The Care Quality Commission
  • Hospice service

Butterwick House

Overall: Good read more about inspection ratings

Middlefield Road, Hardwick, Stockton On Tees, Cleveland, TS19 8XN (01642) 607748

Provided and run by:
Butterwick Limited

All Inspections

02-03 August 2022

During a routine inspection

Our rating of this location improved. We rated it as good because:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and measured patient outcomes. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and all staff were committed to improving services continually.
  • Leaders had made significant improvements since our last inspection which included oversight of clinical and service risks. Managers had good awareness of the challenges the service faced and were implementing key changes to address previously imposed restrictions.

However:

  • The service did not use a recognised scoring tool to monitor patients for deterioration.

1 February 2022 and 2 February 2022

During a routine inspection

Our rating of this service improved. We rated it as requires improvement because:

  • Mandatory training had not been completed by all staff.
  • Not all staff had had an appraisal at the time of inspection.
  • Leaders had improved the way they managed the service since the last inspection in 2021, but there was work to do to sustain and embed improvements.
  • The service had started to engage with the community to plan and manage services but these relationships needed to grow and establish.
  • There were no Fit and Proper Person checks undertaken for the five hospice trustees.

However:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and measured patient outcomes. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and all staff were committed to improving services continually.

07 - 09 September 2021

During an inspection looking at part of the service

Due to the focused nature of this inspection, we inspected but did not rate the service.

  • The service did not always provide mandatory training in key skills to all staff and did not always make sure everyone completed it. Managers did not always monitor mandatory training and did not always alert staff when they needed to update their training.
  • Staff completed but did not always update risk assessments for each patient and did not always remove or minimise risks. Staff knew about specific risk issues regarding the children in their care, however, plans in place to address and respond to risk were not always clear.
  • The service did not have robust oversight of patient outcome monitoring. They did not use the findings to make improvements and achieve good outcomes for patients.
  • Leaders did not always have the capacity, skills, and abilities to run the service. There remained confusion between senior leaders regarding their roles and accountabilities.
  • Leaders and teams did not always use systems to manage performance effectively. They did not always identify and escalate relevant risks and issues and identify actions to reduce their impact.

However:

  • We saw improvement in the personalisation of care plans. These were comprehensive and reflective of current patient need.
  • The provider had taken action to establish an effective system to maintain oversight of the ratification process for policies and procedures.

Our inspection found significant concerns and found continued breaches of regulation which meant that the provider had not complied with the warning notice we issued following the inspection in May 2021. We have issued a notice of decision to impose conditions on the provider's registration.

04 - 06 May 2021

During an inspection looking at part of the service

Our rating of this location stayed the same. We rated it as inadequate because improvements made since our last inspection did not yet justify a higher rating:

  • Staff did not always receive the correct level of training on how to recognise and report abuse but they knew how to apply it. Staff did not always complete and update risk assessments for each patient and remove or minimise risks.
  • Staff did not always identify and quickly act upon patients at risk of deterioration. Staff did not always keep detailed records of patients’ care and treatment. Records were not always clear, up to date, stored securely and easily available to all staff providing care.
  • The service did not always use systems and processes to safely prescribe, administer, record and store medicines.
  • Staff did not monitor the effectiveness of care and treatment. They did not use the findings to make improvements and achieved good outcomes for patients.
  • The provider was undergoing a significant process of change, made up of many different programmes of work. There was a lack of any robust oversight or management of this. Leaders did not run services well using reliable information systems and did not support staff to develop their skills. The governance structure was new and not embedded. The leadership team had gaps in its skills.
  • Staff did not always understand the service’s vision and values, and how to apply them in their work. Staff did not always feel respected, supported and valued. Staff were not always clear about their roles and accountabilities. The service did not always engage well with the community to plan and manage services.

    However:
  • The service had enough staff to care for patients and keep them safe.
  • The service controlled infection risk well. The design, maintenance and use of facilities, premises and equipment kept people safe.

    Following our inspection, we raised significant concerns with the provider by issuing a warning notice relating to breaches of Regulation 12 and 17. In addition, we issued the provider with requirement notices and told the provider that it must take prompt action to comply with the regulations.

14 and 15 October 2020

During an inspection looking at part of the service

We inspected Butterwick House because we had concerns about the quality of services. The provider reported four medicines incidents since reopening to children in July 2020. We were provided with detail of the four incidents by the provider, and on review of this information our concerns were sufficient to merit a short notice, announced inspection. We carried out a focussed inspection at Butterwick House on 14 and 15 October 2020 to review the processes, procedures and practices around medicines management, incidents and governance. We looked at parts of the safe and well-led domains.

We did not rate services because this was a focussed, short notice inspection in response to specific areas of concern. We inspected medicines practices and processes at Butterwick House, the medicines management training provided to staff, and how their knowledge was checked, and how they reported and investigated incidents. We also looked at the wider oversight and management of incident management and risk across the organisation.

We found;

  • The service did not have staff with the right training to keep patients safe from avoidable harm and to provide the right care and treatment.
  • Staff did not keep detailed records of patients’ care and treatment.
  • The service did not use systems and processes to safely prescribe, administer and record medicines.
  • The service did not manage patient safety incidents well. Staff did not always recognise and report incidents and near misses. Managers did not investigate incidents thoroughly and we found no evidence that they shared lessons learned.
  • Leaders did not operate effective governance processes, throughout the service and with partner organisations and did not use systems to manage performance effectively.

We will add full information about our regulatory response to the concerns we have described to a final version of this report, which we will publish in due course.

12 February 2020

During an inspection looking at part of the service

Butterwick House is operated by Butterwick Limited. This service location provides hospice care for children from Stockton, Middlesbrough and surrounding areas. The hospice cared for 42 children and young people in the last year.

Butterwick House is registered as a charitable trust and also receives funding from the NHS.

The hospice has six inpatient beds, two of which are reserved for the provision of respite care.

We carried out a focused inspection on 12 February 2020 to follow up on improvements made by the hospice to address concerns raised at our comprehensive inspection 5 November to the 11 December 2019. The service had recently re-opened following a voluntary suspension of the service for a period of six weeks. At the time of the inspection the hospice was open Monday to Saturday and was only admitting children and young people already known to the service for short-break respite care. It was not taking new referrals or end of life children or young people at this time.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

Services we rate

As this was a focussed inspection, we did not inspect all five key domains. This means the service was not rated on this occasion and ratings from the previous inspection still apply. We inspected areas of; Safe, Effective and Well-led.

At our last inspection we found several issues that the service provider needed to improve;

  • Disclosure and barring checks for staff and volunteers were not updated regularly and the service did not hold a comprehensive record of when to update these. This situation had been improved, all staff had received the appropriate checks and a system had been put in place to ensure managers had clear oversight and were alerted when checks became due.

  • Previously, staff did not have the right levels of safeguarding training to meet intercollegiate guidance (2019). All staff had since been trained to an appropriate level, and policies had been updated to reflect training needs, in line with guidance.

  • Incidents were not always reported and investigated. Learning from incidents was not adequately shared. At this inspection we found the incident policy was being reviewed and work was being undertaken to improve reporting. Nominated staff were to be trained to undertake investigations/ root cause analysis. However, it was still not clear how learning was shared with staff and policies did not make clear staff and the organisation’s responsibilities with regard to being open with children, young people and their families and duty of candour. Work to improve the incident policies and processes was ongoing but needed further work.

  • Medical cover was now available at evenings and weekends to ensure that children and young people could be reviewed quickly if needed.

  • Staff were not previously supported with mandatory training and managers had no oversight of the training needs required for the role. Staff did not always have the right competencies to care for their patients. A training policy had been developed and all staff had been brought up to date with their mandatory training requirements and had undergone a number of clinical competency assessments.

  • Patient records, risk assessments and escalation plans had been brought up to date for the children and young people staying in the hospice at the time of our inspection. A process had been implemented to ensure this happened for every patient at their next attendance / admission. The format of assessments, care plans and other patient documentation had been reviewed and improved. We found risk assessments and care plans were of a good standard.

  • The sunflower room (for deceased patients) and the policy regarding its use was now fit for purpose. The policy covered ventilation, air cooling/ conditioning and the use of a cooling cot and blankets. The room was now safe for use and could be re-opened.

  • Managers were in the process of consulting with their professional networks including the network for children’s hospices in the North East to look at developing indicators or outcomes that could be benchmarked with other similar providers.

  • Governance arrangements including new systems and processes were being strengthened and or implemented to enable proper oversight of performance and risk. This work was ongoing. Governance systems needed to include staff who were employed by other organisations but provided services at the hospice.

  • All policies had been risk assessed and prioritised using a red, amber, green rating system. Work to fully review and update all hospice policies was progressing but was an ongoing piece of work.

  • The service was responsive to the concerns we had brought to its attention and the leadership team were eager to continue their initiatives to improve services.

Although the hospice had made significant improvements, the service needed to continue to limit its admissions to respite care and children already known to the service. We asked the hospice to develop an action plan with clear objectives and milestones to ensure a controlled and safe reopening to new admissions/ referrals, end of life admissions and emergency admissions.

Following this inspection, we told the provider that it must continue with its actions to comply with the regulations breached and requirement notices issued at the last inspection. Details to be found in the inspection report published 26 March 2020.

Ann Ford

Deputy Chief Inspector of Hospitals, North

5 November to 11 December 2019

During a routine inspection

Butterwick House is operated by Butterwick Limited. The service provides hospice care for children from Stockton, Middlesbrough and surrounding areas. The hospice cared for 42 patients in the last year.

Butterwick House is registered as a charitable trust and also receives funding from the NHS.

The hospice has 6 inpatient beds, two of which are reserved for the provision of respite care.

We carried out an unannounced inspection over several visits from the 5 November to the 11 December 2019 using our comprehensive inspection methodology. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. We inspected all five key domains. To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The only service provided was hospice services for children and young people.

Services we rate

Our rating of this service went down. We rated it as Inadequate overall.

We found the following issues that the service provider needs to improve;

  • We saw significant safety concerns in areas such as the hydrotherapy pool, which was being used without a lifeguard or staff with life saving training present

  • Disclosure and barring checks for staff and volunteers were not updated regularly and the service did not hold a comprehensive record of when to update these

  • There was insufficient attention to safeguarding. Staff did not have the right levels of safeguarding training to meet intercollegiate guidance (2019)

  • Incidents were not always reported and investigated. Learning from incidents was not adequately shared. This meant that the risk of incidents happening again was not reduced and we saw evidence of identical, preventable incidents

  • There was no cover by doctors at evenings and weekends to ensure that patients could be reviewed quickly if needed

  • Staff were not supported with mandatory training and managers had no oversight of the training needs required for the role. Staff did not always have the right competencies to care for their patients

  • Patient records and assessments were incomplete and routine assessments were not completed for all patients, including those deemed to be high risk. Opportunities to prevent or minimise harm were missed

  • Patients’ care and treatment did not always reflect current evidence-based guidance, standards and practice

  • There was no formal process to monitor patients’ outcomes. We found there was little appetite by managers to drive improvement

  • Staff did not understand the vision and values and the strategy was not underpinned by detailed realistic objectives and plans

  • The governance arrangements and their purposes were not yet formed. Financial and quality governance were not integrated to support decision making

  • There was minimal evidence of learning and reflective practice

However, we also found the following areas of good practice;

  • Staff demonstrated a good knowledge of their patients’ needs and we saw examples of caring, compassionate interactions with children, young people and their families.

  • Most of the families and children using the service were very happy with the care they had received

  • The service was responsive to concerns when these were brought to its attention and the leadership team were eager to change practice to improve services.

  • The team had developed an in-house pain management tool to meet the needs of children who did not verbalise pain and this had been well received and shared throughout the region

Following this inspection, we raised significant safety concerns with the provider and due to the number and level of concerns, the provider voluntarily suspended services. In addition, we told the provider that it must take some actions to comply with the regulations. We also issued the provider with 23 requirement notices that affected Butterwick House. Details are at the end of the report.

I am placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.’

Ann Ford

Deputy Chief Inspector of Hospitals, North

24 February 2016

During a routine inspection

We inspected Butterwick House on 24 February and 9 and 15 March 2016. The first day of the inspection was unannounced which meant that the staff and registered provider did not know we would be visiting. We informed the registered provider of the dates of our other visits.

Butterwick House provides care and support for babies, children and young people with life limiting and complex healthcare conditions. The services include specialist care, short breaks and respite care, end of life care, and family support before or after death. There are six beds within the hospice, four of which are for children and there is also a transitional unit, with two single bedrooms, to provide care and support to young adults between the ages of 13 to 25 years. The service is purpose built and situated in the grounds of the University Hospital of North Tees. Within the hospice there is a day room, sensory room and a hydrotherapy pool. There is accommodation for parents / carers on the first floor. At the time of our inspection there were three children who used the service.

Butterwick House had a registered manager in place. 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.

There were systems and processes in place to protect children from the risk of harm. Staff told us about different types of abuse and the action they would take if abuse was suspected. Staff were able to describe how they ensured the welfare of children was protected through the organisation’s whistle blowing and safeguarding procedures.

There were enough qualified and experienced staff to meet the needs of the children and young people who used the service. Staff received regular training in areas relevant to their practice. Safe recruitment practices were followed when recruiting new staff and new staff had a structured programme of induction training.

Staff awareness and understanding of risk was good. Staff shared with us how they had dealt with children’s needs changing or dealt with a medical emergency. Risks to children’s safety were appropriately assessed, managed and reviewed. Care records contained a number of risk assessments specific to the needs of each child. The risk assessments had been reviewed and updated regularly.

Parents and carers told us they had been fully involved in drawing up the plan of care and making decisions. Children had been assessed and personalised care plans had been developed which were specific to the individual needs of each child. Evidence of likes and dislikes and what was important to the child was recorded within the plan of care.

The service had medicine management policies and procedures. Appropriate systems were in place for the management of medicines so that children received their medicines safely. The Hospice had developed an excellent pain tool that was personalised to each child. Pain charts provided specific details of any changes the child may demonstrate to indicate their level of pain and a variety of pain relief was available for different types and levels of pain. This helped to ensure that children and young people’s pain was managed effectively

Checks of the building and equipment were completed to make sure it was safe. However, fire drills were not taking place as often as needed. After the inspection the management team contacted the fire authority for advice. They told us they had updated the fire policy in line with the recommendations and fire drills were to be arranged making sure that all staff took part in two fire drills a year.

The hospice employed two doctors who worked during the day Monday to Friday. They were able to review children if they became unwell or deteriorated during their stay. In the event of an emergency children were taken by staff to North Tees hospital and each child was registered with a paediatrician so if any problems or concerns arose during their stay then their paediatrician was contacted for advice or to inform them if the child has been taken to North Tees. Out of hours (after 5pm and on a weekend) staff at the hospice spoke to specialist teams or if there were any concerns about the child’s wellbeing then they went straight to North Tees hospital.

We checked whether the service was working within the principles of the MCA. At the time of our visit, there had been no applications to place a restriction on a person’s liberty. We discussed the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards with staff and the management team. They told us that the impact of the Mental Capacity Act and Deprivation of Liberty Safeguards with regard to hospice care were still being addressed.

Children and young people's nutritional and hydration needs were assessed and recorded in care plans. Where needed the advice of the speech and language therapy service was sought so staff had guidance on supporting children and young people with eating and drinking.

The kitchen operated seven days a week and all meals were freshly prepared by the catering team. For children and young people who were able to eat orally, there was flexibility of food choices and if a child or young person wanted something special to eat, staff made every effort to provide this. Mealtimes were family orientated with hospice staff, children and young people [and their families if they wanted] all eating together. Most children and young people who were artificially fed brought in their own nutritional feeds and their usual regime was followed by the care team.

Butterwick House provided child and family centred care. Families were able to stay with their child throughout the duration of their stay. On the first floor of the service there was a comfortable flat with a lounge, two bedrooms and a bathroom. There was also a smaller lounge area with tea and coffee making facilities which overlooked the playroom downstairs in the main area of the hospice. Parents and carers told us this resource was invaluable.

Staff were extremely affectionate and caring in their approach to all children. They regularly provided reassuring touches, gave lots of smiles and spoke to the children in a kind and caring way. Parents and carers told us their children where excited when coming to stay at the service.

Staff respected children’s privacy and dignity. Staff demonstrated a good understanding of the meaning of dignity and how this encompassed all of the care for a child. Children were taken into the bathroom or bedroom area when they required nappy changes or clothing changes.

The design and layout of the service provided young people (13 to 25 years) with privacy in the form of their own space to be together. There was a modern, bright lounge /dining area with comfortable seating, dining table and kitchen area for young people to use.

End of life care took priority when planning resources for the service. A child or young person approaching the end of life, and their family, could stay at Butterwick House for as long as needed. The care team liaised proactively with consultant paediatricians and the palliative care team.

Children and young people who died at the hospice and some, who died elsewhere, could use the ‘Sunflower Suite’ at Butterwick House. This was a special bedroom that operated on a cooling system allowing the child or young person to lie at rest often until the time of their funeral. The Sunflower Suite could be personalised for each child by their family, the care team or both, for example with favourite toys, pictures, music, and soft furnishings. The hospice went the extra mile and loaned out equipment to bereaved parents / carers to enable their children who had died to remain at home until the funeral.

The family support team were committed to providing excellent support to children, young people and their family. The sibling support group provided a fantastic opportunity for brothers and sisters of sick children or young people to meet up make friends and enjoy wonderful trips out and breaks away. The family support team were available to support families and the care team during end of life care. Following the death of a child or young person, the family support team continued to support the family for as long as needed. Bereaved families were able to access group or individual counselling.

Staff at the service supported people to create beautiful memories. There was a memory book in which there were photographs of children and young people and messages and remembrance. Each year in January there was a service held in memory of the children and young people who have died. A representative from the family support unit sent out invites to the family and carers of the deceased child or young adult. Staff at the hospice attended and took the memory book to put on the alter. Staff told us this was a thanks giving and celebration event.

The service had a beautiful chapel which could be used by children, young people, parents and carers. A chaplaincy service was available two hours each day from Monday to Friday. There were also services held in the chapel three times a week. This chapel could be used by people of all faiths.

The registered provider had a system in place for responding to people’s concerns and complaints. Parents and carers did not report any concerns to us.

There were effective systems in place to monitor and improve the quality of the service provided. Staff told us that the service had an open, inclusive and positive culture.

12 May 2013

During a routine inspection

We decided to visit the service on Sunday to gain a wider view of the service provided. This was part of an out of normal hours pilot project being undertaken in the North East region.

At the time of the inspection there were three children using the service. We observed the care that was provided to them, spoke with four staff and four parents. The children using the respite service had complex needs and were unable to verbally communicate their views and experiences to us. We observed children's experiences of their stay and their interactions with each other and the staff. We saw that the interactions between the children and staff were extremely positive. We found throughout the inspection visit, staff interpreting children's needs and children responding appropriately.

We found that children's nursing records contained detailed information about their specific health, care, social and emotional needs. Parents were positive about the care their children had received. They said, "He/she likes coming here, they are really happy and we are over the moon." "Very satisfied with the care and support provided, they loved coming here, it has been brilliant." "They are also at the end of the phone for advice."

We found there were good systems in place for working with other health and care professionals.

We found the premises that people, staff and visitors used were safe and suitable.

We found there was an effective complaints system in place at the home.

4 July 2012

During a routine inspection

We were unable to speak directly with the children who were staying at the hospice. We did however conduct telephone interviews with the parents of three children and also spoke with one young person on the phone.

We were told that all of the parents felt fully consulted and involved in decisions about the care and support provided to their children.

We observed how staff interacted with the children and some of the care and support that was given to them. We saw that staff treated the children with dignity and respect. We saw that all personal care was undertaken in the children's own rooms behind closed doors.

We saw that the staff gave explanation to children about what was happening at all times. We also noted that the staff offered the children simple choices and were able to follow their non verbal responses and gestures to ensure that the child's correct choice was provided.

The young person spoken with said, "I am treated very well, I couldn't ask for better" and "They care for me the way I want." They confirmed they had choices in terms of menus, activities and how to spend their time when they were at the hospice.