some care and support provided both by staff and volunteers within ‘wellbeing’ and communal areas of the hospice. As part of our inspection we looked at a number of records. This included policies and procedures that supported practice including the complaints procedure. We looked at medicine records, staff training records and staff rotas. There were full and extensive records supporting the quality monitoring systems in the home that were viewed. Including notes of meetings and associated action plans. A number of certificates demonstrating maintenance and servicing of equipment and facilities.

We looked at records in paper and electronic format relating to three people receiving care from the ‘hospice at home’ team and two people within the ‘in patient unit’. These included risk assessments, full assessment of needs, care plans and documentation relating to people’s choices around their care.

Before our inspection, we reviewed the information we held about the home that included notifications received. A notification is information about important events which the service is required to send us by law.  We reviewed the Provider Information Record (PIR) and previous inspection reports before the inspection. The PIR was information given to us by the provider. This enabled us to ensure we were addressing potential areas of concern.

We last visited the service on 23 November 2012 when we found the service was compliant. This service relocated to a new purpose built location in October 2013.

This report was written during the testing phase of our new approach to regulating adult social care services. After this testing phase, inspection of consent to care and treatment, restraint, and practice under the Mental Capacity Act 2005 (MCA) was moved from the key question ‘Is the service safe?’ to ‘Is the service effective?’

The ratings for this location were awarded in October 2014. They can be directly compared with any other service we have rated since then, including in relation to consent, restraint, and the MCA under the ‘Effective’ section. Our written findings in relation to these topics, however, can be read in the ‘Is the service safe’ sections of this report.

Updated 26 February 2015

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 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

The inspection was announced. We told the provider two days before our visit that we would be coming.

St Wilfrid’s Hospice provided nursing care for people over the age of 18 living with a life limiting illness. The staff provided treatment and care for physical symptoms and helped people with addressing emotional, spiritual and social wellbeing. They also provided support to families and close friends during the illness and bereavement.

St Wilfrid’s hospice provided three distinct services. These included an ‘in patient unit’ which provided accommodation and had up to 20 bedrooms with en suite showers and toilets. ‘Wellbeing’ provided therapy and support to people who were able to come to the hospice and use its facilities.  People living at home received care, treatment and support from the ‘hospice at home’ team who were co-ordinated from the hospice.

There was a registered manager in post at the hospice.  A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People and their relatives told us that they felt safe when in the care of the hospice staff. Staff working for the hospice understood the needs of people and consulted with them throughout the care delivery. People and their families were involved in the planning of care and were treated with kindness and compassion with due regard to their privacy and dignity.  

Records showed that staff had received training on safeguarding vulnerable adults and the Mental Capacity Act 2005. Staff were able to tell us what they would do if they had any concerns and talked about when people were not able to make decisions for themselves. Meetings were held with relatives and health care professionals to make decisions in people’s best interest.

Staff were appropriately trained and skilled and provided care in a safe environment. They all received a thorough induction when they started work at the hospice and fully understood their roles and responsibilities, as well as the values and philosophy of the hospice. The staff had also completed additional training to ensure that the care provided to people was safe and effective to meet their needs.

St Wilfrid’s Hospice had the resources, that included skilled staff, facilities and equipment and well-established contacts with other health and social care professionals that ensured effective care delivery for people wherever they needed and wanted it. Feedback from all sources was used in a productive way to improve the service.

There was a strong management team which listened and supported the staff and volunteers working for the service. There was a clear clinical governance structure in place that involved staff at all levels to establish and maintain the best possible care for people.