The Care Quality Commission (CQC) carried out an unannounced inspection at the 10-bed Barnsley Hospice in Church Street, in April and May after whistleblowers raised concerns.
The CQC said there were 164 incidents, including 67 falls involving patients between January 2020 and March 2021, however staff “did not know what incidents to report and how to report them”.
The hospice had reported three serious incidents over the 15-month period. None were classed as being more than “moderate” although a patient suffered a broken hip in one fall, and in another, a dislocated shoulder.
The report said: “Staff told us they saw examples of falls which were dismissed as ‘a unique set of circumstances’ and not reported. A serious incident in 2020 was not correctly identified as such until three months later, leading to a delay in reporting to the commissioner.”
It said recurring incidents like falls “were not prevented, nor the risk lessened, because staff did not fully investigate the causes of these, nor learn from them.”
The hospice, whose previous rating of good has now slipped to “inadequate”, was issued three warning notices relating to the safe care and treatment of patients, its capacity to safeguard patients and the overall management of the service. Just a handful of hospices have been previously rated as inadequate in England by the care watchdog.
During the pandemic the hospice, which is run by Barnsley Hospice Appeal, had undertaken a “difficult restructure” of staffing in the inpatient unit.
The report found that “led to resignations, whistleblowing to CQC and low morale in remaining staff”.
Some patients were also having to wait an “unacceptable” time to be admitted - including one who had to wait 27 days.
On average between October 2020 and March 2021 people were waiting four days, even though the hospice was not full and less patients were being referred than before the pandemic.
However the report said patients were treated with compassion and kindness, saying buzzers were answered promptly and staff took time to interact with patients and their loved ones in a respectful and considerate way.
Sarah Dronsfield, CQC’s head of hospital inspection, said they would monitor the hospice closely and return in the next six months to check on progress.
She said: “The safe care and treatment of people using services is our highest priority and they deserve safe, effective high-quality care.”
Chief executive of Barnsley Hospice Julie Ferry said they accepted the findings and were “extremely concerned and disappointed” about the shortcomings identified.
She said they were taking “robust action” to tackle the issues and said there were positives in the report around their caring, which was rated good.
She said: “We’d like to apologise to the people of Barnsley who we feel we have let down.
“It has been a very challenging 18 months for us, as it has for many organisations and individuals, but that is not an excuse.
“We will be redoubling our efforts to provide the best care and support possible for patients and families in their time of need.”
Sir Steve Houghton leader of Barnsley Council, said the council was trying to do everything they could as a partner agency to "get behind them and put it right".
He said: "It is an incredibly important facility for the people of Barnsley and needs to be of the right quality and ethos clearly for the client group it deals with.
"We have received assurances that measures are being put in to rectify those problems and as a council we have offered all our help and support to put it right."
The hospice looks after people with progressive life-limiting illnesses, such as cancer and motor neurone disease, and needs to raise nearly £2m a year to fund patient care and support for families.
A further £1.6m is provided by Barnsley’s NHS Clinical Commissioning Group.