Announced Inspection Report: Independent Healthcare St Columba’s Hospice | St Columba’s Hospice Ltd | Edinburgh 31 January 2012
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 2012
First published March 2012
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Contents 1
Background
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2
Summary of inspection
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3
Key findings
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Appendix 1 – Requirements and recommendations
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Appendix 2 – Inspection process
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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’), and 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 these standards, the Act gives us 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 measure compliance against expected standards and regulations be firm, but fair have members of the public on some of our inspection teams ensure our staff are trained properly tell people what we are doing and explain why we are doing it treat everyone fairly and equally, respecting their rights take action when there are serious risks to people using the independent healthcare services we inspect if necessary, inspect services again after we have reported the findings publish reports on our inspection findings which will be available to the public in a range of formats on request, and 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. You can, however, complaint
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directly to us about an independent healthcare service without first contacting the service. Our contact details are: Healthcare Improvement Scotland Elliott House 8–10 Hillside Crescent Edinburgh EH7 5EA Telephone:
0131 623 4300
Email:
safeandclean.his@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 a voluntary hospice providing 24-hour specialist palliative care to people over the age of 16 years. The hospice provides palliative care for up to 30 inpatients. Care is provided using a multidisciplinary team of healthcare staff, which includes nurses, doctors, a pharmacist, physiotherapists, occupational therapists, social workers, members of the clergy and counsellors. There is a day hospice service run by experienced palliative care nurses where up to 15 people can attend the hospice from home 3 days every week. This service provides people with holistic care and support with their illness. In addition, complementary therapies are provided 2 days every week on an appointment basis. The hospice provides a community palliative care service where specialist nurses visit people at home to offer support and advice about their illness. There is also a team of trained volunteer staff who support St Columba’s Hospice in various activities such as fundraising, gardening, driving and serving in the hospice coffee rooms. The hospice is situated in extensive private grounds within a residential area of north Edinburgh overlooking the River Forth. There are landscaped gardens to the front, side and rear of the building and all of the bedrooms face onto a well-maintained garden area. We carried out an announced inspection to St Columba’s Hospice on Tuesday 31 January 2012. The inspection team was made up of two inspectors and a public partner. One inspector led the team and was responsible for guiding them and ensuring the team members were in agreement about the findings reached. Membership of the inspection team visiting St Columba’s Hospice can be found in Appendix 4. We assessed the service against three Quality Themes related to the National Care Standards. Based on the findings of this inspection, this service has been awarded the following grades: 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: 6 - Excellent In this inspection, evidence was gathered from several sources. This included: information leaflets healthcare records staff records medicines records policies and procedures Independent Healthcare Inspection Report (St Columba’s Hospice: St Columba’s Hospice Ltd) - 31 January 2012
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risk assessments accidents and incidents patient satisfaction surveys, and information leaflets. We had discussions with a variety of people, including: the chief executive the medical director the clinical effectiveness audit facilitator registered nurses, and people who use the service. During the inspections we took into account The Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011. We viewed the following areas of the hospice premises: a sample of single and multi-occupancy bedrooms the day hospice area communal areas such as sitting rooms group activity rooms relatives’ overnight rooms, and nurses’ office. During this inspection, we did not assess and report any observations on the existing hospice environment. St Columba’s Hospice has plans in place to carry out an extensive refurbishment of the premises starting in February 2012. The people who are currently using the service and existing hospice staff, are scheduled to move to alternative premises on a temporary basis to allow the building work to be completed. Healthcare Improvement Scotland will assess the hospice environment at future inspections. The inspection team spoke informally to 11 people who use the service. Everyone spoke very positively about their individual care and personal experience of attending the hospice. Five of the 11 people spoken to were inpatients and they offered the following information to the inspection team: all were aware of their named nurse medicines and care had been discussed with them one person said they had been given help to find a suitable care home to live in the hospice was clean the open visiting arrangement was positive, and the food was excellent.
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Six of the 11 people spoken to during the inspection were relatives and visitors of people who were inpatients. The relatives and visitors told us: staff were patient and explained the care at a level they could understand they never feel rushed to leave they were encouraged to discuss their loved one’s care, and staff went out of their way to help. Overall, we found evidence at St Columba’s Hospice that: people who use the service are provided with individual palliative care within a structured model of care, treatment and support people are supported by a committed and dedicated multidisciplinary healthcare team people’s care and treatment are regularly reviewed people and their relatives are directly involved in all stages of their care regular satisfaction surveys are being carried out, and very dedicated care and attention is given to people in the final stages of their life, with particular emphasis on care and comfort. We did find that improvements are required in some areas, which include: the need to ensure that people’s healthcare records are fully completed in all areas, and a review of the system to update policies and procedures. This inspection resulted in two requirements and three recommendations. The requirements are linked to compliance with the Act and regulations or orders made under the Act, or a condition of registration. Full details of the requirements and recommendation can be found in Appendix 1. The provider must address the requirements 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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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 St Columba’s Hospice has a number of information leaflets in place to offer to people who use the service. These leaflets are well written and describe clearly the services provided. The leaflets cover several topics, which include palliative care, chaplaincy and spiritual care, infection control, and visiting friends and family. Area for improvement Some of the information leaflets were out of date as the review dates had passed and the leaflets had not been updated. St Columba’s Hospice should review its current system for updating its information.
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No requirements.
Recommendation a ■ We recommend that St Columba’s Hospice should review its system for reviewing and updating information leaflets. This is to ensure that all written information offered to people who use the service is up to date.
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 During the inspection, there was evidence that St Columba’s Hospice is carrying out satisfaction surveys on a regular basis. The comments from these surveys are reviewed by hospice staff. Completed questionnaires seen during the inspection confirmed that people who use the service have positive views about their care and treatment. Before the inspection, Healthcare Improvement Scotland sent questionnaires to St Columba’s Hospice for people who use the service and their relatives to complete. Nineteen completed questionnaires were received by Healthcare Improvement Scotland and the majority of comments were very positive and complimentary about the healthcare service provided. Area for improvement Some of the questionnaires had comments from people stating that they were not consulted about the development of information leaflets. Other comments were from people who felt that their relatives were not given up-to-date information about the service. St Columba’s Hospice should review the involvement of people who use the
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service when considering the development and review of information leaflets. The hospice should also review how it provides information to relatives.
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No requirements.
Recommendation b ■ We recommend that St Columba’s Hospice 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. Quality Statement 1.2 We ensure that the care, support and treatment received by service users across all aspects of our service provision, is supported by evidence-based practice and up to date policies and procedures. These reflect current legislation (where appropriate Scottish legislation). Grade awarded for this statement: 5 - Very good Eleven written policies and procedures were randomly reviewed during the inspection. All policy documents reviewed were presented in a consistent style which included the title of the policy, the issue date and date for review. The majority of the policies reviewed were up to date. However, a small number of policies were either out of date, or date expired with a handwritten entry next to the old expiry dates. It was unclear when these policies would be formally updated. The out-of-date policies included: clinical audit policy clinical research policy drug alerts staff support policy, and the witnessing of a patient’s will. Area for improvement The system currently used to update policies should be reviewed to ensure that all policy documents are in date at all times. This will ensure staff have the most up-todate reference information.
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No requirements.
Recommendation c ■ We recommend that St Columba’s Hospice 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.
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
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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: 4 - Good We observed several peoples’ healthcare records during the inspection. A comprehensive health assessment is carried out and recorded for each person. This assessment identifies priority healthcare needs with specific attention to palliative care issues such as symptom control, individual comfort and pain relief. Part of each person’s healthcare record is set out to focus on the needs of relatives and there was written evidence that the hospice staff are offering care and support to relatives. All peoples’ healthcare records assessed had written evidence of a multidisciplinary approach towards the care provided. Each record had written evidence of input from nurses, doctors, physiotherapists, occupational therapists and specialist community nurses. All healthcare records viewed during the inspection were completed to a good standard. All individual written entries were observed to be appropriately dated and clearly written. Area for improvement The majority of healthcare records were generally well completed. All written entries viewed were dated, although some entries were not timed or signed by the healthcare professional making the entry. However, there was evidence of a small number of care assessment areas being left blank with no information recorded. It was unclear if these areas had been considered by the healthcare professional in relation to the persons’ illness or simply did not apply. A requirement is made (see requirement 1). The hospice follows recommended guidelines in relation to the subject of resuscitation of inpatients. Each healthcare record viewed during the inspection had consistent information in place on this topic which was considered by healthcare staff during each person’s assessment. However, St Columba’s Hospice uses its own internal document in use for this topic, but healthcare staff do not always complete it. The completion of this document should be reviewed to ensure consistent completion. Requirement 1 – Timescale: by 31 March 2012 ■ The provider is required to 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.
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No recommendations.
Quality Statement 1.6 We ensure that there is an appropriate risk management system in place, which covers the care, support and treatment delivered within our service and, that it promotes/maintains the personal safety and security of service users and staff.
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Grade awarded for this statement: 5 - Very good There was evidence that actual and potential risks are being identified in relation to the service being provided and written risk assessments produced. Risks are discussed at senior staff meetings. A written risk register was seen dated January 2012. Several risk assessments had been produced in relation to the move to the temporary premises while building and refurbishment work is to be carried out on the existing St Columba’s Hospice premises. Medicines alerts and hazard notices are being received. Accidents and incidents occurring to people who use the service are recorded on an individual basis and detailed records were seen during the inspection. Incidents in relation to medicines are recorded and improvement action taken as necessary. Area for improvement Each person has a comprehensive health assessment carried out in relation to their healthcare needs. The assessment covers many areas of potential risk such as eating and drinking, and manual handling. However, the assessment of people in relation to their risk of falling was observed to be weak. This assessment did not provide assurance that all possible risk factors had been considered. The existing falls risk assessment must be reviewed to ensure a more comprehensive system is implemented. A requirement is made (see requirement 2). Requirement 2 – Timescale: by 31 March 2012 ■ The provider is required to ensure that each person’s health assessment includes clear information in relation to the risk of falling. This is to ensure that an appropriate system, process and procedure is in place for all aspects of a person’s health, safety and welfare.
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No recommendations.
Quality Statement 1.7 We are confident that the quality of service users' care will benefit from regular review of clinical practice within the service. Grade awarded for this statement: 6 - Excellent There was evidence confirming that the care and treatment given to people using the service at St Columba’s Hospice is regularly reviewed. Within people’s healthcare records there was evidence that multidisciplinary healthcare staff are regularly reviewing each person’s illness, pain relief, management of symptoms and the continuing degree of assistance required. The hospice uses care documentation called the ‘Liverpool Care Pathway’ when a person is in the final stages of their life. This documentation assists staff to maintain a clear record of the care provided, focusing on the comfort of a person in their final days and hours. One Liverpool Care Pathway record was viewed during the inspection. This record was fully completed and up to date. Arrangements are in place to monitor any accidents and incidents that occur. Each accident or incident is recorded and the reasons examined in order to prevent future incidents happening.
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There are dedicated staff at St Columba’s Hospice who specialise in assessing how effective the provided care has been. A clinical effectiveness audit facilitator works closely with the clinical staff at the hospice and provides advice and support to ensure that care is provided using recommended guidelines and best practice. Regular audits are carried out and the results provided to staff. Audit topics include: discharge planning people’s experience of pain staff knowledge of Clostridium difficile record-keeping, and resuscitation.
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No requirements.
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No recommendations.
Quality Theme 3 Quality Statement 3.2 We are confident that our staff have been recruited and inducted, in a safe and robust manner to protect service users and staff. Grade awarded for this statement: 6 - Excellent Six staff personnel files were assessed during the inspection. In each staff file, there was good evidence that the necessary pre-employment recruitment information was being obtained in line with current legislation. All of the required information is being obtained before a new member of staff starts work. The information is held securely in an easily retrievable format. There was also evidence in place confirming that staff training is provided.
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No requirements.
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No recommendations.
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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 service to comply with the Act or a condition of registration. Where there are breaches of the regulations, orders or conditions, a requirement must be made. Requirements are enforceable at the discretion of the Healthcare Improvement Scotland. Recommendation: A recommendation is a statement that sets out actions the service provider 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 0.1 Requirements None Recommendation We recommend that St Columba’s Hospice should: a
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.
Quality Statement 1.1 Requirements None Recommendation We recommend that St Columba’s Hospice should: b
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.
Quality Statement 1.2 Requirements None Recommendation We recommend that St Columba’s Hospice should: c
review its system for updating policies and implements a formal review process so that staff have a consistent and reliable source of up-to-date reference information. Independent Healthcare Inspection Report (St Columba’s Hospice: St Columba’s Hospice Ltd) - 31 January 2012
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Quality Statement 1.5 Requirements The provider must: 1
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. Timescale – by 31 March 2012 SSI 2011 No. 182 - Regulation 4(2) The Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011 National Care Standard 2.7 – Assessing your needs (Hospice care)
Recommendations None
Quality Statement 1.6 Requirement The provider must: 2
ensure that each person’s health assessment includes clear information in relation to the risk of falling. This is to ensure that an appropriate system, process and procedure is in place for all aspects of a person’s health, safety and welfare. Timescale – by 31 March 2012 SSI 2011 No. 182 - Regulation 3(a), 3(d) The Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011 National Care Standard 2.3 – Assessing your needs (Hospice care)
Recommendations None
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Quality Statement 1.7 Requirements None Recommendations None
Quality Statement 3.2 Requirements None Recommendations None
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Appendix 2 – Inspection process Inspection is a process which starts with self-assessment, includes at least one inspection to a service and ends with the publication of the inspection report and improvement action plan. First, 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. 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 both by considering the self-assessment data and inspecting 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 6 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.
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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 the Healthcare Improvement Scotland, our inspections and methodology can be found at http://www.healthcareimprovementscotland.org/programmes/inspecting_and_regulati ng_care/independent_healthcare.aspx.
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Appendix 3 – Inspection process flow chart
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Appendix 4 – Details of inspection The inspection to St Columba’s Hospice was conducted on Tuesday 31 January 2012. The inspection team consisted of the following members: Gerry Kennedy Lead Inspector Alastair McGown Regional Inspector Marguerite Robertson Public Partner
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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 You can get printed copies free from: Blackwells Bookshop 53-62 South Bridge Edinburgh EH1 1YS Telephone:
0131 662 8283
Email:
Edinburgh@blackwells.co.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 Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA
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 key components of our organisation.