This inspection took place in 27, 28, 29 July and 1, 2 August 2016 and was announced. When we last visited the hospice on July 2015 we rated the service as Requires improvement. Three recommendations were made regarding improving the culture among staff in the hospice, improving staff awareness of how to escalate concerns and whistleblowing, and the management of medicines.

St Joseph's Hospice, Hackney is registered to provide end of life and palliative care for up to 61 people at the main site and a community palliative care team to approximately 350 people. The on-site service is split into three wards including one respite ward where people stay for a short length of time and are supported to gain skills to better support themselves in the community. The provider also runs a day hospice three days a week on-site which both people living on site and in the community can attend. At the time of inspection there were 20 people using the on-site services.

The hospice 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

While we were carrying out the inspection we received a number of whistleblowing concerns that there was still a bullying culture among staff at the hospice. The registered manager confirmed that while they had made progress on addressing these issues further work needed to be done to improve the culture among some staff groups within the hospice. Staff spoken to directly while we were inspecting the hospice said this was not an issue and felt supported by management.

People were supported to make choices about how their needs were met. People and relatives were involved in decisions about their care. Where people were unable to make decisions about their care their human rights were protected in that best interests decisions were made on their behalf.

People were kept safe. Risks to people were identified and staff took action to reduce those risks. Staff were available and had the necessary training to meet people's needs. Staff responded to people’s needs promptly.

There were systems in place to ensure that people consistently received their medicines safely, and as prescribed.

People were supported effectively with their health needs.

Care was planned and delivered in ways that enhanced people’s safety and welfare according to their needs and preferences. Staff understood people’s preferences, likes and dislikes regarding their care and support needs.

People were provided with a choice of food, and were supported to eat when this was needed. There was a strong emphasis on the importance of good nutrition and hydration and a commitment to providing people with what they wanted to eat and drink in a flexible manner.

People and their relatives told us that the hospice provided excellent care, and that staff were caring, kind and compassionate. People who used the service comments were, “The service is amazing” and “I'm very happy with the care here.” One relative said that staff were, “Exceptionally kind, I have recommended this service to others.” The hospice provided people with multi-professional and person centred care that ensured their physical, emotional, psychological, spiritual and social needs were met. People were treated with dignity and respect. People and relatives told us they consistently received care that met their individual needs.

There was an accessible complaints policy which the registered manager followed when complaints were made to ensure they were investigated and responded to appropriately.

People using the service, relatives and staff said the registered manager was approachable and supportive. Systems were in place to monitor the quality of the service and people an

We spoke with eight members of staff including the chief executive, the director of care, the clinical governance lead and community team manager. We also spoke with a doctor, manager, nurse, and a domestic worker.

We spoke with seven people receiving inpatient care, two people receiving care in the community and three family members. The people we spoke with were very positive about the care being received. One person said, "you get good quality care here and the staff want to really get to know you."

We found that people were asked for their consent before care was delivered. One person told us, "carers will ask me before they wash me." Arrangements were in place for people who lacked the mental capacity to make some decisions themselves.

We found that people received care that met their needs in a clean environment. Staff were observed to follow good hygiene practices and we saw systems in place for the prevention and control of infection. One person using the service said, "the hospice is clean throughout. Someone is always polishing something."

People using the service told us they had no complaints about the service being provided. We saw that complaints were logged and followed up. One person using inpatient services said, "I can complain if I need too, they wouldn't mind. They like to get things right." Another person in the community told us, “I would ring up or email if I wanted to complain." We found that the complaints policy was not written clearly and saw evidence that this was under review.

As part of this inspection we spoke with five people who used the service on the day of our visit and one relative. People told us they had been involved in decisions about their care and confirmed they had received information about the hospice and what services were offered.

People and their relatives gave us very positive comments about the quality of care offered by the hospice. They told us they were well cared for, and that the staff members attended to each person’s needs without delay. One person described the quality of service as “exceptional”. Another person said, “they treat everyone equal, which is nice. They have such love. They understand everything we are going through. I couldn’t wish for better care.”

Care staff were positive about the care that they provided and said they felt “proud” and “privileged” to work for St Joseph's Hospice. One member of staff described the quality of care provided as “superlative” and they told us they “would be happy to be treated at St Joseph's”.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

This inspection took place on 23, 24 and 28 July 2015 and was unannounced. At our last inspection we found that the provider was meeting all of the regulations we checked.

St Joseph’s Hospice provides palliative care to up to 61 people at the main site and a community palliative care service to approximately 385 people living in the boroughs of Newham, Tower Hamlets and Hackney and City. The on-site service is split into three wards including one respite ward where people stay for a short length of time and are supported to gain skills to better support themselves in the community. The provider also runs a day hospice three days a week on-site which both people living on site and in the community may attend.

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.

People were protected from the risk of harm and potential abuse and relatives told us the service was safe. An on-site social work team provides expert advice in safeguarding matters. However, people were not always protected from the risk of systemic poor practice because staff were not always supported to escalate concerns. Despite recent steps taken by the provider, not all staff felt they could raise concerns freely within the service and did not know which outside agencies to contact.

People told us that pain control was effective, however, the storage, administration and prescription of medicines was not always effective. There was good practice around people self-administering medicines that supported their independence.

Although there were clinical vacancies, the provider employed agency and bank staff to cover these vacancies and people told us their needs were met. However, this meant that people did not always receive care from the same members of staff and people and their relatives could not always tell us who was in charge of their care. People were kept safe by a robust recruitment procedure.

People were protected from the risk of harm because effective risk assessments were completed to prevent an occurrence of a specific risk. We noted that assessments were updated as people’s risk level changed.

The control and prevention of infections was well managed and the service was clean and odour-free.

Staff had the knowledge to meet people’s needs. Staff completed an induction and probationary period to equip them for their roles. There was a programme of training available for clinical and non-clinical staff as well as volunteers that was tailored to their roles.

People were supported to live their life in the way they chose. Staff discharged their duty under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People were supported to express themselves and make choices about their care. The provider had arranged for advocates and people were fully involved in care planning, including decisions about what they wanted to happen to them at the end of their life.

People were supported to eat and drink enough with input from the on-site dietitian when required. Staff were aware of the significance food plays in a person’s life as their health deteriorates and dealt with this sensitively. People were supported by a wide range of on-site health care professionals to maintain their optimum health.

Staff developed caring relationships with people using the service and feedback from people was very positive. The provider respected and celebrated people’s diversity, including their sexual orientation, religion and culture. The service strove to promote people’s independence and the respite ward gave people the opportunity to “recharge their batteries” and learn new coping mechanisms.

People received personalised care that was responsive to their needs. There was holistic psychosocial support available to people to increase wellbeing. People were supported to maintain their interests and partake in activities. The provider limited isolation by encouraging visits from loved ones.

People felt their concerns were listened to and the provider worked hard at obtaining feedback from people and their relatives.

Team work and staff morale was not always well managed which posed a risk to the quality of care delivered. There were a number of new initiatives coupled with managerial vacancies and a period of high turnover of staff which meant teams were not always well led. There were pockets of tension amongst staff and not all appraisals had been completed.

Incident and accidents were well managed and improvements were put in place to help prevent them re-occurring.

The service was organised in a way that promoted safe care through effective quality monitoring. The provider was part of networks in the sector to ensure standards at the service met those of the field

We have made two recommendations about the management of controlled drugs and staff culture.