25 January 2023
Barnsley Hospice is operated by Barnsley Hospice Appeal. It provides hospice care for adults living in Barnsley and the surrounding area. The hospice has 10 inpatient beds, and provides day hospice services, bereavement and family support.
Barnsley Hospice Appeal is an independent charity and company limited by guarantee. The service is registered for diagnostic and screening procedures and treatment of disease, disorder or injury and has a registered manager in place to oversee this. CQC last inspected Barnsley Hospice in January 2022.
25 January 2023
We carried out a comprehensive inspection of this service as part of a follow up, as the service had previously been inspected in April and May 2021 and January 2022 and was rated inadequate.
At the last inspection we found significant safety concerns and we imposed urgent conditions using our section 31 powers on the service’s registration to drive improvement and ensure patients were safe. These conditions were specifically in relation to the clinical assessment review and risk identification of patients, admission assessment processes and COVID-19 management processes and policies. The application of conditions required the service to urgently complete a full review of all patient records to ensure appropriate documentation and risk management process were in place. We issue conditions where the care a service is responsible for, falls short of what is legally required, tell the service what was not right, and explain how long they have to comply with the regulations.
At this inspection we found the service had made significant improvements and had taken prompt action to comply with the regulations.
Our rating of this location improved. We rated it as outstanding because:
- People are protected by a strong comprehensive safety system, and a focus on openness, transparency and learning when things go wrong. Staff had training on how to recognise and report abuse and they knew how to apply it.
- Staff completed and updated risk assessments for each patient and removed or minimised risks. Risk assessments considered patients who were deteriorating and in the last days or hours of their life.
- The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
- The service used systems and processes to safely prescribe, administer, record and store medicines.
- The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
- Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. They followed national guidance to gain patients’ consent.
- People were truly respected and valued as individuals and are empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service
- The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
- Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
- All staff were committed to continually learning and improving services.
- The service should consider auditing ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms.
- The service did not provide leaflets in multiple languages.