St Clare's Hospice

⚠ 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.

⚠ 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 …

⚠ 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.

⚠ 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.

⚠ -Care plans were generic and did not reflect the persons individual needs.

⚠ 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.

⚠ 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.

⚠ None of the nurses had received an appraisal in the last 12 months.

⚠ None of the clinical staff had received a clinical competency review.

⚠ 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.

⚠ 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 …

⚠ 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 …

⚠ 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.