This inspection took place 26 and 27 October 2016 and was announced.

Fair Havens is a ten bedded hospice for adults providing palliative medicine and nursing care on an inpatients and day care basis. Other services are co-ordinated from the establishment that include: Macmillan nurses, bereavement support, chaplaincy and home care services.

There was a registered manager in post. At the time of our inspection they were on long term leave and the service was being managed by a manager who was in the process of submitting their registration to CQC. They were supported by the Chief Executive Officer (CEO) and management team.

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.

People felt safe. Staff had received training to enable them to recognise signs and symptoms of abuse and how to report them. People had risk assessments in place to enable them to be as safe and independent as they could be.

Effective recruitment processes were in place and followed by the service to ensure staff employed were suitable to work with people who used the service. There were sufficient staff, with the correct skill mix, on duty to support people with their care and treatment needs.

Medicines were managed safely. The processes in place ensured that the administration and handling of medicines, including controlled medicines, was suitable for the people who used the service.

Staff and volunteers received a comprehensive induction process and on-going training. They were well supported by the manager and the management team. Staff had attended a variety of training to ensure they were able to provide care based on current practice when providing care and treatment for people.

Staff gained consent before supporting people or providing care and treatment. People were supported to make decisions about all aspects of their life; this was underpinned by the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff were knowledgeable of this guidance and correct processes were in place to protect people.

People were able to make choices about the food and drink they had, and staff gave support when required.

Staff provided care and support in a caring and meaningful way. They knew the people who used the service well. People and relatives, where appropriate, were involved in the planning of their care and support. People’s privacy and dignity was maintained at all times.

A complaints procedure was in place and accessible to all. People knew how to complain. Effective quality monitoring systems were in place. A variety of audits were carried out and used to drive improvement.

People with whom we spoke said “continuity of care was good” and “the staff are so friendly they would help you with anything”. People told us they felt safe and cared for at Fair Havens hospice. Carers were complimentary about the support given to them and family members by staff and counsellors, and that they enjoyed the carers days provided in the day unit on a regular basis.

We saw that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. People experienced care, treatment and support that met their needs and protected their rights. Staff were supported appropriately and there were monitoring systems in place to regularly assess and monitor the quality of service that people receive.

Only two people were well enough to speak with us at the time of our visit. They said that the staff are ‘wonderful’ and that they are given good information about the service and treatments. One person said they felt their care had been managed very well whilst they had been at Fair Havens and that it had been ‘joined up’ with other agencies involved in their care. The other person with whom we spoke said that the care at night time was particularly good. Both felt that there were enough staff on duty to cope with the work they had to do and that they did not have to wait very long for assistance if they pressed their call bell.

We spoke with three people using the service and three people’s relatives. We were told that the care was good, that staff were very caring and responsive to any needs they had. We were told that if there were any queries or problems then people or their relatives felt able to raise them with staff. Comments included, “I cannot praise them [staff] enough.” “I have a lovely room.” “I’ve got no complaints.” “It’s a lovely home.” “I can’t fault the treatment I’ve had here.” “It’s very clean and very hygienic.”

We considered if the service was safe and a specialist advisor accompanied our inspector at this inspection. We spoke with ten staff including nursing, cleaning, managers and maintenance staff. We found that whilst the premises were not purpose built, arrangements had been made to make people using the service comfortable during their stay. Staff told us that they were looking to develop a purpose built hospice locally.

During our visit we identified issues regarding fire and health and safety and we contacted other regulators for these areas for their consideration as to if they should take any regulatory action. We found that some infection control systems needed reviewing to ensure that people were not at risk. We found that the provider had systems in place for the monitoring and maintenance of equipment. We found that the provider had systems in place to ensure the service was well led and effective and to review reported issues and identify actions.