We undertook an unannounced focused inspection of the Prospect Hospice on 20 and 21 February 2018. This inspection was carried out in response to concerns we received related to the service. The concerns centred on the inpatient unit and were focussed on low staffing numbers, out of date staff competencies, increased safety incidents/complaints, low staff morale/wellbeing and allegations of bullying by senior staff.

The inpatient unit at the Prospect Hospice provided care and support for adults living with and dying from advanced and progressive life limiting illnesses. The inpatient unit is a 16-bed inpatient facility which provided respite care, symptom control and care at the very end of life. There were eight individual patient rooms and two four-bedded male and female bays. At the time of our inspection, one of the inpatient rooms had been temporarily converted into a patient gym, which effectively reduced the number of inpatient beds to 15.

There was a registered manager in post, Clare Robinson. 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 inspection team consisted of two inspectors. During the inspection visit, the team:

• Spoke with four patients and four relatives;

• Reviewed 13 patient records;

• Reviewed relevant data, including policies, procedures and meeting minutes;

• Spoke with 23 members of staff; including seven healthcare assistants, nine registered nurses, two doctors, two administration staff, the clinical lead and two head of service leads.

• We also spoke with two directors, the chief executive officer and a trustee of the board.

The Care Quality Commission last inspected the service in November 2016 and rated the provider as good overall.

This inspection took place on 8 and 9 November 2016 and was announced. We gave the registered manager 48 hours’ notice of the inspection because we wanted key people to be available.

Prospect Hospice’s principal activities were to provide timely and responsive care and support for people living with and dying from advanced and progressive life limiting illnesses. The 16-bed in-patient facility provided respite care, symptom control and care at the very end of life. There was a range of day services offering therapeutic and social opportunities for out-patients, including complementary and creative therapies. The Prospect at Home service provided practical support and nursing care up to 24 hours a day, in people’s own home. Their clinical nurse specialist service provided advice, support and information for people at home and in local care homes, plus supported end of care life at the local hospital in Swindon.

A consultant-led medical team provided care across the range of the hospice services. Rehabilitation services included physiotherapy, occupational therapy and dietary advice through a dietician employed by the local hospital. The family support team worked with people and their families and offered bereavement services including welfare advice, drop-in sessions, carer’s cafes and a carers’ course.

There was 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.

People who used the hospice services were safe. All staff received safeguarding adults and children training and would know what to do if there were any concerns about a person’s welfare. Nurses and health care assistants were trained how to use moving and handling equipment safely. All risks to people’s health and welfare were assessed and then well managed, in order to reduce or eliminate, that risk. Safe recruitment procedures were used to ensure that only suitable staff were employed. Medicines were well managed. This meant the service had the appropriate steps in place to protect people from being harmed and to keep them safe.

People were safe because the staffing levels were sufficient to meet their needs. The staffing levels in the in-patient unit and the day hospice were determined by the number of people being looked after and their care and support needs. The Prospect at Home service had a flexible workforce in order to be able to accommodate demand. This part of the service was already recruiting additional staff because of the increase in referrals from people who wanted to be supported to die in their own home.

All staff had a programme of mandatory training to complete. This enabled them to carry out their roles and responsibilities. New staff completed a robust induction training programme and there was a programme of refresher training for the rest of the staff. Staff received palliative and end of life training and had the necessary skills and qualities to provide compassionate and caring support to people and their relatives.

People were supported to make their own choices and decisions where possible. Staff understood the principles of the Mental Capacity Act (2005) and key staff understood the Deprivation of Liberty Safeguards and how this affected their service. Where people lacked the capacity to make decisions because of their condition or were unconscious staff worked within assumed consent but checked with healthcare professionals and relatives before providing care and support.

People were provided with a nutritious meal or food they liked or were able to eat, when they were an in-patient or attending the day hospice. They were provided with the assistance they needed to eat and drink where thi

Prospect Hospice provides dedicated end of life care and specialist palliative care services to people living in the Swindon and North East Wiltshire. At this inspection visit we looked at the in-patient services and day services. These are situated within the hospice.

The hospice was currently undergoing a programme of refurbishment to provide two lodges which families could access during their relatives stay.

People came to the in-patient unit and day services for a variety of reasons. This could be to help them with symptoms that they may have found difficult to manage. This could include sickness, pain or breathlessness. People could also access support with their emotional needs or for their family if required. We spoke with people who received a service from the hospice who told us they were happy with the quality of care and treatment provided. We were told the staff were friendly, respectful and professional.

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Staff we spoke with explained that they would always seek permission before undertaking any tasks. They said they respected people’s right to refuse care if ‘they didn’t feel up to it’ but would always check if they required support later.

We found clinical and non-clinical areas were clean and tidy and free from odours. Patients we spoke with and their relatives said they had no concerns about hygiene standards within the hospice. There was personal protective equipment, such as gloves and aprons available for the use of staff.

Policies and procedures that were followed by staff promoted the safe obtaining, storage administration and disposal of people’s medicines.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Staff we spoke with told us they felt supported and could raise any concerns. They said that managers had an ‘open door’ policy which meant that they could seek guidance and support as needed.

We met with six service users; four visitors and five staff. All of the service users and their visitors were unanimous in their praise of the quality of care they received and the way that staff cared for them.

One person said that their care was "spot on" and that staff were "fantastic". Another person said that "nothing was too much trouble" for the staff.

Service users and their visitors told us that they felt involved in their care and that they were provided with information to enable them to make informed decisions and choices.

We saw that staff from all disciplines took pride in their work and noted that the hospice was clean; welcoming and well maintained. Service users told us that their rooms were cleaned daily. We saw catering staff offering choices to people and we were told that their meals were "beautifully presented" and also of a high quality.

People receiving care told us they felt that staff treated them with respect and kindness and we observed staff talking to people in a friendly and professional way. One of the service users was having some banter with one of the staff and that demonstrated that staff had been able to engage with people and build up a rapport with them.

People told us that they felt safe within the hospice and staff told us that they were able to identify and discuss any concerns they had in relation to safeguarding.

We saw that there were effective systems in place to evaluate care and treatment.

A person who was using the hospice for the first time told us they had been reluctant to go there but that the experience was positive. They told us their ”health had improved due to the confidence they had in the service”. They said it had been a "marvellous experience".

The person told us how the hospice had been instrumental in arranging for specialist furniture to assist them when they returned home and how this had meant they were able to return home for Christmas.

Another person said that the hospice staff had helped resolve issues with their diet and that this had an overall effect on their well being. We saw that there were choices available for lunch and people told us how they had been given other options.

People said they were admitted for pain management and treatment was successful.

We saw the accommodation and how spacious the rooms were. One of the people told us how staff had arranged for their spouse to stay in their room overnight.

People told us about the welfare benefits advice they had been given and how this was very much appreciated.

Both of the people we spoke with told us they would return to the hospice whenever they needed.

A member of staff told us they “liked being able to give so much” they said they “liked contact with people and saw many positives in their work including seeing people achieve their goals”. They also told us they had learnt so much from the dignity and respect shown to people”. Another staff member said they felt supported by their colleagues and the management and was confident that if they needed help they would receive it. A further member of staff told us about completing statutory training and attending various study days recently.

Relatives told us how they intended to “give something back to the hospice” by fundraising or volunteering.

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Prospect Hospice is operated by Prospect Hospice Limited. The service provides community and inpatient hospice care. The inpatient unit is a 16-bed facility which provides respite care, symptom control and care for patients at the very end of life. During this inspection we only inspected the inpatient unit.

We inspected this service, unannounced, on 2 and 3 August. This was a focused inspection to follow up areas of serious concern which we identified following an inspection in February 2018. We issued a warning notice in March 2018 and required the provider to make significant improvement by 14 June 2018. During our inspection on 2 and 3 August we identified additional concerns, which were incidental to the warning notice. We therefore returned to further investigate these concerns on 14 and 15 August 2018. We did not inspect all key questions or all elements of key questions, but focussed on elements of ‘safe’, ‘effective’ and ‘responsive’ and ‘well led’ domains. For this reason, we did not rate this service.

The warning notice served on the provider in March 2018 identified areas for significant improvement:

• Staff did not receive appropriate support, training, supervision, appraisal of professional developments as was necessary to allow them to carry out their roles safely and effectively. There was no training policy which set out staff training requirements and training records were out of date and incomplete. Registered nurses were undertaking clinical tasks for which they did not have up to date clinical competencies.
• There was no formalised process for recording when agency staff were used, or evidence of induction training and we could not be assured that agency staff were suitably skilled.
• There was no formalised system for recording, monitoring or reviewing when patient admissions were delayed or refused due to staffing levels on the inpatient unit.
• The provider failed to seek or act promptly on staff feedback to evaluate and improve services. Seven anonymous complaints had been received from staff about the culture on the inpatient unit and these had not been investigated promptly. The provider had not responded to widely expressed staff concerns about staffing levels and patient safety on the inpatient unit.

During this inspection we found:

• The requirements of the warning notice had not been met. The provider had submitted an improvement plan to us, as asked by CQC, in response to our previous concerns. We judged that they had not made progress at sufficient pace. The improvement plan was not supported by sound evidence and we found some assurances provided by the organisation were factually inaccurate.
• The training policy had been reviewed but it was not complete or fit for purpose for all staff employed by the organisation.
• There remained insufficient oversight of the employment of agency staff and a lack of assurance about their level of competence.
• There was incomplete evidence to support the assurance given to us, that most staff were up to date with clinical competencies and had completed a performance appraisal.
• There were many occasions where nurse staffing on the inpatient unit did not meet planned levels and therefore left the ward potentially unsafe.
• Staffing levels had a negative impact on their ability to provide a service and therefore the number of beds had been reduced. This had in turn had an impact on the local populations choice. This had resulted in six patients being unable to die in their chosen place of death.

Findings incidental to the warning notice were as follows:

• We were concerned about a lack of clinical leadership due to the long-term absence of the director of patient services and the vacant head of patient services position. The inpatient unit was led by the clinical lead, a band 7 nurse, who was working excessive hours and was under significant pressure. The risks associated with her resilience and wellbeing had not been acknowledged or acted upon promptly by the provider.
• Staff understanding of safeguarding processes was poor, so we could not be assured that vulnerable people sufficiently were protected from abuse. Volunteers did not have sufficient training in safeguarding.
• Systems and processes to prevent and protect people from healthcare-associated infection were not effective. We saw unsafe practice where staff did not take necessary precautions to prevent the spread of infection when nursing patients in isolation.
• There was a lack of oversight about patient records. We saw that risk assessments, for example, about nutrition and hydration and pressure area care, were not always completed and updated.
• The service did not manage patient safety incidents well. There was no formal incident investigation process to ensure that learning from incidents was identified and cascaded to staff to improve patient safety.
• Compliance with mandatory training for volunteers was poor. Only one out of 42 volunteers had received safeguarding training and volunteer compliance with manual handling, fire safety and health and safety were mixed.
• Some equipment on the inpatient unit, including equipment required in an emergency, was not properly maintained.
• Although the chief executive and trustees had arranged a series of visits to engage with staff on the inpatient unit, many staff continued to feel unsupported by the senior management team, who they said were not visible leaders.
• The trustees and the chief executive had not given sufficient scrutiny and challenge to the improvement plan.
• Patient safety, quality and sustainability did not receive sufficient coverage in the organisation’s board meetings, where the focus was on reputational risk and risks to income generation.
• Governance systems and processes were not effective, and we were not assured that there was adequate oversight or management of risks to patient safety and patient experience.
• The chief executive took the decision, following our inspection on 2 and 3 August to temporarily reduce the number of beds within the inpatient unit from 12 to six. This closure was not appropriately planned, communicated or implemented and the impact of this closure on patients and the wider healthcare system had not been assessed.

However:

• The provider had processes to provide oversight of when and how agency staff were used.
• The provider had processes to gain oversight of when staffing levels affected admissions to the inpatient unit.
• The management of medicines on the inpatient unit had improved.
• The service was taking steps to improve staff engagement.

Nigel Acheson

Deputy Chief Inspector of Hospitals