An unannounced inspection took place at St Joseph’s Hospice on 11 & 12 December 2017.

At the previous inspection of 4, 5 & 7 July 2017 the provider was found to be inadequate and the service was placed in ‘special measures’ by CQC. We found breaches of regulations in all key questions we inspect (Is the service safe, effective, caring responsive and well led?).

The purpose of 'special measures' is to:

Ensure that providers found to be providing inadequate care significantly improve.

Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in 'special measures' are inspected within six months of the publication of the inspection report.

At this inspection we found improvements had been made. This meant the service was no longer rated inadequate and could be removed from 'special measures' by the Care Quality Commission (CQC).

Following the inspection in July 2017 we issued an urgent statutory notice requiring the provider not to admit any further people to St Joseph’s Hospice. The urgent statutory notice also required the provider to carry out a review of the quality assurance systems that were in place; the introduction of medicines management audits; the introduction of clinical compliance checks; appraisal of the individual competencies of all persons employed and also the directors at St Joseph’s Hospice and to issue a policy that is in accordance with the requirements of the Mental Capacity Act 2005 (MCA) in relation to the use of covert medication and administration of covert medication.

In light of the improvements we found at the December 2017 inspection we have now lifted this statutory notice which prevented people being admitted to the service. The provider had also complied with the other conditions of the urgent statutory notice.

We have revised the rating for the hospice following our inspection; however the service cannot be rated as ‘good’. To improve the rating to ‘good’ would require a longer track record of consistent good practice.

St Joseph’s Hospice provides care and support to terminally ill people and their families within the Liverpool and Sefton areas.The hospice provides care for people with progressive, degenerative conditions and for people with a brain injury. The hospice also provides end of life care and support to families of terminally ill patients. The hospice has accommodation and facilities for 29 people. At the time of our inspection 17 people were receiving a service at the hospice.

People in a hospice receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a registered manager. 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 of the Health and Social Care Act 2008 and associated regulations about how the service is run.

At the inspection in July 2017 we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as medicines were not administered safely. We found concerns around the way some medicines were administered and recorded which placed people at high risk of harm. There were issues in the way some medicines were stored.

At this inspection reviewed the management of medicines. The hospice was working closely with external health professionals to improve the medicines arrangements in the hospice. We saw that people now received their medicin

St Joseph’s Hospice provides care and support to terminally ill people and their families within the Liverpool and Sefton areas. The hospice has accommodation and facilities for 29 people. It provides care for people with progressive, degenerative conditions and for people with brain injury and terminal illness. The hospice also provides end of life care and support to families of terminally ill patients. There were 25 people accommodated at the time of the inspection.

This was an announced inspection which took place over three days on 4, 5 & 7 July 2017.

The service had a registered manager. 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 of the Health and Social Care Act 2008 and associated regulations about how the service is run.

The service last received a full comprehensive inspection in July 2016 and at that time we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations; we rated the service as ‘requires improvement’. A Warning Notice was served in relation to Regulation 12, of the Health and Social Care Act 2008, Regulated Activities Regulations 2014, by way of unsafe medicine management.

We completed a ‘focused’ follow up inspection in October 2016 and we found breaches relating to care and treatment, medicines, safeguarding and acting on complaints had been met; the service remained in breach of regulations regarding good governance because they failed to ensure the proper arrangements were in place to assess, monitor and improve the quality and safety of services and maintain accurate complete records of the treatment provided to people. The hospice retained an overall rating of ‘requires improvement’.

We returned in July 2017 to carry out this comprehensive inspection and found the service had not improved and there were further breaches of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014. The service had been unable to demonstrate sustained compliance with standards of quality and safety and there was a failure to sustain improvement, by way of safe medicine management at the hospice. In turn, we found a failure of governance and oversight by the registered persons. We found breaches of regulations with respect to; Regulation 12 Safe care and treatment (medicines management), Regulation 11 Consent to care and treatment, Regulation 17 Good governance and Regulation 18 Staffing (with respect to support and competency of staff).

We found medicines were not administered safely. We found failings with safe and secure storage of medicines, lack of safe administration including missed dosages of medicines and lack of consultation and safe protocols when people refused medicines, lack of guidelines for specialist administration of medicines and lack of adequate records for the administration of prescribed thickeners (used for thickening fluids for people with swallowing difficulties). We found there was a failure to assess the risks to people’s health and wellbeing.

We found that when people were unable to consent, the principles of the Mental Capacity Act 2005 were not always followed.

We found the nursing staff was not receiving periodic supervision and staff employed were not appraised to ensure acceptable levels of competence were maintained or they demonstrated the necessary competences and skill to carry out specialised care safely.

Some of the systems for auditing the quality and safety of the service were not being carried out consistently and had not identified the failings we found. Overall governance did not provide adequate monitoring of standards in the hospice and we found repeated breaches of regulations. There was a failure to maintain accurate and complete records of care and treatment for people. We also found that care documents were not alway

We carried out an unannounced comprehensive inspection of this service in July 2016 when five breaches of legal requirements were found. We found a breach in regulation regarding the safe management of medicines and we took enforcement action in respect of this breach. We served the provider with a statutory Warning Notice regarding medicines not being managed safely. We found a breach of regulation as the service had not followed agreed protocols for reporting an allegation of abuse to the local authority and to us the CQC (Care Quality Commission); poor care planning and monitoring of care; a lack of an effective system and process for dealing with complaints; assuring the safe management of the service. We asked the provider to take action to address these concerns.

After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection on 25 & 26 October 2016 to check that they had they now met legal requirements. This report only covers our findings in relation to the specific area / breach of regulation. This covered three questions we normally asked of services; whether they are 'safe', ‘responsive’ and ‘well led.’ The question 'was the service effective' and ‘was the service caring' were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Joseph’s Hospice on our website at www.cqc.org.uk.

There has been a change of manager since the last inspection. A new manager was in post and they have applied for the position of registered manager for St Joseph’s Hospice. 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.

St Joseph's Hospice is run by St Joseph's Hospice Association which is a registered charity and company which also runs a number of hospices overseas.

The hospice has accommodation and facilities for 29 people across Liverpool, Sefton and West Lancashire. There are three units; St Francis House with eight ground floor rooms and 10 single rooms on the first floor; San Jose building has 11 ground floors single rooms.

St Joseph's Hospice provides care and support people with progressive, degenerative conditions and for people with brain injury and terminal illness. The hospice also provides end of life care and support to families of terminally ill patients. The service is supported by a local consultant in palliative medicine, other consultants who specialise in psychiatry and elderly medicine and local GPs with an interest in palliative care.

At our last inspection in July 2016 we had found the home in breach of regulations relating to the safe administration of medicines. This was because medicines were poorly managed and medicine practices at that time put people at risk. At this inspection we found people were protected against the risks associated with medicines. We saw improvements around gaps in recording of controlled drugs (medicines that require extra checks and special storage arrangements because of their potential for misuse); medicines that required refrigeration; the practice for staff to ‘share’ medicines belonging to one person with another had ceased; clear directions for the application of creams and appropriate records for the use of thickening agents for drinks to aid swallowing were in place. This breach had been met.

At the last inspection we had concerns that the service was not following agreed local authority protocols for reporting allegations of abuse with the local authority or with us the CQC. At this inspection our findings showed staff were aware of the safeguarding protocol to follow and on-going tra

This announced inspection of St Joseph’s Hospice took place on 26 & 27 July 2016.

St Joseph’s Hospice provides care and support people with progressive, degenerative conditions and for people with brain injury and terminal illness. The hospice also provides end of life care and support to families of terminally ill patients. St Joseph’s is run by St Joseph’s Association which is a registered charity and company which also runs a number of hospices overseas.

The hospice has accommodation and facilities for 29 people across Liverpool, Sefton and West Lancashire. There are three units; St Francis House with eight ground floor rooms and 10 single rooms on the first floor; San Jose building has 11 ground floors single rooms.

The service is supported by a local consultant in palliative medicine, other consultants who specialise in psychiatry and elderly medicine and local GPs with an interest in palliative care. The hospice is partially funded by the NHS and through fund raising.

People were admitted to the hospice from their own home, hospital, or by a local clinical commission group (CCG). CCGs are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area.

There was a registered manager in post. ‘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’.

St Joseph’s has a board of Trustees, a number of committees, including a clinical governance committee, a chief executive officer (CEO), clinical director (registered manager) and director of income generation.

During our inspection we found a number of breaches in our regulations.

We looked to see if there were systems in place to ensure the proper and safe handling of medicines. We found medicines were poorly managed and current practices put people at risk.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. We found on inspection however that the safeguarding process had not always been followed to protect people from abuse. Incidents that affected people’s welfare had also not always been reported to us in accordance with our regulations. This showed a lack of monitoring around risk.

People’s care planning lacked sufficient detail to help ensure their care needs were being met. Care monitoring records such as diet, fluid and positioning charts were not always completed which meant that an accurate evaluation of care needs could not be made.

The service did not operate an effective system for handling, recording and responding to complaints.

Although systems were in place there appeared to be a fragmented approach in respect of identifying and controlling risks and concerns, reporting on lessons learnt and actions taken. This meant the governance was not robust to assure a safe effective service.

People were supported by sufficient numbers of staff to provide care and support in accordance with individual need. We saw that people received care from a multi-disciplinary staff team which included nurses who were trained in end of life care, care staff, volunteers for complimentary therapies, pastoral staff and a family support officer. People told us the staffing numbers were good and that they received support when they requested and needed it.

Staff sought advice and support from health professionals to optimise people’s health and provide continuity of care. Medical cover was provided at the hospice Monday to Friday and staff had access to the routine ‘out of hours’ GP service and telemedicine via a local clinical commissioning group (CCG).

Risk assessments were in place to ensure people’s health and safety. The risk assessme

At our last inspection in April 2013 we found the provider did not have appropriate arrangements in place to support staff through regular formal supervision and training. Action was needed for this essential standard. Following the inspection we received an action plan from the provider [owner] and this addressed the issues raised. On this inspection we looked to see if these standards had been maintained.

We looked at staff training supervision and appraisal. We also spoke with a person who received care and support from the staff which helped to evidence their competency and their approach to care. Their comments included, ‘’Staff take care of me well." Staff interviewed told us they supported each other and had access to staff training. For example, moving and handling, infection control, end of life care, dementia care and safeguarding adults. The training provided helped to ensure the staff had the skills, knowledge and expertise to care for people.

Staff informed us they received supervision on a 'one to one' basis to discuss issues and support further learning and development. We were shown dates when the supervision meetings had been held. We also saw a system of staff appraisal to help support professional development and performance.

Following our inspection we invited relatives to share with us their views and experience of the care received. One relative of a person living there said “It is like a second home for both my family member who lives at the home and I. The care is excellent, my family member was always well presented with clean pyjamas and bedding everyday.”

We spoke to another family member of a person living at the home. They told us “I can’t praise the staff enough; I can’t find words to explain the care they give to my relative.” They told us that they felt their relative was well looked after and that the staff at the home were welcoming to all family members and kept them fully informed of any changes or concerns. One relative told us “It is a homely environment for all of us to spend quality time together.”

Throughout our visit we observed staff being attentive to the needs of the people in the home and their tone and manner was respectful and caring; showing dignity and respecting privacy as they delivered the care.

Staff told us they had a handover period which was lead by the nursing staff. Staff said they had regular meetings and they felt they were knowledgeable about the people who lived at the home and were aware of their care needs. The staff meetings were split into the teams they worked within; we reviewed the minutes of a meeting which took place 4th July 2012 as part of our evidence for staff support.

St Joseph’s Hospice is operated by St Joseph’s Hospice Association.

The hospice cares for over 200 patients and their families each year from across Liverpool, Knowsley and Sefton. St Joseph’s Hospice is registered as a charity but receives 40% of its funding through the NHS.

St Joseph’s Hospice has 29 beds across three units. St Francis House has two units. St Francis Upper has 10 rooms on the first floor and St Francis Lower has eight on the ground floor. San Jose has 11 rooms, all on the ground floor. We inspected adults’ services on all units.

We carried out an unannounced visit to the hospice from 7 to 9 August 2018. We inspected this service 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 questions.

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 main service provided by this hospital was hospices for adults.

Services we rate

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

• The service had sustained improvements seen at the previous inspection in December 2017.

• We saw the service had continued to improve how medicines were given to patients and recorded. The non-medical nurse prescriber had their competencies regularly checked and reviewed annually by a medical supervisor.

• Care records showed patients’ care plans reflected their needs, preferences and choices. Staff completed care monitoring charts and recorded patients’ level of pain, fluid intake and output and how much food they got through two hourly ‘comfort rounds’.

• Since the last inspection the service had introduced the ‘safety thermometer’ to monitor patient outcomes and service performance on pressure ulcer care and falls.

• Staff received a good level of support through regular supervision and annual appraisal. Staff told us they received good support from the clinical director and the inpatient unit manager.

• We saw that consent was sought from patients and their advocates around key decisions and recorded in care plans. Staff followed the principles of the Mental Capacity Act 2005 and made appropriate applications under Deprivation of Liberty Safeguards when patients lacked capacity to consent to care and treatment.

• The service continued to store confidential information securely. Staff respected confidentiality and updated records and discussed care in the nurses’ station where they could not be overheard or overlooked.

• Systems and processes for assuring standards at the hospice were embedded. Trustees and senior managers showed awareness of issues and had acted to mitigate against these. Improvements and challenges were effectively monitored through finance and clinical governance sub-committees.

• The service ensured there were sufficient number of staff on duty to care for patients. We saw they were actively recruiting qualified nurses. The management had closed one unit to any admissions until enough qualified nurses were recruited to provide safe care and treatment.

• We saw the service had introduced structured handovers of care of patients between shifts which were thorough and attended daily by a senior manager.

• The service had developed links with other providers and hospices in the local area to share learning and good practice. There were many examples of positive engagement with the local community.

However, we also found areas of practice that require improvement:

• Though the service had improved how medicines were given and recorded staff still had to handwrite onto to medicines charts and a second member of staff did not always check and sign these records. There was no information for health care assistants on how often to apply topical preparations and creams.

• We saw that used and full oxygen cylinders were not stored in line with the manufacturer’s best practice guidelines on storage of medical gases.

• Not all communal areas that were used by patients had call bells so patients could not call for assistance if they fell or became unwell when alone in these areas.

• Volunteers who directly supported patients did not receive safeguarding for adults and children training.

• Staff did not use a recognised tool to assess the level of pain experienced by patients who could not speak.

• The service did not provide facilities for patients from different religious or cultural backgrounds.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (Hospitals North)