St Margaret's Somerset Hospice - Taunton

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We rated effective as outstanding. We assessed one quality statement around monitoring and improving outcomes. Patients experienced high-quality, consistent care that met both clinical expectations and their personal needs. People who used the service consistently experienced positive outcomes. Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. Patients’ physical, mental health and social needs were assessed and met. Their care, treatment and support were delivered in line with legislation, standards and evidence-based guidance, including the National Institute for Health and Care Excellence (NICE) and other expert professional bodies, to achieve effective outcomes.

This service scored 100 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Patients reported feeling involved in their care plans, which were regularly reviewed and adjusted based on their feedback and clinical outcomes. Patients and those close to them told us staff provided good care and treatment. Care outcomes were positive, and patients consistently expressed satisfaction with the level of support and the effectiveness of their treatment. Patients and families said they felt listened to and were involved in advance care planning. The hospice had received 494 compliments in 2024 which had increased from the previous year.

Managers and staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. Staff and leaders provided positive feedback regarding the hospice's commitment to monitoring and improving care and treatment. They reported that the regular use of reliable data helped them understand performance trends and identify areas for improvement. Staff highlighted the effectiveness of multi-disciplinary meetings in ensuring care plans were consistently reviewed and tailored to meet both clinical expectations and patient needs. This approach ensured that care outcomes were positive and aligned with patients' expectations. Day hospice patients completed a questionnaire at every session for staff to monitor progress. The service was goal orientated with an aim of ensuring patients met their goals before discharge. For example, one patient wished to be able to walk his daughter down the aisle at her wedding. The physiotherapy team and hospice staff worked hard with the patient and this goal was met.

The service provided care and treatment based on national guidance and evidence-based practice. Managers had procedures in place to ensure that staff followed guidance. Daily multi-disciplinary meetings facilitated comprehensive care planning and review. These meetings ensured that all aspects of patient care were considered and adjusted as needed, supporting positive and consistent outcomes. Regular supervision and appraisals provided staff with constructive feedback and support, enabling them to improve their practice and contribute to the overall effectiveness of care. The service benchmarked performance measures which included medication incidents, accidents including falls, near misses, reportable incidents, safeguarding cases, hospice acquired infections, complaints and compliments. Results showed there had been three CQC reportable incidents. All three of these were patient falls. There was a patient safety investigation into falls on the inpatient ward. Each fall was reviewed during the incident process and no lapse in care had been found. A wider look at falls prevention was underway which included bed rails procedure and compliance. There were 42 medication errors in 2024 compared to 36 in 2023 (17% increase). All incidents were level 1 harm category. The incidents were reviewed, and no specific themes were identified. However, there were procedural issues that had an impact in some incidents, and a review of the drugs room was completed as part of a human factors assessment. Following this, the service made key changes to the drugs room such as removing redundant signage and decluttering. They also increased the induction programme regarding medication management. This had been well received by staff. The service would continue to review medication errors considering the changes to assess impact. There was an audit schedule in place. The preferred place of death was discussed and recorded which was also noted in the patient records we reviewed.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.