Unannounced Inspection Report: Independent Healthcare
St Columba’s Hospice | St Columba’s Hospice Ltd | Edinburgh 21–22 October 13
Healthcare Improvement Scotland is committed to equality. We have assessed the inspection function for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Officer on 0141 225 6999 or email contactpublicinvolvement.his@nhs.net
© Healthcare Improvement Scotland 2013
First published December 2013
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Independent Healthcare Inspection Report (St Columba’s Hospice: St Columba’s Hospice Ltd): 21–22 October 13
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Contents
1
Background
4
2
Summary of inspection
6
3
Progress since last inspection
9
4
Key findings
11
Appendix 1 – Requirements and recommendations
22
Appendix 2 – Inspection process
24
Appendix 3 – Inspection process flow chart
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Appendix 4 – Details of inspection
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Appendix 5 – The National Care Standards
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1
Background
Healthcare Improvement Scotland was established in April 2011. Part of our role is to undertake inspections of independent healthcare services across Scotland. Our inspectors check independent healthcare services regularly to make sure that they are complying with necessary standards and regulations. They do this by carrying out assessments and inspections. These inspections may be announced or unannounced. We use an open and transparent method for inspecting, using standardised processes and documentation. Please see Appendix 2 for details of our inspection process. Our work reflects the following legislation and guidelines: •
the National Health Service (Scotland) Act 1978 (hereafter referred to as ‘the Act’)
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the Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011, and
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the National Care Standards, which set out standards of care that people should be able to expect to receive from a care service.
This means that when we inspect an independent healthcare service, we make sure it meets the requirements of the Act. We also take into account the National Care Standards that apply to the service. If we find a service is not meeting the requirements of the Act, we have powers to require the service to improve. Please see Appendix 5 for more information about the National Care Standards. Our philosophy We will: •
work to ensure that patients are at the heart of everything we do
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measure compliance against expected standards and regulations
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be firm, but fair
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have members of the public on some of our inspection teams
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ensure our staff are trained properly
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tell people what we are doing and explain why we are doing it
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treat everyone fairly and equally, respecting their rights
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take action when there are serious risks to people using the independent healthcare services we inspect
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if necessary, inspect services again after we have reported the findings
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publish reports on our inspection findings which will be available to the public in a range of formats on request, and
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listen to your concerns and use them to inform our inspections.
Complaints If you would like to raise a concern or complaint about an independent healthcare service, we suggest you contact the service directly in the first instance. If you remain unhappy following their response, please contact us. However, you can complain directly to us about an independent healthcare service without first contacting the service.
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Our contact details are: Healthcare Improvement Scotland Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone:
0131 623 4300
Email:
hcis.chiefinspector@nhs.net
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Summary of inspection
St Columba’s Hospice Ltd, trading as St Columba’s Hospice, is registered with Healthcare Improvement Scotland as an independent hospital. The hospice provides specialist palliative care for up to 30 inpatients over the age of 16. Care is provided using a multidisciplinary team of healthcare staff. This includes nurses, doctors, pharmacists, physiotherapists, occupational therapists, social workers, members of the clergy and counsellors. A day hospice service is run by experienced palliative care nurses where up to 15 people can attend from home 3 days every week. This service provides people with holistic care and support with their illness. Complementary therapies are also provided 2 days every week on an appointment basis. The hospice also provides a community palliative care service where specialist nurses visit people at home to offer support and advice about their illness. A team of trained volunteer staff support St Columba’s Hospice in various activities such as fundraising, gardening, driving and serving in the hospice dining and coffee room. At the time of the inspection, the hospice was in temporary accommodation at Kirklands House, Gogarbank, Edinburgh. The hospice is planning to move back to a new purpose-built site at its previous location of Boswell Road, Edinburgh, in May 2014. We carried out an unannounced inspection to St Columba’s Hospice on Monday 21 and Tuesday 22 October 2013. The inspection team was made up of two inspectors. One inspector led the team and was responsible for guiding them and making sure the team members agreed the findings reached. See Appendix 4 for membership of the inspection team visiting St Columba’s Hospice. We assessed the service against four quality themes related to the National Care Standards. Based on the findings of this inspection, this service has been awarded the following grades (more information on grading can be found on page 24): Quality Theme 0 – Quality of information: 5 - Very good Quality Theme 1 – Quality of care and support: 5 - Very good Quality Theme 3 – Quality of staffing: 5 - Very good Quality Theme 4 – Quality of management and leadership: 5 - Very good During the inspection visit, we gathered information from a variety of sources. This included: •
information leaflets
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comment cards and questionnaires from people who use the service
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methods of recording feedback from people who use the service
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minutes of meetings
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healthcare records
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staff records
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risk assessments for falls and the recording of falls, incidents and accidents
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induction, supervision and appraisal systems Independent Healthcare Inspection Report (St Columba’s Hospice: St Columba’s Hospice Ltd): 21–22 October 13
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•
registration checks for all staff groups
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staff training plans and training records, and
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online policies, including adult support and protection and the non-restraint policy.
We had discussions with a variety of people, including: •
registered nurses
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clinical support workers
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domestic staff
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doctors
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a physiotherapist
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a councillor
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an audit facilitator
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the director of clinical services
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the hospice manager
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people who use the service, and
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relatives.
Overall, we found evidence at St Columba’s Hospice that: •
the service provided a very high standard of care, treatment and support to the people who use the service and relatives visiting the service
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the service was well known and linked with other local resources within the NHS as well as other charitable providers
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the service has a dedicated and caring team of staff who are focused on providing care and comfort to all people who use the service and relatives, and
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the service continued to offer a high quality service which was appreciated and commended by people who use the service and relatives.
We did find that improvements are required in some areas, which include: •
the need to develop the methods of getting feedback from people who use the service and relatives
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being more explicit about actions and improvements taken in response to the views expressed by people who use the service and relatives, and
•
ensuring appropriate risk assessments, policies and procedures are put in place for staff to follow about the use of bedrails for people who cannot consent and may injure themselves.
This inspection resulted in one requirement and five recommendations. The requirement is linked to compliance with the Act and regulations or orders made under the Act, or a condition of registration. See Appendix 1 for a full list of the requirement and recommendations.
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St Columba’s Hospice Ltd, the provider, must address the requirement and the necessary improvements made, as a matter of priority. We would like to thank all staff at St Columba’s Hospice for their assistance during the inspection.
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Progress since last inspection
What the provider has done to meet the requirements we made at our last inspection on 31 January 2012 Requirement The provider must ensure that all people’s healthcare records are fully completed in all aspects of their health, safety and welfare needs. This is to ensure that each person who uses the service has an up-to-date healthcare record which confirms the date, time and outcome of all consultations, examinations, assessments and treatments carried out and signed by the healthcare professional making the entry. Action taken We saw that management had focused on checking that staff had completed healthcare records. We found entries were clear, with the names of the healthcare professional making the entry and the time written. Ongoing attention will be needed to ensure that this continues. This requirement is met.
Requirement The provider must ensure that each person’s health assessment includes clear information in relation to the risk of falling. This is to ensure that an appropriate systems, processes and procedures are in place for all aspects of a person’s health, safety and welfare. Action taken We saw a new falls risk assessment has been introduced. Staff complete this on admission and at regular intervals. A falls report is completed if someone has a fall and this is used to check that appropriate actions were taken and signed off by the director of clinical services. An analysis of falls has been made and this shows that improvements have been made. This requirement is met.
What the service has done to meet the recommendations we made at our last inspection on 31 January 2012 Recommendations The provider should review its system for updating information leaflets. This is to ensure that all written information offered to people who use the service is up to date. The provider should review its system for producing information leaflets. This is to consider the involvement of people who use the service in the development of written information about the service. Action taken We found a new information group has been set up which is responsible for reviewing information leaflets. These were being reviewed in light of the planned move to the new-build hospice. All of the current leaflets had been reviewed in the timescales set. This was an ongoing process. The above recommendations are met.
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Recommendation The provider should review its system for updating policies and implement a formal review process so that staff have a consistent and reliable source of up-to-date reference information. Action taken We saw all policies were subject to regular review. However, some of these reviews may have taken place without referring to current best practice, for example the restraint policy. We have made a requirement in this report that this policy is reviewed and developed along with policies for the use of bed rails. This recommendation has been partially met (see Quality Statement 1.5, Requirement 1).
What the service has done to meet the requirement made following a complaint investigation in May 2013 Requirement The provider was required to: •
implement an adult support and protection policy
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ensure that all staff are trained in their responsibilities under the Adult Support and Protection (Scotland) Act 2007, and
•
introduce a system of induction in Adult Support and Protection procedures for new staff.
Action taken We saw the service had implemented a new adult support and protection policy. We asked staff if they were aware of this policy and found that they had been asked to “read and sign” to show that they were aware of this change. Staff knew where to find policies and showed us where these were kept. The policy was detailed and guided staff in reporting procedures to the local authority. Senior staff had been given training and were cascading this to staff within their departments. New staff were able to tell us that it was mentioned in the staff handbook and that there were further training sessions planned. This requirement is met.
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Key findings
Quality Theme 0 Quality Statement 0.1 We ensure that service users and carers participate in assessing and improving the quality of information provided by the service. Grade awarded for this statement: 5 - Very good We found that the service’s performance was very good in relation to the areas we examined for this Quality Statement. We found that people who use the service and relatives were routinely involved in service development and evaluation. St Columba’s Hospice provides a range of leaflets for people who use the service and relatives covering a range of subjects. For example, palliative care, infection control and occupational therapy. The leaflets are well written and provide clear information for people who use the service and their relatives. The hospice’s information group had recently reviewed the leaflets which included welcoming comments and a description of the services provided. This meant that an opportunity for feedback from people who use the service and relatives was offered and encouraged. Paper copies of leaflets are available in the reception area of the hospice. Comment forms, seeking views on the content of the leaflets and their usefulness, had also been placed next to the display area. This meant that the request for comments was easy to see by all people visiting the hospice. A collection box for completed forms was also provided so that comments could be made discreetly. Area for improvement The information group, which was responsible for reviewing the information provided to people who use the service and relatives, currently consists of a range of staff members with no input from people who use the service or relatives. St Columba’s Hospice should consider how the group could include input from people who use the service or relatives when developing any future user information or guidance (see recommendation a in Quality Statement 1.1).
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No requirements. No recommendations.
Quality Statement 0.2 We provide full information on the services offered to current and prospective service users. The information will help service users to decide whether our service can meet their individual needs. Grade awarded for this statement: 5 - Very good We found that the service’s performance was very good in relation to the areas we examined for this Quality Statement. We found that there were major strengths and the identified areas for improvement represent actions to be made on an already very good performance.
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St Columba’s Hospice provided a wide range of leaflets, including a general information booklet for people who use the service and relatives. Leaflets were also available on specific services available, including: •
the day hospice
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community palliative care team
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bereavement service, and
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chaplaincy and spiritual care.
These were available in paper format and on the hospice website. The general information leaflet was also available in audio format and large print. This meant that the information was available in a variety of formats to suit people with hearing or visual impairment. The information included the aims of the service and described what services were available to potential service users. For example, inpatient care, day care and palliative care. We asked people who use the service if they had enough information to help them to decide if they wanted to use the hospice services. All said that they had. They also commented on the very helpful verbal information that staff had given them. We asked if leaflets had been made available in local hospitals and other community services. This was confirmed by staff and some people who use the service. This meant that the information was available to help when needed. Contact details on where to find additional information were also provided. We saw that a 24hour advice telephone line was provided for people who use the service, relatives and professional staff. The service gave leaflets to people who use the service and relatives at their initial assessment. These were also available to primary care staff to help people decide about their future care needs. There was a helpful prompt kept in the patient care records that was ticked when information was provided, so that this could be seen by other staff involved. Areas for improvement The notice board had information about how to make a comment or complaint about the service. However, it could be made clearer that complaints can be made directly to Healthcare Improvement Scotland without the use of the internal procedure if wished (see recommendation made in Quality Statement 4.4). The Information group should continue to review the range of information provided for people who use the service and relatives.
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No requirements. No recommendations.
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Quality Theme 1 Quality Statement 1.1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Grade awarded for this statement: 5 - Very good We found that the service’s performance was very good in relation to the areas we examined for this Quality Statement. We found that people who use the service and relatives were routinely involved in service development and evaluation. We found that clear evidence that the views of people who use the service and relatives were being sought both formally and informally. Questionnaires for people who use the service were used to obtain people’s views, including questions about: •
the environment
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the admission process
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the quality of information provided
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clinical care
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whether they were consulted about their care needs, and
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the services provided.
The clinical services director analysed the results and discussed them at the clinical risk group meetings. This included discussions on areas for improvement. There was a system for ensuring that these comments were listened to and used to make improvements. We were able to evidence, from the minutes of the meetings, that the hospice was proactive in implementing any actions identified. We were also able to evidence, from patient care records, that people who use the service were fully involved in the assessment and planning of their care needs. We noted that this was an ongoing process, with changes being made following any feedback received. The people we spoke with stated that they felt fully involved in any decisions made about their care needs. They were aware of who their named nurse was and had been given information about their role upon admission. More information about the named nurse was also available on ward notice boards. Staff spoken with were able to demonstrate that they knew the needs and wishes of the people who use the service and their families and were aware of what was important to them. All the information leaflets provided by the hospice included welcoming comments and a description of the services provided. Leaflets inviting comments are available in the entrance hall to the service, beside a collection box for responses. A copy of the complaints process for the service was displayed on the notice board in the entrance hall (see recommendation e in Quality Statement 4.4). The service also uses questionnaires to get feedback from those who use the bereavement counselling service. These are sent out after the service has completed the counselling process. We looked at a selection of completed questionnaires. These highlighted very positive comments about the service they had received.
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The hospice was based in temporary accommodation whilst a new hospice is being built. We saw evidence that there had been extensive consultation with people who use the service, visitors and staff with regard to the development. An update on progress was provided on the hospice noticeboard, on their website and in the newsletter which the hospice staff produce three times a year. Areas for improvement We asked what actions the service had taken as a result of the feedback given by people who use the service and relatives. However, we found that this was hard to evidence. The service had gathered feedback in a variety of formats, but had not used these results to produce a clear ‘you said, we did’ type of response that could be seen publically. There was no overarching participation strategy for people who use the service and their relatives. Although there were a number of opportunities to give comments and feedback, the service had not formalised a single policy to explain how it would collect and respond to comments and feedback. The service should consider developing a formal participation strategy to demonstrate how it involves people who use the service and relatives in all aspects of the service provided. This would provide a clear baseline for any future developments (see recommendation a). The results of surveys and any comments received were analysed and feedback was given to staff. We spoke with managers about how extending this, to include people who use the service, would be beneficial to show how views expressed have influenced changes.
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No requirements.
Recommendation a
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We recommend that St Columba’s Hospice should develop a more formal participation strategy, for involving people who use the service and relatives in all aspects of the service. This could include a format for ensuring that feedback obtained is responded to more openly to show what improvements or changes have been made.
Quality Statement 1.5 We ensure that our service keeps an accurate up-to-date, comprehensive care record of all aspects of service user care, support and treatment, which reflects individual service user healthcare needs. These records show how we meet service users' physical, psychological, emotional, social and spiritual needs at all times. Grade awarded for this statement: 5 - Very good We found that the service’s performance was very good in relation to the areas we examined for this Quality Statement. We found that there were major strengths and the identified areas for improvement represent actions to be made on an already very good performance. We looked at patient care records from the inpatient, day hospice and the community nursing service. In all cases, these were completed well with attention to the date and time. All patient care records were also signed by the healthcare professional that had seen the people who used the service. Staff had been reminded about the need to make sure that entries were always made in the patient care records and were aware that this had been an
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issue during the previous inspection. This demonstrated that management had taken action and that improvements in record-keeping had been made. We asked people who use the service if they felt they had been consulted about their care and treatment. All people we spoke with felt that they were kept fully informed and that their care needs were being well met. We saw from the patient care records that there had been an initial assessment, and subsequent input, from a variety of healthcare professionals depending on the person’s assessed needs. This meant that there was a multi-professional input which aimed to meet the complex and changing needs of the people who use the service. We looked at the progress in using the new falls risk assessment. We found that this was used to try to prevent falls with the use of equipment, such as pressure alert mats and low care beds. This meant that this aspect of safety had improved since the last inspection and we saw that the number of falls had decreased. The service used anticipatory care plans to record the future wishes of people who use the service, should their condition deteriorate. We saw that these were completed to record important wishes, such as the preferred place of death. The service had a leaflet explaining resuscitation decisions. This was used in conjunction with staff discussions with people who use the service and their families. We saw that a document was kept to record if a decision had been made. We asked staff if they were aware of these decisions so that correct actions could be taken in the event of a person’s sudden deterioration. Staff were aware of these important decisions for individuals because communication systems were in place to ensure this. This included the use of the white board and the handover sheet which nurses used to make sure important information was passed over from one shift to another. We asked about end of life care and how this would be managed. We were told that the Liverpool Care Pathway was in use at the hospice. This pathway helped staff to record care and make sure that important points were not missed at this time. Staff spoken with confirmed that they were aware of the need for good communication with relatives. This ensures that there is understanding of the purpose of this documentation and that the use of the pathway would always be started following a team discussion and countersigned by a senior doctor at the earliest opportunity (within 24 hours). The continued use of the pathway was in keeping with guidance from the Scottish Government. Hospice management were aware that there were likely to be changes made in the future to the documents about end of life care. During the inspection, we spoke with seven people who use the service. We received many positive comments about the quality of care provided at the service and of the quality of staff. Comments included: •
‘They can’t do enough for you – all staff are lovely.’
•
‘I’ve been so well cared for it’s hard to tell you.’
We received nine completed satisfaction questionnaires from relatives and people who had recently used the hospice services. All agreed that they were happy with the quality of care that they or their relative had received. Comments included: •
‘Have been impressed with the standard of care and attention given to my wife.’
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•
‘So helpful and understanding also provide many various helpful services. Staff excellent to both patients and visitors.’
•
‘As a carer for my husband, I can applaud the care which he has received over the last year. The palliative hospice nurse and also the home care co-ordinator and the carers who attend to personal care are owed thanks. It is also very helpful to be able to talk to professionals at the hospice about concerns, cannot thank you enough.’
Areas for improvement We checked the incidents and accidents records and noted that there had been a recent incident of arm entrapment involving a bed rail. We were told that there was not a risk assessment in place for the use of bed rails. This meant that there was a risk for a small number of people who were agitated or confused. There were three different types of bed in use at the hospice. All were electric adjustable beds with integral bed rails. We discussed this with management and have asked that advice is sought from the bed manufacturers to make sure that an appropriate risk assessment is carried out before using these bed rails. A requirement is made (see requirement 1). The majority of people who use the service were admitted for a short period of time. However, there can occasionally be longer stays. We saw that for a person with dementia, there was very little in the care plan about the effects of this and preferences for involvement in everyday activities in order to meet social needs for stimulation. Staff told us that it was sometimes difficult for them to meet because of the pressures of physical care needs of people who use the service. The short care plans in use do not take account of the needs of a longer stay person with dementia and more should be done to make sure that staff can meet these needs. We discussed this with management and highlighted the ‘promoting excellence’ framework which is available to help staff learn more about meeting the needs of people with dementia (see recommendation b). We asked staff if people who use the service or relatives could view their care plans and multidisciplinary notes. Staff told us that they would follow the ‘access to records’ policy. However, when we viewed this policy it did not mention how the person who uses the service or relative could view their records. We think this should be made clearer to staff to make sure that patients and relatives are able to access their records appropriately (see recommendation c). Requirement 1 – Timescale: by 31 January 2014 (3 months)
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St Columba’s Hospice must implement a risk assessment for the use of bed rails. To do this the provider must:
• take account of the type of bed(s) in use, the risks to the patient of entrapment and of restraint • ensure training and guidance is made available to staff to ensure that no patient has bed rails in use unless it is safe for them to do so, and • ensure alternatives are considered and made available in keeping with restraint best practice guidance.
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Recommendation b
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We recommend that St Columba’s Hospice should ensure that the social needs of people who use the service are met. This should be especially considered in longer stay people who have dementia.
Recommendation c
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We recommend that St Columba’s Hospice should ensure that it is clear to staff how people who use the service and relatives can access their own records if they wish.
Quality Theme 3 Quality Statement 3.1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Grade awarded for this statement: 5 - Very good We found that the service’s performance was very good in relation to the areas we examined for this standard statement. We found that people who use the service and relatives were routinely involved in service development and evaluation. The information provided in Quality Statement 1.1 is also relevant here. Area for improvement See recommendation a in Quality Statement 1.1.
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No requirements. No recommendations.
Quality Statement 3.3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Grade awarded for this statement: 5 - Very good We found that the service’s performance was very good in relation to the areas we examined for this standard statement. We found that there were major strengths and the identified areas for improvement represent actions to be made on an already very good performance. We heard very positive feedback from people who use the service about the qualities of staff. These included: •
‘very caring.’
•
‘they go out of their way for you.’
•
‘they can think of things you need before you even ask.’
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We looked at three sets of staff records. These members of staff had been newly recruited to the service. We found that all of the expected recruitment checks were completed and all necessary information was present. This included: •
a signed and dated application form
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evidence of the interview and selection process
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two or three references with signed and dated forms and headed notepaper, or company stamp, as proof of who the referee was
•
the Protection of Vulnerable Groups (PVG) document (issue numbers and dates were stored to evidence a return from Disclosure Scotland)
•
copies of certificates of qualifications obtained
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a confirmation of registration with the appropriate regulatory body (for registered staff), for example the Nursing and Midwifery Council (NMC), and
•
health declaration and checks using occupational health services.
An induction checklist is in use for new staff. We spoke with a new member of staff about the induction process. They told us a mentor was allocated to new members of staff for support and a workbook would be complete within the first three months of employment. This meant that there was a supportive structure to ensure that new members of staff learn about important policies, procedures and the standards expected of them. We examined the files being used to record checks on staff registrations and found that this was being done routinely for all registered staff groups. This included doctors, nurses and allied health professionals. This meant that any lapse of registration would be picked up quickly by the service and actions would be taken. We spoke with staff about the supervision and appraisal systems. Only some staff had attended supervision sessions. This was a voluntary option and was available if staff wanted to use the sessions. The sessions for supervision were well organised, with a trained facilitator, and aimed to share best practice and support staff who deal with stressful situations on a day-to-day basis. The appraisal system was designed to be carried out annually with the option of a 6 month review if needed (see comments made in areas for improvement). We asked staff members about their knowledge of particular policies. All were aware of where they could find these policies and had some awareness of the content. We could see that new policies were issued to staff and a ‘read and sign’ sheet was used to demonstrate staff looking at these. We checked training records and found that there had been regular training made available for staff. This included both mandatory subjects such as fire, infection control and moving and assisting, as well as further education subjects in palliative care. We noted that staffing numbers had been increased on the ward areas due to the temporary accommodation having a spread out environment. This meant that staff were allocated to specific bays to ensure people who use the service were responded to quickly. People spoken with confirmed that staff were quick to respond to their needs and were attentive. We looked at figures for staff turnover for the last 3 years which indicated a low turnover of staff. This is a good indicator as it means that staff have been a stable group over a long period of time, which can lead to better outcomes for people who use the service.
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We were impressed by the dedication of staff. We found that some travelled a considerable distance to the hospice in its temporary location. Areas for improvement Based on our findings, we found that supervision and appraisal systems could be made more consistent amongst staff groups. This will ensure that participation is regular. Management have agreed to look at this further. We found that there had been a recent request for department leads to provide figures on how many staff had completed appraisals over the last 3-year period. This showed that there was a significant lack of information returned from one area of staffing. Management were aware of this and were keen to rectify as quickly as possible. The training records kept did not allow an easy overview of gaps in training to ensure that these were highlighted and addressed. There was a reliance on paper systems and, at times, this may mean that information is difficult to find. A system, such as a staff training matrix, could be used to make sure that gaps in training are more easily identified. This is a chart that has staff names down one side and training topics along the top. Dates of attendance can then be filled in and those left blank are then easily identified (see recommendation d). Staff had not had specific dementia training and there were increased numbers of admissions of people who use the service with cognitive impairment and dementia. This has been highlighted in Quality Statement 1.5.
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No requirements.
Recommendation d
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We recommend that St Columba’s Hospice should develop a system which clearly identifies staff training needs and any gaps in training. This should also show when updates or refreshers are due.
Quality Theme 4 Quality Statement 4.1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Grade awarded for this statement: 5 - Very good We found that the service’s performance was very good in relation to the areas we examined for this standard statement. We found that people who use the service and relatives were routinely involved in service development and evaluation. The information provided in Quality Statement 1.1 is also relevant here. Area for improvement See recommendation a in Quality Statement 1.1.
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No requirements. No recommendations.
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Quality Statement 4.4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide. Grade awarded for this statement: 5 - Very good We found that the service’s performance was very good in relation to the areas we examined for this standard statement. We found that there were major strengths and the identified areas for improvement represent actions to be made on an already very good performance. The service had introduced new clinical governance structures in the last year. Clinical governance is the term used to describe the systems to make sure the service is accountable for safety, quality and effectiveness of clinical care delivered to people who use the service. This meant that new groups and lines of reporting had been set up with the aim of monitoring and improving the services to people who use the service and relatives. Staff spoken with stated that the new clinical governance structures were an improvement and that this had brought about tighter monitoring and control systems. In particular, the new structure involved a wider group of staff and this was considered to be beneficial. We were told there were risk registers and a clinical risk group. The minutes of each of the group meetings were held on computer. All staff had access to these and could see the action plans being worked on. We spoke with the audit facilitator and were told that there was an audit programme of different topics with different frequencies. For example, medication was audited monthly and infection control every 3 months. This meant that there was an organised programme that checks practices and this can contribute to the quality assurance overview. Hospice staff had regular meetings with the managed clinical network for palliative care. This meant that the hospice was linked with NHS general hospitals and other palliative care settings. As a part of this group, there were expectations of meeting best practice and this included a regular pain audit using Scottish Intercollegiate Guidelines Network (SIGN) 106. This audit meant that practice was monitored and could be improved if areas were highlighted. Reports published on the hospice website gave details of previous audit activity from 2010–2011. These reports showed how changes had been made in response to audit activity. This demonstrated an open culture of sharing audit activity publically. Areas for improvement Although there was a programme of audit, it was not easy to see an overview of what was happening and when. The use of more visual recording charts such as a ‘Gantt’ chart may help monitor progress of these audits and the output of the groups. This was discussed and management agreed to act on this. We could see that the service was monitoring accidents and incidents. However, the incident of arm entrapment and some other bruising incidents, which were related to bedrails, had not been flagged as an issue. More robust incident analysis could be considered to make sure that there is a clear link with health and safety guidance. We saw that information was displayed detailing how to make a complaint. However, very few complaints were recorded. Some greater emphasis could be placed on the recording of ‘concerns’ to help identify areas for improvement. We noted that the complaints information Independent Healthcare Inspection Report (St Columba’s Hospice: St Columba’s Hospice Ltd): 21–22 October 13
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displayed on the notice board gave the name and address of Healthcare Improvement Scotland as an investigator of complaints. However, it was not clear that this route could be used directly without going through the hospice’s own complaints procedure first. We received nine completed questionnaires from relatives, in relation to complaints, and found the following: •
100% of the respondents did not know that they could make a complaint to Healthcare Improvement Scotland if they wished.
•
80% of the respondents did not know that they could make a complaint to the hospice.
Complaints information should be reviewed and made clearer to take account of this feedback (see recommendation e). As commented in Quality Statement 1.1, the development of more structured feedback from people who use the service and relatives would contribute to the quality improvement plan for the service. There was also a need to develop the systems for getting feedback from staff and stakeholders. This feedback can help to verify the experience of care of people who use the service and contribute to the service’s own self-assessment. We would encourage the service to carry out a self-assessment regularly and gain the opinion of others when self grading.
■
No requirements.
Recommendation e
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We recommend that St Columba’s Hospice should encourage the recording of ‘concerns’ and it is made clearer about the direct route to make a complaint to Healthcare Improvement Scotland.
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Appendix 1 – Requirements and recommendations The actions that Healthcare Improvement Scotland expects the independent healthcare service to take are called requirements and recommendations. •
Requirement: A requirement is a statement which sets out what is required of an independent healthcare provider to comply with the Act, regulations or a condition of registration. Where there are breaches of the Act, regulations, or conditions, a requirement must be made. Requirements are enforceable at the discretion of Healthcare Improvement Scotland.
•
Recommendation: A recommendation is a statement that sets out actions the service should take to improve or develop the quality of the service but where failure to do so will not directly result in enforcement.
Quality Statement 1.1 Requirements None Recommendation We recommend that St Columba’s Hospice should: a
develop a more formal participation strategy, for involving people who use the service and relatives in all aspects of the service. This could include a format for ensuring that feedback obtained is responded to more openly to show what improvements or changes have been made.. National Care Standard 21 [Hospice Care] - Advocacy, comments, concerns and complaints
Quality Statement 1.5 Requirement The provider must: 1
implement a risk-assessment for the use of bed rails. To do this the provider must: •
take account of the type of bed(s) in use, the risks to the patient of entrapment and of restraint
•
ensure training and guidance is made available to staff to ensure that no patient has bed rails in use unless it is safe for them to do so, and
•
ensure alternatives are considered and made available in keeping with restraint best practice guidance.
Timescale – 31 January 2014 (3 months) Regulation 3(a) The Healthcare Improvement Scotland (Requirements as to Independent Health Care Services ) Regulations 2011
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Recommendations We recommend that St Columba’s Hospice should: b
ensure that the social needs of people who use the service are met. This should be especially considered in longer stay people who have dementia. National Care Standard 2.3 [Hospice Care] - Assessing your needs National Care Standard 3.1 [Hospice Care] - Guidelines and legislation
c
ensure that it is clear to staff how people who use the service and relatives can access their own records if they wish. National Care Standard 3.6 [Hospice Care] - Guidelines and legislation
Quality Statement 3.3 Requirements None Recommendation We recommend that St Columba’s Hospice should: d
develop a system which clearly identifies staff training needs and any gaps in training. This should also show when updates or refreshers are due. National Care Standard 6.4 [Hospice Care] - Staff
Quality Statement 4.4 Requirements None Recommendation We recommend that St Columba’s Hospice should: e
encourage the recording of ‘concerns’ and it is made clearer about the direct route to make a complaint to Healthcare Improvement Scotland. National Care Standard 21.4 [Hospice Care] - Advocacy, comments, concerns and complaints
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Appendix 2 – Inspection process Inspection is part of the regulatory process. Each independent healthcare service completes an online self-assessment and provides supporting evidence. The self-assessment focuses on five quality themes: •
Quality Theme 0 – Quality of information: this is how the service looks after information and manages record keeping safely. It also includes information given to people to allow them to decide whether to use the service and if it meets their needs.
•
Quality Theme 1 – Quality of care and support: how the service meets the needs of each individual in its care.
•
Quality Theme 2 – Quality of environment: the environment within the service.
•
Quality Theme 3 – Quality of staffing: the quality of the care staff, including their qualifications and training.
•
Quality Theme 4 – Quality of management and leadership: how the service is managed and how it develops to meet the needs of the people it cares for.
We assess performance by considering the self-assessment, complaints, notifications of events and any enforcement activity. We inspect the service to validate this information and discuss related issues. The complete inspection process is described in the flow chart in Appendix 3.
Types of inspections Inspections may be announced or unannounced and will involve physical inspection of the clinical areas, and interviews with staff and patients. We will publish a written report 8 weeks after the inspection. •
Announced inspection: the service provider will be given at least 4 weeks’ notice of the inspection by letter or email.
•
Unannounced inspection: the service provider will not be given any advance warning of the inspection.
Grading We grade each service under quality themes and quality statements. We may not assess all quality themes and quality statements. We grade each heading as follows:
We do not give one overall grade for an inspection. The quality theme grade is calculated by adding together the grades of each quality statement under the quality theme. Once added together, this number is then divided by the number of statements.
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For example: Quality Theme 1 – Quality of care and support: 4 - Good Quality Statement 1.1 – 3 - Adequate Quality Statement 1.2 – 5 - Very good Quality Statement 1.5 – 5 - Very good Add the grades of each quality statement together, making 13. This is then divided by the number of quality statements (there are 3 quality statements), making 4.3. This is rounded down to 4, giving the overall quality theme a grade of 4 - Good. However, if any quality statement is graded as 1 or 2, then the entire quality theme is graded as 1 or 2 regardless of the grades for the other statements.
Follow-up activity The inspection team will follow up on the progress made by the independent healthcare service provider in relation to their improvement action plan. This will take place no later than 16 weeks after the inspection. The exact timing will depend on the severity of the issues highlighted by the inspection and the impact on patient care. The follow-up activity will be determined by the risk presented and may involve one or more of the following: •
a further announced or unannounced inspection
•
a targeted announced or unannounced inspection looking at specific areas of concern
•
an on-site meeting
•
a meeting by video conference
•
a written submission by the service provider on progress with supporting documented evidence, or
•
another intervention deemed appropriate by the inspection team based on the findings of an inspection.
Depending on the format and findings of the follow-up activity, we may publish a written report. More information about Healthcare Improvement Scotland, our inspections and methodology can be found at: http://www.healthcareimprovementscotland.org/programmes/inspecting_and_regulating_care /independent_healthcare.aspx.
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Appendix 3 – Inspection process flow chart How we inspect hospitals and services: We follow a number of stages in our inspection process.
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Appendix 4 – Details of inspection The inspection to St Columba’s Hospice was conducted on Monday 21 and Tuesday 22 October 2013. The inspection team consisted of the following members: Sarah Gill Inspector Gill Swapp Inspector
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Appendix 5 – The National Care Standards The National Care Standards set out the standards that people who use independent healthcare services in Scotland should expect. The aim is to make sure that you receive the same high quality of service no matter where you live. Different types of service have different National Care Standards. There are Care Standards for: •
independent hospitals
•
independent specialist clinics
•
independent medical consultant and general practitioner services, and
•
hospice care.
When we inspect a care service we take into account the National Care Standards that the service should provide. The Scottish Government publishes copies of the National Care Standards online at: www.scotland.gov.uk
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We can also provide this information: •
by email
•
in large print
•
on audio tape or CD
•
in Braille (English only), and
•
in community languages.
Edinburgh Office Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB
Glasgow Office Delta House 50 West Nile Street Glasgow G1 2NP
Phone: 0131 623 4300
Phone: 0141 225 6999
www.healthcareimprovementscotland.org The Healthcare Environment Inspectorate, the Scottish Health Council, the Scottish Health Technologies Group and the Scottish Intercollegiate Guidelines Network (SIGN) are part of our organisation.