We inspected Butterwick House on 24 February and 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 House provides care and support for babies, children and young people with life limiting and complex healthcare conditions. The services include specialist care, short breaks and respite care, end of life care, and family support before or after death. There are six beds within the hospice, four of which are for children and there is also a transitional unit, with two single bedrooms, to provide care and support to young adults between the ages of 13 to 25 years. The service is purpose built and situated in the grounds of the University Hospital of North Tees. Within the hospice there is a day room, sensory room and a hydrotherapy pool. There is accommodation for parents / carers on the first floor. At the time of our inspection there were three children who used the service.

Butterwick House 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.

There were systems and processes in place to protect children 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 children was protected through the organisation’s whistle blowing and safeguarding procedures.

There were enough qualified and experienced staff to meet the needs of the children and young people who used the service. Staff received regular training in areas relevant to their practice. Safe recruitment practices were followed when recruiting new staff and new staff had a structured programme of induction training.

Staff awareness and understanding of risk was good. Staff shared with us how they had dealt with children’s needs changing or dealt with a medical emergency. Risks to children’s safety were appropriately assessed, managed and reviewed. Care records contained a number of risk assessments specific to the needs of each child. The risk assessments had been reviewed and updated regularly.

Parents and carers told us they had been fully involved in drawing up the plan of care and making decisions. Children had been assessed and personalised care plans had been developed which were specific to the individual needs of each child. Evidence of likes and dislikes and what was important to the child was recorded within the plan of care.

The service had medicine management policies and procedures. Appropriate systems were in place for the management of medicines so that children received their medicines safely. The Hospice had developed an excellent pain tool that was personalised to each child. Pain charts provided specific details of any changes the child may demonstrate to indicate their level of pain and a variety of pain relief was available for different types and levels of pain. This helped to ensure that children and young people’s pain was managed effectively

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.

The hospice employed two doctors who worked during the day Monday to Friday. They were able to review children if they became unwell or deteriorated during

We decided to visit the service on Sunday to gain a wider view of the service provided. This was part of an out of normal hours pilot project being undertaken in the North East region.

At the time of the inspection there were three children using the service. We observed the care that was provided to them, spoke with four staff and four parents. The children using the respite service had complex needs and were unable to verbally communicate their views and experiences to us. We observed children’s experiences of their stay and their interactions with each other and the staff. We saw that the interactions between the children and staff were extremely positive. We found throughout the inspection visit, staff interpreting children's needs and children responding appropriately.

We found that children's nursing records contained detailed information about their specific health, care, social and emotional needs. Parents were positive about the care their children had received. They said, "He/she likes coming here, they are really happy and we are over the moon." "Very satisfied with the care and support provided, they loved coming here, it has been brilliant." "They are also at the end of the phone for advice."

We found there were good systems in place for working with other health and care professionals.

We found the premises that people, staff and visitors used were safe and suitable.

We found there was an effective complaints system in place at the home.

We were unable to speak directly with the children who were staying at the hospice. We did however conduct telephone interviews with the parents of three children and also spoke with one young person on the phone.

We were told that all of the parents felt fully consulted and involved in decisions about the care and support provided to their children.

We observed how staff interacted with the children and some of the care and support that was given to them. We saw that staff treated the children with dignity and respect. We saw that all personal care was undertaken in the children's own rooms behind closed doors.

We saw that the staff gave explanation to children about what was happening at all times. We also noted that the staff offered the children simple choices and were able to follow their non verbal responses and gestures to ensure that the child's correct choice was provided.

The young person spoken with said, "I am treated very well, I couldn't ask for better" and "They care for me the way I want." They confirmed they had choices in terms of menus, activities and how to spend their time when they were at the hospice.