St Cuthbert's Hospice

Our rating of this location went down. We rated it as requires improvement because:

• The service did not ensure all staff completed mandatory training in accordance with the provider’s policy and target compliance rate.
• Not all staff received appropriate levels of safeguarding training in accordance with Intercollegiate guidance (2019).
• The provider’s safeguarding policy did not include guidance for female genital mutilation (FGM).
• The service did not always control infection risk well.
• The service did not have clear admission and exclusion criteria to ensure only appropriate patients were admitted to the hospice.
• Not all staff had training in key skills, for example, competency training and refresher training to manage patients with complex needs including but not limited to tracheostomy, nasogastric tubes (NGT) and percutaneous endoscopic gastrostomy (PEG) tubes. Policies for staff regarding management of patients with these medical devices were not relevant and specific to the services provided.
• The provider did not evidence that all staff completed a full induction programme, in accordance with the provider’s policy.
• Managers did not always assess and monitor the effectiveness, quality, and safety of the service in accordance with the provider’s policy.
• The provider did not have service level agreements for some services provided by the local NHS trust.
• Leaders did not always have oversight of risks. For example, they did not ensure all identified risks affecting the service in line with local policy were escalated to the risk register and mitigated as far as possible. These included but were not limited to infection prevention and control (IPC), management of the cold room, staff training compliance and competencies and disclosure and barring service checks for volunteer staff.
• The provider did not ensure its statement of purpose was up to date and accurately reflected management and regulated services provided.

However:

• The service had enough staff to care for patients and keep them safe from harm and abuse.
• Staff assessed most clinical risks to patients, acted on them and kept good care records.
• They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it.
• Managers mostly monitored the effectiveness, quality, and safety of the service in accordance with the provider’s policy.
• 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.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
• Staff understood the service’s vision and values, and how to apply them in their work. 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 the community to plan and manage services and all staff were committed to improving services continually.