Saint Michael's Hospice (North Yorkshire Hospice Care) was rated overall Good following an unannounced inspection in November 2023, with an Outstanding rating for caring reflecting exceptional compassion, dignity, and community outreach. Minor concerns were noted around emergency medication checks, staff deployment affecting bed availability, and incomplete follow-through on some safety alerts, none constituting regulatory breaches.
Concerns (5)
moderateMedication management: “We identified 2 products within emergency medications that were out of date, however the checks completed at the beginning of the month only identified 1 product as being out of date and no action had taken place.”
moderateStaffing levels: “we saw several examples where bed numbers had been reduced, the maximum number of staff had not been deployed, and patients were waiting on the waiting list.”
moderateIncident learning: “Managers did not always ensure that actions from patient safety alerts were implemented and monitored.”
minorGovernance: “the 'improving mouth care' action was recorded as complete and being implemented in September 2022 and had not recognise the risk of oral sponges still being in use found on inspection.”
minorStaff competency: “Staff were not always aware of the procedure to carry out cardiopulmonary resuscitation (CPR) for someone nursed in bed... staff spoken with were not aware of this.”
Strengths
· Outstanding caring domain with consistently compassionate, dignified, and person-centred care praised by patients and families as 'exceptional' and 'invaluable'.
· Proactive community outreach including services for homeless, rural, and marginalised populations through innovative roles such as the care connector.
· Strong multidisciplinary working with external partners including NHS dietitian SLA, Citizen's Advice Bureau SLA, and daily ICS engagement.
· Robust safeguarding culture with a dedicated safeguarding team, comprehensive training framework, and 100% DBS compliance across reviewed files.
· Well-structured governance with clinical incident group, clinical services governance group, and regular board-level reporting and risk registers.
Quality-Statement breakdown (33)
safe: Mandatory trainingGood
safe: SafeguardingGood
safe: Cleanliness, infection control and hygieneGood
safe: Environment and equipmentGood
safe: Assessing and responding to patient riskGood
safe: StaffingGood
safe: RecordsGood
safe: MedicinesGood
safe: IncidentsGood
effective: Evidence-based care and treatmentGood
effective: Nutrition and hydrationGood
effective: Pain reliefGood
effective: Patient outcomesGood
effective: Competent staffGood
effective: Multidisciplinary workingGood
effective: Seven-day servicesGood
effective: Health promotionGood
effective: Consent, Mental Capacity Act and Deprivation of Liberty SafeguardsGood
caring: Compassionate careOutstanding
caring: Emotional supportOutstanding
caring: Understanding and involvement of patients and those close to themOutstanding
responsive: Service delivery to meet the needs of local peopleGood
responsive: Meeting people's individual needsGood
responsive: Access and flowGood
responsive: Learning from complaints and concernsGood
well-led: LeadershipGood
well-led: Vision and StrategyGood
well-led: CultureGood
well-led: GovernanceGood
well-led: Management of risk, issues and performanceGood
well-led: Information ManagementGood
well-led: EngagementGood
well-led: Learning, continuous improvement and innovationGood