This unannounced inspection took place on 17, 18, 19, 20, 23 & 24 October 2017. The first day of the inspection was unannounced, which means the staff at Derian House hospice did not know we were coming. We last Inspected Derian House on 29 July and 2 August 2016. At the inspection in 2016 we rated the Hospice as ‘Good’ overall and ‘Good’ for the domains of Safe, Effective, Responsive and Well-led. We rated the Caring domain as ‘Outstanding’. We made two recommendations following the inspection. One recommendation was regarding processes around the disposal of drugs and the service level agreement in place for pharmacy provision. The other recommendation was ensuring that an appropriate consent policy was in place that met the guidance of the GMC and RCN and complied with the Gillick competency and that this was followed in practice. The Gillick competency is a term originating in England and is used in medical law to decide whether a child is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. At this inspection we found that our recommendation for the issues raised around medicines management had been met however a valid and appropriate consent policy was not in place and we found that consent was not always gained appropriately. We found this to be a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 in relation to regulation 11, Need for consent.
Derian House Children's Hospice provides palliative and end of life care for children and young people who have life limiting or life threatening conditions. The hospice is set in its own ground and provides accommodation for nine children in the main house and four young people in the lodge. There are four self-contained flats which are used by families. The hospice also provides a service for children and young adults in their own home. This is known as Derian at Home.
Bereavement support for parents and siblings is provided before, during and after end of life care and this support is not time limited. The hospice covers a wide geographical area including; Chorley, Preston, South Ribble, South Lakes, Fylde Coast, Wigan, Bolton, Rochdale, Blackburn, Burnley and Salford. This incorporates working with ten different Local Authorities to provide 24/7 End of Life support. Care consists of approximately 80% respite and 20% end of life care. Attendance at the hospice does vary due to the types of service offered. For the 12 month period prior to our inspection occupancy was averaging at just over 53%.
Derian House had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We were able to have a conversation with one young person during the two days we were at Derian House and also had discussions and contact with relatives. Via conversations and through observations we had no concerns with the safety of people using the service. We received positive comments from families with regards to the safety of their loved ones when they were being cared for by Derian House staff.
Fire safety issues had been highlighted as a concern prior to us undertaking our inspection via an anonymous whistle-blower. Lancashire Fire and Rescue Service (LFRS) had visited the hospice before our inspection and they had fed back to us their recommendations. We saw evidence from LFRS and the service to show these recommendations had been undertaken and that fire safety was of paramount importance to the service. Steps had been taken to address the issues highlighted to us prior to our inspection.
Suitable recruitment processes were in place and followed ensuring that people employed as staff or recruited as volunteers, were competent and safe to work with vulnerable children and young people.
Appropriate staffing levels were observed to be in place to meet the assessed needs of the children and young people receiving care and support. Due to the short term nature of the service and the fact that people’s needs were different from week to week, rotas were designed to be flexible and accommodate this fact.
An infection prevention and control policy was in place at the hospice. During the course of our inspection we toured the premises, viewing a selected number of bedrooms and all communal parts of the hospice including bathrooms and toilets throughout all parts of Derian House. All areas were observed to be clean.
Children and young people’s medicines were managed well including how they were stored, administered, recorded and disposed of. We observed medicines to be administered in a professional and appropriate manner. The hospice had recorded 30 medicines errors for the period of 2017 up to the date of our inspection. These had been dealt with appropriately and lessons had been learnt. Changes to the medicines policy were made following conversations we had with the management of the service.
Risk assessments were not always up to date, and therefore reflective of children and young people’s latest needs. We have made a recommendation about this.
The staff we spoke with had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. They understood how the legislation impacted the people who used the service. Whilst we did find issues with how consent was gained given the nature of the service offered at Derian House, we judged the hospice to be compliant in this area.
Children and young people were supported well with their nutritional and hydration needs. The cook we spoke with was knowledgeable of children and young people’s needs as were the care staff we spoke with. Aside from one issue regarding the consistency of one person's diet, records accurately reflected needs in this area.
All the feedback we received from relatives, and from the one young person we were able to speak with, was extremely positive. We were told of a staff team that was caring, empathetic and professional. More than this, we were told countless stories of how the service was a sanctuary for families and one they could not have coped without in times of extreme difficulty. This was true from a practical and emotional perspective. Some families still received support many years following the death of their loved ones.
We found care plans to be person centred and to contain a lot of accurate information about children and young people’s general and specific needs. As with risk assessments, they were not always fully reflective of children and young people’s most up to date needs. Work was continuing within the care team to engage with external partners to ensure that the hospice was included in all reviews of care and support to ensure that when children and young people accessed Derian House, the service had a fully up to date picture of people’s needs.
The service had a robust and effective complaints system in place. The policy was on display and contained the details of external organisations as well as the hospice’s internal procedures.
A wide range of activities were offered to the children and young people who accessed Derian House. Relatives we spoke with praised the service in this area and we saw that children and young people had a choice in how they spent their time at the hospice.
The services on offer to children and young people were constantly being developed or expanded in line with local demand. We saw several good examples of new services at different stages of development, as well as existing services being realigned or expanded to meet needs.
We spoke with 57 staff, across both the care and support side of the service, some of whom were ex-employees at the hospice. A large percentage of staff we spoke with, and had contact with, told us of a working environment which we judged to be extremely unhealthy and broken. We heard many testimonies, with specific details, about how staff were bullied, belittled and how they felt unable to raise these concerns within a safe environment. Whilst the hospice had a large range of auditing and monitoring systems in place they had not picked up and/or dealt with these and other issues. This was therefore a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 in relation to regulation 17: Good Governance.
Relatives we spoke with did not raise any concerns about the atmosphere or culture within the hospice. As with all the feedback we received from families conversations about the service were extremely positive. This included any conversations we had about how they perceived the culture of Derian House. This was very positive as it meant the issues staff were experiencing were not adversely affecting the care and support offered to children and young people using the service.
You can see what action we told the provider to take at the back of the full version of the report.