This announced inspection took place on 28 November and 7 December 2016. We last inspected the service in January 2015 and at that inspection we found the service was not meeting all the regulations that we inspected. We found one breach of regulation 17, good governance in relation to records and assessing and monitoring the quality of service provision.

Following our inspection in January 2015, the provider sent us an action plan to show us how they would address our concerns. We undertook this inspection to check the provider had followed their plan and to confirm they now met legal requirements.

Castleside House provides a range of services, which consist of hospice support within people’s own homes, a lymphoedema clinic to people with life limiting conditions, bereavement services, holistic therapy drop in sessions and drop in support services for people who need a quiet space to reflect or receive additional comfort or assistance. Lymphoedema is a long-term (chronic) condition that causes swelling in the body's tissues. As the majority of this service is free, a charity shop (although not part of the registered element of the service) had recently been opened in Berwick which sold donated items to raise funding to further support the service. We also noted that the service was supported by a large number of local volunteers who were recognised by the trustees and the staff team as invaluable to the service as a whole. At the time of the inspection there were five people registered for the hospice at home service.

The service had 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.

The registered manager had implemented a number of changes within the service since we last inspected and had taken into account the improvements that were required. There were further improvements to be made within good governance, however not sufficient to warrant a continued breach of this regulation.

People and their relatives that we spoke with were very positive about the service and felt safe when in the care of the staffing team. One person said, “They [staff] use the hoist and they are really gentle when putting the sling round me and they make sure I am completely safe. I have total confidence in them.”

Records showed that staff had received training on safeguarding vulnerable adults and the Mental Capacity Act 2005. Staff were able to tell us what they would do if they had any concerns and talked about when people were not able to make decisions for themselves.

Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA) and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’. We found the provider was complying with their legal requirements.

People and their relatives generally managed their own medicines, however, when staff had cause to support people they followed safe working practices.

Risk had been assessed and we saw evidence in people’s records that areas where risk could be reduced this had been taken to protect the people whom staff supported. No accidents or incidents were recorded but staff knew what to do and how to deal with them if something should occur of this nature.

There were enough staff and volunteers working at the service to support the people who used it. People reported that staff had never let them down and were always present when they should have been to provide them with care. Volunteers were used extensively throughout the hospice service, for example in the bereavement services. The various ele

We spoke with two people about the care and support they received from this service. People told us they were happy with the service, and with staff. People said, "I am kept fully involved at all times" and "I couldnt' fault the support I get." A relative's comments included, "Excellent service, it helped knowing they were there when we needed them and when we did need them they were marvellous."

We viewed care records for two people. We found that care needs were assessed, planned and delivered in a way which met people's individual needs. We found that people had knowledge of, and had consented to, their care plans. People told us, "Everything is explained and staff listen to what I need" and "I have improved so much with the treatment I receive."

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.

We found that staff were trained and supported in their roles. People told us, "Staff are very knowledgeable and make sure you get the most up to date care."

People's personal records were accurate, fit for purpose and held securely. Other records were kept in an appropriate form.

People told us they were happy with the care, treatment and support they received at Castleside House.

People we spoke with said, "I am really happy", "I am absolutely delighted with the care I receive" and "It is just lovely, relaxing and peaceful."

People said they received medical and specialist attention when they needed it and everything was clearly explained. People told us, "X knows exactly what they are doing, they explain everything as many times as you want" and "I feel really supported and in control, everything is just made really clear."

People we spoke with said, "I cannot say enough about the place, it as haven of peace and so restful", "Staff attitudes are so positive" and "I have marvelous results from excellent treatment."

People told us the premises were clean, comfortable and warm. They said, "I like the place, it is calm" and "What a great place to go and relax, it is so peaceful."

The inspection was carried out over two days. We visited the service’s head office on 28 and 29 January 2015.

The last inspection was carried out 17 January 2014. We found they were meeting all the regulations we inspected.

Castleside House provides a range of services, such as a hospice at home service, lymphoedema management, bereavement support and therapeutic drop in sessions. The hospice at home and lymphoedema management services were regulated by CQC. The other services were not regulated by CQC because they were out of scope of the regulations.

The lymphoedema management service was accessed by people with a palliative and non-palliative diagnosis. The British Lymphology Society (BLS) defines lymphoedema as, “The term used to describe swelling that can occur anywhere in the body, but most commonly affects the limbs.”

Care and treatment was carried out in people’s homes by registered nurses and care workers. Bereavement support, lymphoedema management and therapeutic drop in sessions were provided at the service’s two centres in Alnwick and Berwick upon Tweed.

There were three people using the hospice at home service and 85 people were accessing the lymphoedema management service at the time of our inspection.

A registered manager was 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 and associated Regulations about how the service is run.

All people and relatives were extremely positive about Castleside House. One relative said, “Anyone facing end of life care should have access to care from Castleside House. They make the passing easier for both the patient and their families.” Another said, “I just don’t think that I would be able to look after her at home without it, it’s an incredible service.”

There were safeguarding policies and procedures in place. Staff knew what action to take if abuse was suspected.

The registered manager informed us that they did not manage people’s medicines, although they were currently looking at providing this area of care.

Staff informed us that they assessed risks to people and themselves such as moving and handling. However, these risks were not documented. This omission meant that that while risks had been identified there was insufficient information recorded as to how the risks would be managed.

Staff told us that training was available. They said they had also completed further training in their main jobs with other providers since Castleside House was a second job for most staff. Records of staff training however, were not always available.

People and relatives informed us that staff were caring and treated people with dignity and respect. Comments included, “Thank God for the service. For the last 48 hours she had the best possible care” and “It was only for two days, but I felt like I’d known them forever. They were like old friends.”

Staff were knowledgeable about people’s needs. People, relatives and health and social care professionals told us that they considered that Castleside House provided a responsive service which met the needs of people and their families. Comments included, “They are outstanding, excellent, amazing – 100% outstanding”; and, “I can’t put into words how marvellous they were.”

People and relatives told us that they thought the service was well run and provided an excellent service. Comments included, “If I had to give it marks out of 100, I would give it 1000 out of a 100, that’s what I would give them”; “Everything was first class all the way” and “It’s outstanding from my point of view.”

We found however, that although people and health and social care professionals were complimentary about the service, an effective system to regularly assess and monitor the quality of service was not fully in place. Formal audits or checks of certain aspects of the service were not carried out in areas such as care plans and training.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These related to records and assessing and monitoring the quality of service provision. This corresponded with one breach of the new Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach related to good governance. You can see what action we told the provider to take at the back of the full version of the report.