This comprehensive inspection took place on 9, 10 and 12 April 2018. The first day was unannounced.

We previously inspected the service on 22 August; 5 and 7 September 2016 and 6 October 2016. At the last inspection the service was rated as ‘requires improvement’ overall and requires improvement in three key questions; safe; effective and well-led. One breach of regulation was found at the last inspection relating to regulation 12, safe care and treatment. This was because people who used the service and others were not always protected against the risks associated with smoking and oxygen use.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe; effective and well-led to at least good.” At this inspection we found the provider had followed their action plan and improvements had been made to ensure people were safe when using oxygen.

St Margaret’s Somerset Hospice is a charity which provides a range of hospice services for adult patients with life-limiting illnesses or advanced progressive conditions and support for their families and carers. They provide a service for people with a range of conditions including cancer. Services include an inpatient unit (IPU) with 12 beds in Yeovil. This means the hospice are able to prioritise beds for those people with more complex symptom control or end of life care needs.

Referral to the hospice was usually prompted by the presence of uncontrollable symptoms, physical, psychological and spiritual or complex end of life care needs or referral to other hospice services. The average length of stay was two weeks with some people being discharged home or to a local care home.

Most people are able to remain in their own home, supported by the community services. There are five community teams supporting people across Somerset, bringing the benefits of hospice care to those who can remain at home. 3800 people are supported across the Somerset community per year with an average of 300 on the community caseload at any one time.

The Sunflower Centre provides support for people who are well enough to live at home but would like the specialist support that St. Margaret’s can offer during the day. The centre at Yeovil is open Monday to Wednesday from 9.30am to 4.30pm and provides emotional, spiritual and social support, symptom control and management, as well as a range of complementary therapies. Practical advice on nutrition, rehabilitation, finance and benefits is also available. Carers are welcome to attend as well.

Other services include 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). Bereavement and counselling service were also offered to people and their relatives or friends.

The service provides specialist advice and input, symptom control and liaison with healthcare professionals. The hospice has a 24 hour out of hour’s advice line and central referral centre (CRC). One person reported , “It has been a great support to me…”

There was a registered manager in post; who was also the governance director for the service. 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.

There is a second St Margaret’s Hospice in Taunton which is rated outstanding. The two services work very closely together. Services are free to people, with St Margaret’s receiving some NHS funding and the remaining funds are achieved through fundraising and charitable donations. The hospices are largely dependent on donations and fund-raising and are assisted by over 1200 volunteers.

The service was clear

St Margaret’s Somerset Hospice is a charity which provides a range of hospice services for adult patients with life-limiting illnesses or advanced progressive conditions and support for their families and carers. This means they provide a service for people with a range of conditions including cancer. Services include an inpatient unit (IPU) with 12 beds in Yeovil. This means the hospice are able to prioritise beds for those people with more complex symptom control or end of life care needs. The majority of people are supported by community services with over 600 people supported across the Somerset community at any given time.

This inspection was carried out on 22 August, 5 and 7 September and 6 October 2016 by one adult social care inspector, with a second inspector on 6 October, a pharmacist inspector, a bank inspector, a specialist advisor 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. This was an unannounced inspection on the first day.

A serious incident occurred at the end of 17 September 2016. A person using the service died as a result of fatal injuries sustained during a fire when the person was smoking whilst using an oxygen cylinder. The service clinical director informed us of the incident on 18 September 2016. We went back to the service on 6 October 2016 to make sure action had been taken by the service to reduce the risk of this happening again. We have rated safe, effective and well-led as requires improvement. This is because we found some failings in how the risk relating to smoking materials and oxygen use was managed and risk assessed. For example, there had been a lack of communication about the person’s smoking history and compliance to safe practice, two risk assessments directly linked to smoking risk had not been completed or reviewed and training did not contain adequate detail to ensure staff were aware of safe practices in this area.

There is a registered manager who is responsible for the service. 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 and associated Regulations about how the service is run. There is a second St Margaret’s Hospice in Taunton and the two services work very closely together. Services are free to people, with St Margaret’s receiving some NHS funding and the remaining funds are achieved through fundraising and charitable donations. The hospices are largely dependent on donations and fund-raising and are assisted by over 1200 volunteers.

The service provided includes specialist advice and input, symptom control and liaison with healthcare professionals. The hospice has a 24 hour out of hours advice line and central referral centre (CRC). Referral to the hospice was usually prompted by the presence of uncontrollable symptoms, physical, psychological and spiritual or complex end of life care needs or referral to other hospice services. The average length of stay was two weeks with some people being discharged home or to a local care home. The service was clear about their local demographic meaning that they had an understanding of the community they served and continuously monitored how best the service could meet their needs. They followed national guidelines such as the National End of Life Care Strategy. The aim of the National End of Life Care Strategy is to enable people to die in the place of their choice and this was the aim of St Margaret’s as much as possible.

The registered manager was open and transparent in their approach. Staff told us they felt valued and inspired by the leadership team and the registered manager to provide a high quality service. Emphasis was placed on continuous improvement of the service.

Comprehensive

We spoke with two people who were receiving treatment and a family member. We were told that they were very happy with the care and treatment that they had received. There were comments such as "It is marvellous here" and "They really understand". We saw that staff protected people's privacy and maintained their dignity.

Care and attention was paid to people's individual needs so that they received effective and appropriate treatment. Staff were trained to understand the specific needs of people requiring end-of-life care. Unexpected events were analysed and used as learning opportunities. The quality of treatment and care was closely monitored and the results of clinical audits were used to improve practice if necessary.

Staff were supported and managed effectively and were encouraged to up-date their skills and knowledge. Professional and organisational skills were regularly assessed and further development encouraged.

At the time of our inspection, there were nine people staying in the in-patient unit at St Margaret's. The Sunflower Day Centre operates Monday to Wednesday and was not in use when we visited.

We spoke with staff, people who used the service and their relatives, looked at records and observed the care and support provided in the in-patient unit.

People told us that they were happy with the way they were cared for and said that they were respected and involved in their care. One person said “the care here is excellent”. A relative of an individual being cared for told us that she felt “completely included" in her relative's care.

We saw that staff were respectful, polite and caring and received good training. There was a relaxed and professional atmosphere throughout the service.

Staff told us they felt well supported in their roles and were able to access support from their managers and other staff when required.

Care plans reflected each person’s needs and preferences. It was clear that the service did everything it could to ensure people who were at the end of their life had their care and treatment needs met.