This unannounced inspection took place on 17, 18, 19, 20, 23 & 24 October 2017. The first day of the inspection was unannounced, which means the staff at Derian House hospice did not know we were coming. We last Inspected Derian House on 29 July and 2 August 2016. At the inspection in 2016 we rated the Hospice as ‘Good’ overall and ‘Good’ for the domains of Safe, Effective, Responsive and Well-led. We rated the Caring domain as ‘Outstanding’. We made two recommendations following the inspection.

One recommendation was regarding processes around the disposal of drugs and the service level agreement in place for pharmacy provision. The other recommendation was ensuring that an appropriate consent policy was in place that met the guidance of the GMC and RCN and complied with the Gillick competency and that this was followed in practice. The Gillick competency is a term originating in England and is used in medical law to decide whether a child is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. At this inspection we found that our recommendation for the issues raised around medicines management had been met however a valid and appropriate consent policy was not in place and we found that consent was not always gained appropriately. We found this to be a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 in relation to regulation 11, Need for consent.

Derian House Children's Hospice provides palliative and end of life care for children and young people who have life limiting or life threatening conditions. The hospice is set in its own ground and provides accommodation for nine children in the main house and four young people in the lodge. There are four self-contained flats which are used by families. The hospice also provides a service for children and young adults in their own home. This is known as Derian at Home.

Bereavement support for parents and siblings is provided before, during and after end of life care and this support is not time limited. The hospice covers a wide geographical area including; Chorley, Preston, South Ribble, South Lakes, Fylde Coast, Wigan, Bolton, Rochdale, Blackburn, Burnley and Salford. This incorporates working with ten different Local Authorities to provide 24/7 End of Life support. Care consists of approximately 80% respite and 20% end of life care. Attendance at the hospice does vary due to the types of service offered. For the 12 month period prior to our inspection occupancy was averaging at just over 53%.

Derian House had a registered manager. 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 were able to have a conversation with one young person during the two days we were at Derian House and also had discussions and contact with relatives. Via conversations and through observations we had no concerns with the safety of people using the service. We received positive comments from families with regards to the safety of their loved ones when they were being cared for by Derian House staff.

Fire safety issues had been highlighted as a concern prior to us undertaking our inspection via an anonymous whistle-blower. Lancashire Fire and Rescue Service (LFRS) had visited the hospice before our inspection and they had fed back to us their recommendations. We saw evidence from LFRS and the service to show these recommendations had been undertaken and that fire safety was of paramount importance to the service. Steps had been taken to address the issues highlighted to us prior to our inspection.

Suitable recruitment processes were in place and followed ensuring that people employed as staff or recruited as volunteers,

This inspection was announced and took place on 29 July and 2 August 2016. The service was last inspected in May 2014 and was rated overall as ‘Good’ using the pilot wave inspection methodology in place at the time.

Derian House Children’s Hospice provides palliative and end of life care for children and young people who have life limiting or life threatening conditions. The manager has been registered with the Care Quality Commission since September 2013. The hospice is set in its own ground and provides accommodation for nine children in the main house and four young people in the lodge. There are four self-contained flats which are used by families. The hospice also provides a service for children and young adults in their own home. This is known as Derian at home. Bereavement support for parents and siblings is provided before, during and after end of life care and this support is not time limited. We were given an example of one family who had recently come to the hospice for support ten years after their child died. Support has been given to this family.

The hospice covers a wide geographical area including; Chorley, Preston, South Ribble, South Lakes, Fylde Coast, Wigan, Bolton, Rochdale, Blackburn, Burnley and Salford. This incorporates working with ten different Local Authorities to provide 24/7 End of Life support. Support consists of approximately 80% respite and 20% end of life care. During the 12 month period prior to our inspection the hospice had supported 40 children and young people through to the end of their life.

The hospice employed 75 staff within the care team at the time of our inspection, in addition to this there were over 200 volunteers working within the hospice and externally, for example within Derian House shops or as fundraisers.

The one young person we were able to speak with told us they felt safe at the hospice. Families we spoke with also told us they felt safe leaving their children in the care of staff at the hospice. This included families whose children had very complex needs. Some of the families we spoke with became very emotional when speaking about the care and support given by Derian House as it was the only service they entrusted to look care for their children outside of their immediate family.

The hospice had a safeguarding and whistleblowing policy in place which was being followed in practice. This meant that staff had clear guidance to enable them to recognise different types of abuse and who to report it to if it was suspected. Staff were appropriately trained to recognise and respond to potential safeguarding incidents.

We looked at the systems in place at the hospice for medicines management. There was good evidence to show that medicines were audited effectively and that staff were trained and competency checked for administering medicines. However we found some issues including the current service level agreement for the provision of a pharmacy service not being an agreement between two separate legal entities, that an authorised witness to oversee the disposal of controlled drugs should be appointed and disposal records should include the two signatures of the staff involved in the disposal process. We have made a recommendation regarding these issues.

We looked at arrangements at the hospice in relation to Infection Prevention Control (IPC). An audit by an external company had taken place shortly before our inspection which had identified some minor issues. The issues had already been placed into an action plan and the hospice was working towards addressing them. The issues were mainly with reference to recording and administration. We found no issues with IPC during our inspection.

We found the service to be appropriately staffed with the correct skill mix of nursing, care and domestic staff to cater for the complex needs of the children and young people using the service. We also looked at recruitment processes and found the service had recruitment policies

Derian House Children’s Hospice provides palliative and end of life care for children and young people who have life limiting or life threatening conditions. The manager has been registered with the Care Quality Commission since September 2013. The hospice is set in its own ground and provides accommodation for nine children in the main house and four young people in the lodge. There are four self-contained flats which are used by families. There were two children and two young people using the service at the time of our visit. The hospice also provides a service for children and young adults in their own home. This is known as Derian at home. Bereavement support for parents and siblings is provided before, during and after end of life care.

We spoke with five parents. All told us they were happy with the service and they felt their child was safe and well cared for. We also spoke to a young person who used the service and they confirmed they enjoyed their stays in the lodge. Appropriate procedures and staff training were in place to ensure children and young people were protected from harm.

Staff had an understanding of the Mental Capacity Act 2005 and the Deprivation of Liberty safeguards. (The Act protects the rights of people who are not able to make a decision for themselves). The registered manager explained she planned to carry out staff training and implement capacity assessments. This will ensure these issues are given more consideration as part of routine care practice.

Before children and young people used the service a full assessment was carried out of their needs. This ensured they could be cared for appropriately in the hospice. Each child and young person had a care plan which was supported by a series of risk assessments. Whilst all care plans and risk assessments were up to date, we found the plans and assessments could be further developed by incorporating more information about children and young people’s wishes and preferences.

During our visit we observed staff to be attentive and sensitive to the needs of children and young people staying in the hospice. Children and young people’s dignity was maintained at all times. We found staff were motivated and worked well as a team. Staff had access to ongoing training and supervision. This meant they were well supported in their role. All staff spoken with told us they really enjoyed their work.

Children and young people received compassionate and supportive care when they were nearing the end of their life. Parents and appropriate professionals were involved in a plan of care, which was reviewed on a daily basis. This ensured staff were aware of their wishes and they could respond quickly to any changing need.

All parents and staff spoken with felt the hospice was well led and organised. The registered manager had a clear action plan and vision of how she wanted to improve the service. She had also developed ways of learning from any mistakes and was open about changes which were being made. This meant the registered manager had arrangements in place to develop and improve the hospice.

People's diversity, values and human rights were respected. We observed staff supporting people in ways which maintained people's dignity.

We spoke to two parents following our inspection who told us: “Wonderful attitude, the support they give.” “It’s amazing, can't put into words the special and unique experience. Nothings too much trouble, it was the norm. All the things you thought weren’t possible, were possible and effortless.”

We also spoke with two young people to ask them about their experience of Derian House, they told us: “There is loads of stuff to do, but it is up to us.” “I enjoy staying with other people like me; I get on well with staff as well.”

Children's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

We saw that where other professionals were involved in the person's care, information about their involvement was documented with a summary of their latest contact.

People who use 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.

Staff received appropriate professional development. The training lead provided us with an up to date record of induction, staff training, including staff who that had accessed National diplomas.

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Children, young people and their families were satisfied with the care they received in the hospice, one person told us, “I really like it here, the staff are very friendly” and a family member commented, “I feel so comfortable here and I am made very welcome”.

Children and young people had an individual care plan which was reviewed each time they visited the hospice. During our visit, we saw there was positive, sensitive and kind staff interaction with the children and young people.

Staff had awareness of the safeguarding procedures relating to children and vulnerable adults and confirmed they had received appropriate training.

We found shortfalls with the systems used to manage medication and not all records were fully completed. Audits had been carried out; however, there was no evidence action had been taken to address the shortfalls.

Staff were provided with appropriate training opportunities and new staff undertook a detailed programme of induction. All young people and family members made complimentary comments about the staff team.

We found shortfalls in the monitoring of the quality of the service. There was no evidence incidents had been investigated. We also saw no evidence of appropriate action being taken to address the issues and circumstances reported in the incident reports. This meant children and young people were not fully protected from the risks of inappropriate and unsafe care.

Families and young people using the service told us they were very satisfied with the care and treatment provided. One family member said, “They are so caring and they care for the whole family” and another person commented “The staff are very happy, so it’s a happy place”. Young people visiting the Lodge said the hospice was a “great” place to stay and the staff were “very understanding and kind”. During our visit, staff interacted positively with the children and young people and we saw that they explained their actions before carrying out any care tasks and involved the children and young people in conversations wherever possible.

Families and young people were fully involved in decisions about their care and their needs were fully discussed and reviewed each time a child or young person was admitted into the service. We saw evidence of this involvement in the care planning process. Therapeutic activities were arranged throughout the day in line with the children and young people’s interests, age and condition. Two young adults told us how much they had enjoyed a recent trip to the pub.

The staff team comprised of a wide range of professionally qualified staff including nursing, medical, physiotherapy, play and bereavement support staff. Staff told us they were well supported in their roles and there were continual opportunities for training and development. We saw evidence of the how the staff were supported and trained in the files we looked at during the visit.