St Clare's Hospice

Independent Healthcare Org · North East

Overall Rating
Inadequate Last inspected 13 September 2018
Domain Ratings
Safe
Inadequate
Effective
Inadequate
Caring
Good
Responsive
Inadequate
Well-led
Inadequate

View Full CQC Report

13 must-do actions
10 should-do actions

Must-Do Actions (13)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider must ensure medicines are managed in line with national guidance (NICE 2016) and produce a medicines management policy which is service specific.
Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
The provider did not have a policy or process for the management of medicines, which was service specific. We saw examples of medication errors which had not been investigated or escalated and had resulted in patient harm.
Must Do
Safe
The provider must ensure safeguarding processes are developed to ensure all staff fully understand how to report, investigate and learn from safeguarding alerts. In addition, all staff must receive training in line with Intercollegiate guidance (2018)
Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment
Staff told us they did not understand their responsibilities in relation to safeguarding. This included the interim registered manager and Chief Executive. The provider did not record when what level of safeguarding training staff had completed or when refresher training was required. There was no evidence the safeguarding vulnerable children …
Must Do
Safe
The provider must develop robust incident management processes, to ensure all incidents are reported, investigated and lessons learnt following incidents are shared.
Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
The providers incident management process was not was fit for purpose as incidents were not investigated and lessons learnt were not recorded or shared with staff.
Must Do
Safe
The provider must ensure that risks to patients are identified, assessed and monitored consistently and that action plans in assessments and care plans are updated and contain enough detail to enable staff to reduce those risks effectively. This includes environmental risk.
Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
Premises were not risk assessed in order to protect patients and staff from the potential of harm or injury. We saw patient risk assessments, which were incomplete or had not been reviewed. Examples of this included falls and moving and handling assessments.
Must Do
Effective
The provider must ensure care plans are individualised and person centred and reflect the needs and choices of each patient as an individual.
Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
-Care plans were generic and did not reflect the persons individual needs.
Must Do
Effective
The provider must ensure an accurate record is maintained of the amount of fluids given and taken by all patients.
Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
We saw two fluid balance charts in use for two patients. However, we saw gaps in the recordings and intake of diet and fluids for these patients.
Must Do
Safe
The provider must ensure all staff have the necessary skills and training to enable them to be competent in their role.
Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment, Regulation 18 HSCA (RA) Regulations 2014 Staffing
The provider did not have a policy or process to ensure staff received appropriate training. There was no training matrix or other method of monitoring and documenting that all relevant training had been undertaken and updated in a timely fashion.
Must Do
Well-led
The provider must ensure all staff receive an appraisal every year.
Regulation 18 HSCA (RA) Regulations 2014 Staffing
None of the nurses had received an appraisal in the last 12 months.
Must Do
Effective
The provider must ensure all staff receive clinical competency supervision to ensure staff are providing care and treatment in line with national guidance and best practice.
Regulation 18 HSCA (RA) Regulations 2014 Staffing
None of the clinical staff had received a clinical competency review.
Must Do
Responsive
The provider must improve the complaints processes, so that patients understand how to make a compliant and staff investigate and learn following complaints.
Regulation 17 HSCA (RA) Regulations 2014 Good governance
We saw that processes in place to manage complaints were not robust as actions following a complaint could not be evidenced at the time of inspection.
Must Do
Well-led
The provider must improve governance processes to drive improvement. This includes the implementation of clinical auditing, review of all policies to ensure staff provide care and treatment in line with national guidance and best practice.
Regulation 17 HSCA (RA) Regulations 2014 Good governance
We were not assured that leaders of the service understood how quality was measured within the service and we did not see a drive towards improvement. We saw limited audit activity within the service and no actions or sharing of information following audits which had been completed. Governance processes were …
Must Do
Safe
The provider must ensure all staff providing direct unsupervised care or treatment have completed disclosure and barring checks.
Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment
There was no policy or process to recheck staff that had undergone initial disclosure and barring checks. This resulted in staff not being checked for several years. We saw five volunteers working within the building. We saw volunteers brought food and drink to patients and direct patient support was sometimes …
Must Do
Responsive
The provider must ensure patients from different religious or cultural backgrounds have all their needs met and provide translations services when needed.
Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
The service did not provide facilities to meet the cultural and spiritual needs of patients of different faiths and cultural backgrounds. Staff were unclear as to which translations services were available and how to use them.

Should-Do Actions (10)

Recommended improvements to enhance service quality.

Should Do
Caring
The provider should ensure that all patients are given enough support and opportunity to be fully involved in the planning of their own care.
Should Do
Effective
The provider should review all DNACPR processes, to establish consent and ensure all staff are aware of those patients whom have a DNACPR inplace.
Should Do
Effective
The provider should strengthen mental capacity and best interest processes and ensure they are completed consistently.
Should Do
Responsive
The provider should review and access and flow within the hospice to ensure patients access care and treatment at the right time.
Should Do
Well-led
The provider should review the on call arrangements for the hospice and ensure there is clarity in regard to which managers are on call.
Should Do
Well-led
The provider should develop workable plans to turn their vision and strategy into action.
Should Do
Well-led
The provider should discuss all clinical risks with trustees to demonstrate sufficient scrutiny is applied to all concerns.
Should Do
Well-led
The provider should clearly identify timely actions and clear lines of accountability, following clinical governance meetings.
Should Do
Well-led
The provider should review the culture within the hospice and identify positive processes to improve current concerns. Specifically in relation to bullying.
Should Do
Well-led
The provider should investigate and carry out further analysis to understand the reasons for high staff sickness.

Previous Inspection (4 April 2018)

Rating: Requires Improvement Type: Comprehensive inspection Actions: 1 should-do
1 repeated
Location Details
CQC ID: 1-106196515
Local Authority: South Tyneside
Region: North East
Inspection Report
Type: Comprehensive inspection
Date: 13 September 2018
Rating: Inadequate
Actions: 13 must-do , 10 should-do
AI-extracted 17 Feb 2026