We inspected Butterwick Hospice on 3, 9 and 15 March 2016. The first day of the inspection was unannounced which meant that the staff and registered provider did not know we would be visiting. We informed the registered provider of the dates of our other visits.

Butterwick Hospice (inpatient unit) provides specialist palliative and end of life care to a maximum number of 10 people. The hospice is purpose built and within the building there are additional facilities including a day centre. The hospice is situated in the grounds of the University Hospital of North Tees.

The hospice had a registered manager in place. 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.

We saw staffing numbers and skills mix were sufficient to provide a good level of care and keep people safe. Experienced palliative care nurses were employed to provide care and support to people. At the time of the inspection the hospice did not employ its own palliative care consultant, however, another palliative care consultant provided cover for three sessions a week and at other times staff at the hospice had access to the palliative consultant rota for advice. We were told that interviews for a palliative care consultant were taking place. After the inspection we were informed that a palliative care consultant had been appointed who will work across the North Tees and Hartlepool NHS Foundation Trust and Butterwick Hospice. They were due to start in September 2016. Medical cover after 5pm was provided by Northern Doctors which is a GP led service.

There were systems and processes in place to protect people from the risk of harm. Staff told us about different types of abuse and the action they would take if abuse was suspected. Staff were able to describe how they ensured the welfare of vulnerable people was protected through the organisation’s whistle blowing and safeguarding procedures.

The management of medicines was safe and people told us their pain was well managed.

Checks of the building and equipment were completed to make sure it was safe. However, fire drills were not taking place as often as needed. After the inspection the management team contacted the fire authority for advice. They told us they had updated the fire policy in line with the recommendations and fire drills were to be arranged making sure that all staff took part in two fire drills a year.

Risks to people’s safety had been assessed by staff and records of these assessments had been reviewed. Staff were able to describe in detail individual risks for people and action they would take to ensure their safety. However, some risk assessments were insufficiently detailed which meant that staff did not always have the written guidance to keep people safe.

We found that safe recruitment and selection procedures were in place and appropriate checks had been completed before staff began work. This included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

Staff had been trained and had the skills and knowledge to provide support to the people they cared for. Staff understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were working within the law to support people who may lack capacity to make their own decisions.

People told us the food provided was good. Nutritional assessments were undertaken to identify risks associated with poor nutrition and hydration.

Staff understood people’s individual needs and the support they and their family members required. We saw that care was provided with kindness and compassion. People who used the service and a relative

This inspection was carried out by one adult social care inspector. This was a scheduled inspection and the focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led.

At the time of the visit there were 7 people using the service. Our inspector spoke with one visiting relative and one person who used the service. We reviewed records relating to the management of the regulated activity, which included two sets of care records relating to people who used the service and a range of documentation used when assessing and monitoring the quality of service provision.

Is the service safe?

We found that the provider had systems in place to ensure that risks were readily identified and assessed to ensure the safety of people who used the service. Staff had completed safeguarding of vulnerable adults training and this training was up to date with staff able to explain safeguarding processes confidently.

Is the service effective?

We found that visitors were able to visit their relatives and friends at the service freely in line with people’s wishes.

People had their care and treatment needs assessed prior to admission to the service. Relatives or representatives could have involvement with these assessments in line with people’s wishes. Specific plans of care were developed from these assessments ensuring that all care delivered to people was done so following discussion about their identified needs. People were encouraged to express their wishes about how they wanted their care to be delivered.

Is the service caring?

We saw that the service offered a range of holistic care and relaxation techniques to people who used the service. Staff we spoke with spoke with kindness and compassion about the care that they provided to people. Care and support was offered to people who used the service as well as their family members and friends.

Is the service responsive?

Care plans demonstrated that where the needs of people changed this triggered reassessment and planning of care. Where appropriate this included intervention and input from a range of healthcare professionals such as GP’s, nurses, social workers and relatives. We saw that clinical decision making was supplemented by a member of the Trust palliative care team where necessary.

Is the service well led?

The provider had developed quality assurance systems to actively monitor and assess the quality of the service they provide. The documentation we looked at demonstrated that incidents were reported, investigated and analysed for learning outcomes.

The provider had developed mechanisms to capture the feedback and experiences of people who used the service, their relatives or representatives and this was used to take forward actions to improve the service.

What people told us:

We spoke with one relative and two people who used the service. Comments made to us included, "You cannot put a price on this place, they (staff) have been amazing, so very caring, we have asked ourselves so many times where they find them, they are unbelievable." "They have helped us so much, I don't know how we would be coping if we didn't have the care and support from here." "I don't know how they do it, but for a place filled with so much sadness, the staff manage to bring out so much happiness."

On the day that we visited we were unable to speak with many people who used the service as they were resting or receiving holistic care. One person we did speak with told us that they had attended the hospice a number of times for respite care. They told us that they always felt very well informed from the moment they arrived at the service. We spoke about staffing levels and they told us that they had never experienced any issues with staff, they told us, "They are all great, nothing is too much trouble." They said that alarm bells were responded to quickly and said that staff were very attentive.

During the inspection we spent time observing the interactions with staff and patients who used the service. We spoke with two patients who used the service and one relative of a patient. We also spoke with the manager, the clinical lead, one of the physicians and three staff.

We saw that staff were attentive and treated patients with dignity and respect. Staff responded quickly when patients called for help. We saw that staff communicated well with people and explanations of care were given in a way that could be easily understood. One patient said, "The doctors are brilliant, they fully explained things in a way we understood." "Privacy and dignity are well respected and I feel safe and secure.”

We found that patients had nursing and treatment plans in place that were up to date and reflected their medical and nursing needs. We also found that staff worked in collaboration with other health and social care professionals.

We found that patients were cared for in an environment that was homely, clean, well maintained and safe. Although, attention was needed to the hot water temperatures to two wash hand basins.

We found that patient's needs were met by sufficient staff with appropriate skill, knowledge and training. We did, however see that the training and support system for staff was under review.

We saw that there were systems in place should patients want to raise concerns or complaints about the service.

During this inspection, we concentrated on the in-patient unit within the hospice.

We spoke with two people who were in-patients at the hospice. They told us that they were treated with dignity and respect at all times. They also told us that they were fully involved in decisions about their treatment and care plans.

One person told us, "I have been involved in my treatment and care plans at all time, I have been fully consulted and am aware of my discharge plan/arrangements." They also said, "I am always treated with dignity and respect and the staff always introduce themselves."