St Julia’s Hospice is operated by Cornwall Hospice Care Limited. The hospice provided care and treatment within nine inpatient beds. Cornwall Hospice Care Limited also provided a service at Mount Edgecumbe hospice which was located within St Austell.

The hospice provides care and treatment for patients with a life-limiting condition aged 18 years or over.

We inspected this service using our focussed inspection methodology. This unannounced inspection took place on 18 July 2018. We focussed on the safe and well-led domains following concerns raised to us. The concerns were in respect of staffing levels, staff training, low staff morale and allegations of bullying.

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.

There was a registered manager in post, Dawn Tame-Battell. 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.

During the inspection visit, the team spoke with 12 members of staff, including registered nurses, health care assistants, consultants, occupational therapist, administration staff, hospitality staff, community engagement nurse, head of care, the clinical lead, the chief executive officer, the medical director and the registered manager. We also spoke with four patients to seek their views of the service provided. We reviewed five sets of patient records and relevant documents, including policies, procedures and meeting minutes.

The Care Quality Commission last inspected the service in May 2016 and rated the provider as outstanding overall. We have not re-rated the service at this inspection.

We regulate hospice services but we do not currently have a legal duty to rate them when they are inspected as a focussed inspection. We highlight good practice and issues service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

• Staff were familiar with safeguarding processes which ensured patient safety and knew how to safeguard adults from abuse.
• Systems prevented and protected patients from healthcare-associated infections. The hospice environment was clean and hygienic in appearance.
• Systems to manage the environment and equipment kept patients safe.
• Patients were monitored for deterioration in their condition.
• Eligibility criteria ensured patients were suitable to be admitted to the hospice.
• Sufficient staff were available to provide care and treatment for patients at the time of the inspection.
• Patient records were well maintained and stored securely.
• External professionals had access to a 24-hour support and advice line from the hospice. Patients and their representatives were advised to telephone the hospice directly following their discharge. This enabled a system of support to patients following their discharge.

• The leadership structure within the organisation was clear and staff were aware who they reported to.
• Staff were familiar with the organisation’s strategy, vision and values and were provided with the opportunity to be involved in the development of these.
• The executive team had taken action to address low morale and allegations of bullying through the provision of meetings and reintroduction of the staff.

We found areas of practice that require improvement:

• The system for monitoring staff training did not ensure all mandatory and additional training had been completed. Safeguarding children training was not provided and not all staff had completed safeguarding adults training. This included volunteers, clinical staff, board members and trustees. Training had not been provided to all staff who were required to investigate incidents.
• There had been an increased turnover of staff at the hospice and this had resulted in staff not being able to be released to complete mandatory training.
• The system for checking resuscitation equipment was not fully compliant with the organisation’s policies as weekly checks were not consistently undertaken.
• Staffing levels were not assessed in relation to patient dependency. There was no tool for assessing how many staff were needed in relation to patient dependency levels. Filling shifts at short notice was challenging for the ward and impacted on the work being undertaken.
• The management of prescription pads (FP 10) did not ensure an audit trail of prescriptions used.

While staff reported incidents, learning was not currently shared between the provider’s two hospices and there was no agreed standard used to assess the seriousness of an incident. Medicine errors were investigated and appropriate action taken, but this learning was not shared across the organisation.

• Staff were not familiar with relevant national guidance and recommendations to ensure they were providing up to date care and treatment.
• The board of executives and trustees were not always accessible to staff. The organisation was aware of this and had taken measures to address this.

Following this inspection, we told the provider it must take some actions to comply with the regulations and it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals (South)

The inspection took place on 10 and 11 May 2016 and was unannounced. We previously inspected the service on 14 December 2013 and found no breaches of regulations in the standards we looked at.

The provider, Cornwall Hospice Care Limited is a registered charity committed to providing specialist palliative and end of life care for people, over the age of 18 years, irrespective of diagnosis. The provider runs two hospices in Cornwall, Mount Edgcumbe in St Austell and St Julia’s in Hayle. St Julia’s Hospice, is registered for 10 beds, and provides specialist care for people with life limiting illnesses. It is purpose built and located adjacent to St Michael's Hospital in Hayle. It provides inpatient care for people needing help with complex symptom management, pain control and end of life care. People are referred to the hospice by health professionals, in liaison with their GP or hospital consultant. At the time of the inspection, eight people were being cared for at the hospice.

Services included physiotherapy and lymphoedema clinics. (Lymphoedema is a chronic long term condition that causes swelling in body tissues. It can be a primary or secondary condition). The service had built a dedicated outpatient suite so they could provide more day services nearer to people's home, but this facility had not yet been commissioned for use.

The hospice had a team of about 50 volunteers, who worked in various roles such as greeting people and visitors at reception, chatting to people, serving lunch and making drinks and snacks. They also helped with laundry and flower arranging.

The service had a new registered manager, the Director of Patient Services who registered in December 2015. They managed both hospices, supported by a unit manager at each location. 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 received outstanding care from highly motivated staff who developed exceptionally positive caring and compassionate relationships with them. The service had an open and positive culture that placed people at the heart of everything they did. Staff treated people with sensitivity, dignity and respect. People’s emotional and spiritual needs were met by staff who were knowledgeable and confident to care for and comfort them. Families and those that mattered to the person were supported to spend quality time with them.

People received excellent care, based on best practice from experienced staff with the knowledge, skills and competencies to support their complex health needs. For example, the hospice used national best practice tools to assess people’s symptoms each day. This helped staff address each person’s physical and emotional needs which improved their quality of life. People received their medicines on time and in a safe way, and were kept peaceful, comfortable and pain free.

Hospice staff were committed to promoting excellent end of life care for people in Cornwall, by providing a programme of education and training for a wide range of health and social professionals working in hospitals, care and nursing homes and in the community. This meant more people received high quality end of life care from skilled staff in their preferred location and avoided hospital admissions. The hospice used link roles to lead and actively champion staff to provide people with evidenced based, best practice care. For example, for Motor Neurone Disease (MND), foot care and falls prevention.

The service was committed to excellence through research to identify ways to further improve their service. The hospice was awarded a prize by the Royal Society of Medicine in the research category section in 2015, for pioneering work in spinal pain relief. T

We spoke with people who were receiving care and treatment at St Julia’s Hospice at the time of our inspection visit who told us their experience had been positive. We found people were treated as individuals and received person centred care and support. Comments made by people we spoke with included; “I have complete trust in the staff", and “I am looked after very well, I have no complaints and nothing is too much trouble for any of them [the staff] ).

We also spoke with people who were visiting friends and / or family who all provided positive feedback. We were told; “I felt at peace within an hour of us arriving here”, “the staff feel like part of an extended family and they look after all of our family and make sure we are OK” and “nothing is too much trouble, X tells me they feel safe here and that means I don’t worry when I go home”.

We found the nutritional needs of people were met and we observed and people told us that there was a wide choice of food provided, which was of a high quality.

Medicines were managed safely and staff ensured people received their medication as prescribed by the medical staff.

Staff were supported in their roles by the provision of appropriate training. Staff told us they were respected by the organisation and felt valued and supported.

Records were maintained appropriately and people who used the service were informed about how to access their personal records.

We met with people who were inpatients or relatives at the hospice. People we spoke with were very happy with the services provided by St Julia's Hospice.

One person told us "There is such good atmosphere when you walk in the door." Another person told us "It is so tranquil and calm. I receive five star care. "

They all said the environment was pleasant, restful and clean.

Everybody said they were fully consulted about their care and treatment. People told us continuity of care was very good and they felt supported. One person said:" It is a wonderful facility and communication is excellent."

People spoke highly of the meals provided and told us they were always given choices. They said that meals were well presented and appetising.

There were sufficient staff to meet the needs of the people who required care and treatment.

People said they knew how to raise any concerns and were given the opportunity to provide feedback on the level of service received. Everyone we spoke with told us the staff were very helpful, kind and knowledgeable about their needs. One person said:" they are so thoughtful".

We spoke to one person using the service and one relative. Other people were not well enough to talk to us on the day of our visit. People told us they were given plenty of information and kept up to date on the support and choices available. They told us that staff respected their privacy, dignity and personal choices and preferences.

We were told the care provided was excellent and that staff were professional, kind and extremely caring; nothing was ever too much trouble. Comments included, “The care is definitely to a high standard”, “It is amazing care compared to other services”, “As soon as my relative has pain the staff are there to help” and “The doctors are amazing and always make five minutes to talk to us”.

People told us that there were enough staff to care for them. Comments about the staff included, “I trust all the staff, they provide amazing care”, “The staff are really lovely” and “We are very lucky, the staff work well together like a family and they make you very welcome”.

People using the service told us they could air their views at any time to any of the staff or the management team. They told us about the counselling service and how helpful this was to them.