The inspection took place on 27 and 28 September and 6 October 2016 and was unannounced. We previously inspected the service in December 2013 and found no breaches of regulations in the standards we looked at.

The inspection team included a lead inspector, pharmacist inspector, a nurse specialist 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 provider is The Dorothy House Foundation Limited, a registered charity. It employs 430 staff and over 1200 volunteers. The service covers an area of 700 square miles and accepts people from Bath and North East Somerset (BANES), and parts of Wiltshire and Somerset.

Dorothy House Hospice is located in Winsley, just outside Bath and has just celebrated 40 years of providing care for local people. It is registered for 10 beds and provides specialist palliative and end of life care for adults, with life limiting illness or complex symptom management needs. At Dorothy House six people were being cared for at the inpatient unit when we visited. End of life care is for people who are considered to be in the last year of life. The service used referral criteria to identify people who would benefit from admission, and the average length of stay was 11 days. The inpatient unit provided 142 people with a compassionate and dignified death in the last year. People could access the service in a variety of ways, via referrals from local GP's and consultants in the NHS, or from people or family members/carers (with the person’s permission).

The inpatient unit had eight single rooms and one double room, with ensuite bathroom facilities. A restaurant was available and there were lots of quiet spaces for people and families to use. A wide variety of art and craft work, pictures and paintings were on display, which provided a calm and tranquil ambience throughout. A purpose built extension included a stunning chapel/spiritual space with lovely views over the beautifully landscaped grounds. There were ample car parking spaces, including disabled access spaces.

A hospice at home night sitting service provided care for people receiving end of life care at home and for two nights a week, so carers could have some rest. An Enhanced Discharge Service provided home care over 24 hours so people, who wanted end of life care at home, could be discharged from hospital at short notice.

A 24 hour advice line which offered people, relatives, hospital and community based professionals support and advice on palliative and end of life care. Day care services were offered at Winsley, which included social groups, activities, creative art therapy, complementary therapies and carer’s support groups. Two outreach centres, one at Trowbridge and the other at Peasedown St John provided a relaxed and informal drop-in and signposting service for anyone affected by a life-limiting illness, including family members and carers. The centres hosted group workshops and community groups, and had treatment rooms. Dorothy House nurse specialists were based at the outreach centres and visited people at home to support and provide pain management and symptom control and worked closely with local GP’s and community nurses.

Volunteer roles included administrative support to inpatient and day patient units, bereavement, complementary therapies, volunteer drivers, gardeners and retail services. They also offered befriending services to people and provided respite for carers.

The service had a registered manager who was the medical director. 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, relatives and healthcare professi

We met with people who were attending a rehabilitation programme, and people attending day and outpatient services, as well as a person whose relative was in the inpatient unit and another with previous experience of that unit. We received no negative comments about people’s experience of the service.

People recalled to us their initial contacts with Dorothy House. They felt very included in how services were shaped around them, because they were given time to explain their individual circumstances and experiences to specialist staff who understood them. One person said “it has been like that from the very first phone call and they are always spot on”. One person was impressed by how swiftly Dorothy House were able to offer them an assessment, after their GP had made a referral. Another person said “I can’t believe it’s all free”.

People we spoke to were all agreed about the approachability and helpfulness of staff and volunteers. A person said doctors and nurses at the hospice gave all the time needed for talking with them in private: “staff talk to you, not at you. You feel that you are listened to”. They experienced care provided as always focused on maintaining people’s dignity. Another person spoke in very similar terms: “Nothing was ever too much.

”People saw it as a strength of the service that their individual needs could be matched by availability of the right people at the right time. This included volunteers who provided services such as transport, escorting and support to the functioning of groups.

People felt fully included in the planning of their care and support. One person said “they accept if you change your mind or just don’t feel up to joining in, they can understand the realities of being like this.”

People told us consistently that they were provided with information that was easy to understand, at appropriate times. They were aware of how to raise any concern and were confident in the organisation to respond constructively to any comment.

People considered the hospice environment at Winsley to be of a very high standard. A visiting relative described the inpatient unit and wider surroundings as “lovely”. They had encountered no restrictions on personalising the room occupied by their relative. They described all areas they had seen as “spotless”. People at the outreach centre were impressed that the service had been able to find a facility that was so well suited to their needs.

We spoke with two patients receiving respite care in the in-patient unit and the relatives of two people using the Hospice at Home service.

We were informed the staff gained consent before they delivered care and treatment. One patient told us “everything has been upfront and there was no pressure, the treatment I was offered I wanted.” The other patient said “they explain things as they go along.” A relative reported “they discuss what they need to do and ask ‘how do you want to do it. There are no problems if XX refused, the implication of decisions would be explained.”

Patients knew the reasons for their admission to the in-patient unit. The two patients we spoke with told us the purpose of their referral to the in-patient unit and about the expected length of their stay. They told us about the personal support they received and how their care was monitored by the staff. The care action plans we looked at were brief and needed to be more detailed to follow good practice guidance.

The relatives of two people who used the Hospice at Home service told us staff recorded the care delivered to their family member. The relatives told us hospice staff used the district nurses’ documentation to record the care and treatment they delivered. Relatives told us they had read the reports and one relative told us “yes I read the file at times but rarely, I have so much confidence. Where it needs information is passed on.” The other relative we spoke with said “yes I have read the file and reflects what has been done.” The member of staff in day to day charge of the Hospice at Home service told us care plans were to be developed in the near future.

Safe systems for medicine administration were in place. One person told us they had been asked if they wanted to self-administer their medicine. We saw where patients were considered safe to administer their medicines a competency assessment to ensure this had taken place. Another patient told us they had not been asked and told us “It does seem daft because I was doing it before I arrived and I will be doing them when I go home.” Where patients had capacity but were not considered safe to self-administer their medicines the justification of this decision was not documented.

People told the staff were good and skilled to meet their needs. One patient told us “jolly good bunch of staff very kind and helpful.” Another patient told us “staff are brilliant and skilled.”

We saw the staff attended a combination of compulsory and essential training was provided to meet the values of the organisation and to meet the needs of the service users. For example health and safety, safeguarding adults equalities and diversity training.