St Catherine's Hospice - Scarborough...1 St Catherine's Hospice - Scarborough Quality Report 07/08/2019 and specialist palliative counselling services which includes a service for

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Outstanding –

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Outstanding –

Are services responsive? Outstanding –

Are services well-led? Good –––

Overall summary

St Catherine’s Hospice is operated by St Catherine’sHospice Trust. The hospice currently provides 14inpatient beds and has the capacity to open up to 16inpatient beds if the service demands. It also provides awell-being centre and other outpatient facilities. Thehospice provides a hospice at home service (in

collaboration with Marie Curie) across the Scarboroughand Filey region, specialist palliative care services whichincludes outpatients and in reach to the acute trust aswell as support to local care homes. Outpatient servicesinclude a lymphoedema clinic, physiotherapy andoccupational therapy services, complementary therapy

StSt Catherine'Catherine'ss HospicHospicee --ScScarborarboroughoughQuality Report

Throxenby Lane,Newby,Scarborough,North YorkshireYO12 5RETel: 01723 351421Website: https://www.saintcatherines.org.uk

Date of inspection visit: 14 May 2019 and 4 June2019Date of publication: 07/08/2019

1 St Catherine's Hospice - Scarborough Quality Report 07/08/2019

and specialist palliative counselling services whichincludes a service for families. The hospice also providesa specialist palliative social work service, spiritual care,carer support, education for patients and families and anout of hours telephone support line.

The hospice provides care to adults only althoughchildren are included in any family counselling serviceswhere appropriate. The hospice cared for 2388 patientsfrom February 2018 to January 2019; 681 were aged 18 to65 years and 1,825 were over the age of 65. Fifteenchildren aged from four to 17 were seen through thecounselling service offered to families.

We inspected this service using our comprehensiveinspection methodology. We carried out the inspectionon 14 May 2019 and 4 June 2019.

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

Services we rate

We rated this service as Outstanding overall.

• The service had enough staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to providethe right care and treatment.

• Staff completed and updated risk assessments foreach patient, risk assessments considered patientswho were deteriorating and in the last days or hoursof their life. Risk assessments considered patients’capacity dignity and choice.

• Staff recognised and reported incidents and nearmisses. Managers investigated incidents and sharedlessons learned with the whole team and its widernetwork.

• The service provided care and treatment based onnational guidance and evidence-based practice.

• Doctors, nurses and other healthcare professionalsworked together as a team to benefit patients,communicating effectively with other agencies toensure the best possible care and coordinationacross services.

• There was individual consultation with patientswhich ensured that food was appropriate to theirindividual needs and preferences, so it wasappealing to the patient and they were not put off bytoo large portion sizes.

• Staff treated patients with compassion and kindness,respected their privacy and dignity, and tookaccount of their individual needs to ensureperson-centred care.

• Feedback from people who used the service, thosewho are close to them and stakeholders wascontinually positive about the way staff treatedpeople. Patients said that staff went that extra mileand their care and support exceeded theirexpectations. Patient feedback regarding theemotional support from all staff groups and serviceswas consistently, extremely positive.

• There were multiple examples of where staff hadgone the extra mile to ensure person-focussed,exceptional care.

• Staff empowered patients and families to bepartners in care, practically and emotionally.People’s individual needs and preferences werecentral to the delivery of tailored services.

• The service was proactive in its approach tounderstanding the health needs of the localpopulation and working with other providers in thelocal health economy to ensure the service wasplanned and delivered in a way that met thoseneeds.

• Staff actively encouraged patients to give feedbackand dealt with any concerns as far as possible assoon as they were raised. Staff at all levels in theorganisation were engaged with improving servicesas the result of complaints.

• Leaders had the integrity, skills and abilities to runthe service. They understood and managed the

Summary of findings


priorities and issues the service faced. They werevisible and approachable in the service for patientsand staff. They supported staff to develop their skills.Staff felt supported and valued.

• The service had a vision and strategy that werefocused on sustainability of services and aligned tolocal plans within the wider health economy.

• All staff were committed to continually learning andimproving services. Leaders encouraged innovationand participation in research.

However, we also found the following issues that theservice provider needs to improve:

• The hospice had undertaken a mapping exercise ofsafeguarding training with the requirements in theadult and children’s intercollegiate guidance. Thishad identified gaps in adult safeguarding trainingrequirements at all levels and children’srequirements at levels one and two.Work wasunderway to address the gaps but this needed to beimplemented and embedded. Safeguarding policies/ procedures needed updating with the traininglevels required for the different staff groups.

• There was an ongoing review of all policies andprocedures to bring them up to date with currentguidance and best practice and there were still somepolicies out of date.

• Resuscitation equipment had not always beenchecked as per the services protocols.

• There was no evidence of actions taken, whenmedicine fridge temperatures went outside of therequired range

• Only 70% of junior registered nurses had received anappraisal in the last 12 months.

• Processes and systems in place regarding; trusteerecruitment and oversight/ management of theirperformance or development needs, audit andperformance target setting and monitoring, keepingpolicies and procedures up to date with currentguidance and best practice and oversight ofdisclosure and barring certificates were not robust.

• There were gaps in information to committees andboard to enable full oversight and governance of theservice.

• The business continuity plan was a work in progress.

Following this inspection, we told the provider that itshould make some improvements, even though aregulation had not been breached, to help the serviceimprove. Details are at the end of the report.

Anne Ford

Deputy Chief Inspector of Hospitals (NorthernRegion)

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Hospiceservices foradults

Outstanding –We rated the service as outstanding overall. Safe,effective and well-led were rated as good. Caring andResponsive were rated as outstanding.

Summary of findings


Contents

PageSummary of this inspectionBackground to St Catherine's Hospice - Scarborough 7

Our inspection team 7

Information about St Catherine's Hospice - Scarborough 7

The five questions we ask about services and what we found 9

Detailed findings from this inspectionOverview of ratings 14

Outstanding practice 42

Areas for improvement 42

Summary of findings


Location name here

Services we looked atHospice services for adults

Locationnamehere

Outstanding –


Background to St Catherine's Hospice - Scarborough

St Catherine’s Hospice is operated by St Catherine’sHospice Trust. The hospice opened at its current site in2004. It is an independent hospice in Scarborough, NorthYorkshire. The hospice primarily serves the communitiesof the Scarborough and Filey area. It also accepts patientreferrals from outside this area.

The hospice provides inpatient beds, a hospice at homeservice, specialist palliative care services, outpatientservices including a lymphoedema clinic, therapy andcounselling services, a specialist palliative social workservice and an out of hours telephone support line. Thehospice provides care to adult patients and support totheir families.

At the time of the inspection, a new manager had recentlybeen appointed and was in the process of registering withthe CQC to be the registered manager for the service. Aregistered manager is a person who has registered withthe CQC to manage the service. They have legalresponsibility for meeting the requirements of the Healthand Social Care Act 2008 and associated regulationsabout how the service is run.

St Catherine’s was previously inspected by CQC using anadult social care framework in 2016 and was rated asoutstanding overall. It was rated as Good for Safe andEffective and outstanding for Caring, Responsive andWell-led.

Our inspection team

The team that inspected the service comprised a CQClead inspector, one other CQC inspector and a specialistadvisor with expertise in end of life care. The inspectionteam was overseen by Sarah Dronsfield, Head of HospitalInspection.

Information about St Catherine's Hospice - Scarborough

The hospice had one inpatient unit which could take upto 18 patients. St Catherine’s Hospice Trust is currentlyregistered to provide the following regulated activities atSt Catherine’s Hospice - Scarborough:

• Diagnostic and Screening Procedures

• Personal Care

• Transport services, triage and medical adviceprovided remotely

• Treatment of disease, disorder or injury

During the inspection, we visited the inpatient unit, spenttime visiting patients with the hospice at home team anda clinical nurse specialist. We spoke with 15 staffincluding registered nurses, health care assistants,reception staff, medical staff, senior managers and one ofthe trustees. We spoke with two patients in the inpatientunit and two patients and their family members on home

visits. During our inspection, we observed patient careand interactions and reviewed nine sets of patientrecords. We also reviewed other information and dataabout the hospice and provided by the hospice to makeour judgements.

There were no special reviews or investigations of thehospice ongoing by the CQC at any time during the 12months before this inspection. We inspected the serviceusing new methodology on 14 May 2019, our inspectionwas announced at short notice, to ensure that everyonewe needed to speak with was available. We then carriedout a follow-up inspection on 4 June 2019.

Activity

The hospice cared for 2388 patients from February 2018to January 2019; 681 were aged 18 to 65 years and 1,825were over the age of 65. Fifteen children aged from four to17 were seen through the counselling service offered to

Summaryofthisinspection

Summary of this inspection


families. The hospice provided its services to patientsunder NHS funding agreements. The hospice did notprovide any privately funded services as the managementteam felt this would potentially create a conflict ofinterests.

The hospice employed a total of 154 staff this included;10 medical staff employed by the hospice there were afurther four trainees who worked under practisingprivileges. The hospice employed; registered nurses,healthcare assistants, clinical and non-clinical managersa range of allied health and social care professionals anda range of other support and administrative staff. Therewere 504 volunteers supporting St Catherine’s hospice,shops and fundraising activities.

Track record on safety (from February 2018 to January2019)

• Zero - Never events

• Zero - Serious incidents

• 63 - Clinical incidents; 36 no harm, 24 low harm and 5near miss. (April 2018 to October 2018)

• Zero incidences of hospital acquiredMeticillin-resistant Staphylococcus aureus (MRSA),

• Zero incidences of hospital acquiredMeticillin-sensitive staphylococcus aureus (MSSA)

• Zero incidences of hospital acquired Clostridiumdifficile (c.diff)

• Zero incidences of hospital acquired E-Coli

• Eight - formal complaints

• 152 - written compliments

Services accredited by a national body:

• The service was working towards achievingISO27001/13 accreditation with regard toinformation technology and informationgovernance.

Services provided at the hospice under service levelagreement:

• Health and safety management for all areas of thehospice trust was provided by another companyunder a service contract / agreement.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated safe as Good because:

• The service provided mandatory training in key skills to all staffand the overall compliance rate was 89% at the 31 March 2019

• Staff understood how to protect patients from abuse and theservice worked well with other agencies to do so.

• The service controlled infection risk well.• The design, maintenance and use of facilities, premises and

equipment kept people safe.• Staff completed and updated risk assessments for each patient

and removed or minimised risks. Risk assessments consideredpatients who were deteriorating and in the last days or hours oftheir life.

• The service had enough staff with the right qualifications, skills,training and experience to keep patients safe from avoidableharm and to provide the right care and treatment.

• All staff had access to an electronic records system that theycould all update.

• The service used systems and processes to safely prescribe,administer, record and store medicines.

• The service managed patient safety incidents well. Staffrecognised and reported incidents and near misses. Managersinvestigated incidents and shared lessons learned with thewhole team and its wider network.

• The service used monitoring results to improve safety.

However, we also found the following issues that the serviceprovider needs to improve:

• The hospice had undertaken a mapping exercise ofsafeguarding training with the requirements in the adult andchildren’s intercollegiate guidance. This had identified gaps inadult safeguarding training requirements at all levels andchildren’s requirements at levels one and two. Work wasunderway to address the gaps but this needed to beimplemented. Safeguarding policies / procedures neededupdating with the training levels required for the different staffgroups.

• Resuscitation equipment had not always been checked as perthe services protocols, gaps in the records indicated checkswere not always made daily or weekly when they should havebeen.

Good –––




• There was no evidence of actions taken, when medicine fridgetemperatures went outside of the required range

Are services effective?We rated effective as Good because:

• The service provided care and treatment based on nationalguidance and evidence-based practice.

• Staff gave patients enough food and drink to meet their needsand improve their health. There was individual consultationwith patients which ensured that food was appropriate to theirindividual needs and preferences, so it was appealing to thepatient and they were not put off by too large portion sizes.

• Staff assessed and monitored patients regularly to see if theywere in pain and gave pain relief in a timely way.

• Staff monitored the effectiveness of care and treatment. Theyused the findings to make improvements.

• The service made sure staff were competent for their roles.Managers appraised staff’s work performance and clinicalsupervision was available to provide support and development.

• Doctors, nurses and other healthcare professionals workedtogether as a team to benefit patients. They supported eachother to provide good care and communicated effectively withother agencies.

• Key services were available seven days a week to supporttimely patient care.

• Staff gave patients practical support to help them live well untilthey died.

• Staff supported patients to make informed decisions abouttheir care and treatment.


• Some policies such as the recruitment of volunteers’ policyneeded reviewing it did not have an issue or review date.

• Only 70% of junior staff nurses had received an appraisal in thelast 12 months.

Good –––

Are services caring?We rated caring as Outstanding because:

• People were truly respected and valued as individuals and wereempowered as partners in their care.

• Staff treated patients with compassion and kindness, respectedtheir privacy and dignity, and took account of their individualneeds.

Outstanding –




• Feedback from people who used the service, those who areclose to them and stakeholders was continually positive aboutthe way staff treated people. Patients said that staff went thatextra mile and their care and support exceeded theirexpectations.

• Staff prioritised the individual needs of patients by ensuringthat they understood how they could help the patient anddemonstrated innovative ways to meet their needs.

• Staff could provide multiple examples of where they had gonethe extra mile to ensure person-focussed, exceptional care.

• Staff provided emotional support to patients, families andcarers to minimise their distress. Staff recognised andrespected the totality of people’s needs. They always tookpeople’s personal, cultural, social and religious needs intoaccount.

• The hospice provided emotional support to patients and theirrelatives through offering a range of psychological supportoptions. Patient feedback regarding the emotional supportfrom all staff groups and services was consistently, extremelypositive.

• Staff supported and involved patients, families and carers tounderstand their condition and make decisions about theircare and treatment.

• There was a strong, visible person-centred culture. Staff werehighly motivated and inspired to offer care that was kind andpromoted people’s dignity. Relationships between people whoused the service, those close to them and staff were strong,caring and supportive. These relationships were highly valuedby staff and promoted by leaders

• People who use services are active partners in their care. Staffare fully committed to working in partnership with people andmaking this a reality for each person. Staff always empowerpeople who use the service to have a voice and to realise theirpotential. They show determination and creativity to overcomeobstacles to delivering care. People’s individual preferencesand needs are always reflected in how care is delivered.

• People’s emotional and social needs are highly valued by staffand are embedded in their care and treatment.

Are services responsive?We rated responsive as Outstanding because:

• Services were tailored to meet the needs of diverse groups ofpeople and were delivered in a way to ensure flexibility, choiceand continuity of care.

Outstanding –




• People’s individual needs and preferences were central to theplanning and delivery of tailored services. The services wereflexible, provided choice and ensured continuity of care.

• The involvement of other organisations and the localcommunity was integral to how services were planned andensured that services met people’s needs. There wereinnovative approaches to providing integrated person-centredpathways of care that involve other service providers,particularly for people at the end of their life including thosewith multiple and complex needs.

• There was a proactive approach to understanding the needs ofdiverse groups of people and to deliver care in a way that metthose needs and promoted equality. This included people whowere in vulnerable circumstances or who had complex needs.

• Patients could access the specialist palliative care serviceswhen they needed it. Waiting times from referral toachievement of preferred place of care and death were in linewith good practice.

• There was active review of complaints and how they weremanaged and responded to, and improvements were made asa result across the services. People who used services wereinvolved in the review.

• Staff actively encouraged patients to give feedback and dealtwith any concerns as far as possible as soon as they wereraised. Staff at all levels in the organisation were engaged withimproving services as the result of complaints.

Are services well-led?We rated well-led as Good because:

• Leaders had the integrity, skills and abilities to run the service.They understood and managed the priorities and issues theservice faced. They were visible and approachable in theservice for patients and staff. They supported staff to developtheir skills.

• The service had a vision for what it wanted to achieve and astrategy to turn it into action, developed with all relevantstakeholders. The vision and strategy were focused onsustainability of services and aligned to local plans within thewider health economy.

• Staff felt supported and valued. They were focused on theneeds of patients receiving care. The service providedopportunities for career development. The service had an openculture where patients, their families and staff could raiseconcerns without fear.

Good –––




• The service had a clear governance structure. Staff at all levelswere clear about their roles and accountabilities and hadregular opportunities to meet, discuss and learn from theperformance of the service.

• Leaders and teams identified and escalated relevant risks andissues and identified actions to reduce their impact.

• The service collected a variety of data and analysed it tounderstand performance in specific areas, make decisions andimprovements.

• The information systems were integrated and secure. Data ornotifications were consistently submitted to externalorganisations as required.

• Leaders and staff actively and openly engaged with patients,staff, equality groups, the public and local organisations to planand manage services. They collaborated with partnerorganisations to help improve services for patients.

• All staff were committed to continually learning and improvingservices. Leaders encouraged innovation and participation inresearch.


• We were not assured that the processes and systems in placeregarding trustee recruitment, audit and performancemonitoring and oversight of essential human resourceinformation such as training data and currency of disclosureand barring certificates were robust.

• Key performance information presented to the board andcommittees tended to be around activity and lacked analysis toeasily identify themes and trends or to monitor or benchmarkperformance. There were gaps in the information provided tocommittees and board needed for thorough governance.

• The business continuity plan was a work in progress.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Hospice services foradults Good Good Good

Overall Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Outstanding –

Responsive Outstanding –

Well-led Good –––

Are hospice services for adults safe?

Good –––

We rated safe as good.

Mandatory training

• The service provided mandatory training in key skillsto all staff and the overall compliance rate was 89% atthe 31 March 2019

• The mandatory training was comprehensive and metthe needs of patients and staff.

• Mandatory training topics included the MentalCapacity Act and deprivation of liberty, safeguardingchildren and adults, moving and handling, complaints,infection prevention and control, equality anddiversity, fire safety, cardio-pulmonary resuscitationand medicines management. The training was amixture of e-learning and face-to-face sessions.

• The overall compliance rate for nursing and medicalstaff at the hospice was 89%.

• The hospice wanted to achieve 100% compliance withmandatory training. The training target was not metbut compliance with most modules was over 85% withthe exception of safeguarding children which was 72%and equality and diversity which was 77%.

• Managers monitored mandatory training howeverthere was no systematic process in place to monitorcompliance and this data did not appear in clinicalgovernance committee or board minutes.

• Staff we spoke with said that they were up to date withtheir mandatory training and they received reminderswhen training was due or when training had expired.

• There was a structured induction process for staff toensure they had the skills needed for their roles. Allstaff including bank staff were provided with inductionand orientation to their work area, mandatory trainingand there were series of individualised competencesfor staff of different roles to work through.

Safeguarding

• Staff understood how to protect patients from abuseand the service worked well with other agencies to doso.

• Staff knew how to identify adults and children at riskof, or suffering, significant harm and worked with otheragencies to protect them. We observed one memberof staff appropriately making a safeguarding alert dueto their concerns regarding how a patient’s financeswere being managed.

• Staff we spoke with knew how to make a safeguardingreferral and who to inform if they had concerns. Stafftold us they discussed any safeguarding cases at theirmonthly staff meeting and as part of their reflective /clinical supervision sessions.

• The service made appropriate alerts, notifications andraised concerns to safeguard their patients.

• The service had safeguarding procedures for childrenand vulnerable adults, which were accessible to staffon the shared intranet. While the procedures gaveclear guidelines for what staff should do if theysuspected abuse and where to access support and

Hospiceservicesforadults

Hospice services for adults

Outstanding –


information the children’s procedures were not in linewith intercollegiate guidance: ‘Safeguarding Childrenand Young People: Roles and competencies for HealthCare Staff’ (March 2014) with regard to training.

• The safeguarding adult’s procedure includedinformation on level of training for staff in differentroles; awareness level – for all staff including shopvolunteers, alerter level for all staff with patientcontact and responder / referrer level for medical,nursing and other clinical staff. Training requirementsneeded to be in line with intercollegiate guidance‘Adult Safeguarding: Roles and Competencies forHealth Care Staff: August 2018’ and this was not clear.

• We saw evidence that managers had already mappedtheir current training to the intercollegiate guidancefor adults and children and had identified the gapsand how they could meet the training requirementsgoing forward.

• The service reported that 99% of staff involved in thecare of adults had been trained to SafeguardingVulnerable Adults Level 1 and 65% had been trained toLevel 2.

• The overall training compliance for children’ssafeguarding training at 31 March 2018 was 72%.Managers told us the rate was low because of the gapsidentified in the mapping exercise as they werelooking at alternative ways of providing training. Thisexercise had now been completed so it was expectedtraining compliance would soon increase.

• The service had a safeguarding lead for adults andchildren and staff knew who to go to if they neededadvice or support. The service safeguarding lead wastrained to level 3.

• The service reported that there was only onecounsellor working directly with children and theywere trained to level 3 in in safeguarding children.

• The service monitored and recorded which patientshad appointed people with lasting powers of attorneywhich ensured all staff were aware who was able tomake decisions on behalf of their patients and in whatcapacity.

• All clinical staff and other staff working in directcontact with patients were checked through thedisclosure and barring service prior to being

appointed. The policy was that these checks weremade again every five years. It was difficult to establishthat all staff had current checks as the service wastransitioning from a paper human resource system toan electronic one. However, the random staff files andIT records we looked at did show those staff membershad checks that were in date. The managers will beable to have clear oversight of currency of disclosureand barring certificates when all staff records are onthe new system.

• The hospice was unable to evidence safeguardingtraining and current checks for all the trustees on ourfirst visit. Managers were sure these would have beencompleted on appointment but some may have beencarried out more than five years ago. However, by ourreturn visit all trustees had made new applications forthe checks to be renewed and managers providedassurance that trustees were to completesafeguarding training on an annual basis in line withother staff.

• The hospice management team had recently decidedto and had carried out disclosure and barring servicechecks for all volunteers working in the St Catherine’sshops and had also provided safeguarding awarenesssessions for these staff.

Cleanliness, infection control and hygiene

• The service controlled infection risk well. Staff usedequipment and control measures to protect patients,themselves and others from infection. They keptequipment and the premises visibly clean.

• All ward areas were clean and had suitable furnishingswhich were clean and well-maintained.

• We found that areas we visited were visibly clean andtidy. We reviewed a recent patient led assessment ofthe care environment which had some minor issuesnoted for improvement.

• Cleaning records were up to date and demonstrated

• During the inspection, we observed that staff werecompliant with hand hygiene policies, including ‘barebelow the elbows and personal protective equipmentpractices.



Outstanding –


• Facilities for hand hygiene were available throughoutthe service, staff and visitors we saw were compliantwith use.

• Staff we spoke with said that they had access topersonal protective equipment (PPE). We observedstaff using gloves and aprons appropriately.

• Staff cleaned equipment after patient contact andlabelled equipment to show when it was last cleaned.Reusable equipment we reviewed such as commodeswere clean, labelled as clean and ready for use andwell maintained. Toilets in empty rooms were alsolabelled to provide assurance to patients that the areahad been cleaned and was ready for use.

• All staff were expected to undertake training ininfection prevention and control, compliance withtraining at the 31 March 2019 was 87%.

• All rooms were single occupancy so were available forpatients requiring isolation.

• There was an annual programme of 16 infection,prevention and control audits in clinical andnon-clinical areas. The consolidated audit report for2018 - 2019 showed compliance levels in the majorityof areas were above 90%. Compliance with handhygiene, protective equipment and care of thedeceased patient were all at 100%. Any areas ofnon-compliance were noted for improvement actionsto be taken.

• Managers told us they had sought the advice andsupport of the local hospital domestic supervisorystaff to help develop cleaning standards for theturnaround of beds and patient rooms.

• Between February 2018 and January 2019, the servicehad no instances of the following healthcare acquiredinfections Methicillin-resistant Staphylococcus aureus(MRSA), Methicillin-sensitive Staphylococcus aureus(MSSA), Escherichia coli (E-coli) or Clostridium Difficile(C. Diff).

Environment and equipment

• The design, maintenance and use of facilities,premises and equipment kept people safe. Staff weretrained to use them. Staff managed clinical waste well.

• The service had suitable facilities to meet the needs ofpatients’ families.

• Patients could reach call bells and staff respondedquickly when called.

• The service had enough suitable equipment to helpthem to safely care for patients. Community staff toldus they could get a same day delivery for essentialequipment and they were able to ‘fast track’ otherequipment which would be received within a week.

• Staff disposed of clinical waste safely. We sawappropriate processes for segregation of waste,including colour coded waste and facilities fordisposal of sharps. We saw that community staff usedsingle use sharps bins.

• Resuscitation equipment was available for staff to use,this was stored behind a locked door, however all staffhad electronic access fobs. Resuscitation equipmentwe checked was clean and ready for use. There was achecklist held separately from the equipment butthere were gaps in the records that indicatedequipment was not always checked as regularly as itshould.

• The inpatient unit was secure with restricted access toauthorised staff, patients and visitors.

• Staff we spoke with said that they had adequatestocks of equipment and we saw evidence of stockrotation. All storage areas were clean, well-organisedand stock was stored off the floor. The hospice athome team had a process in place for ordering andcontrol of stock.

• We reviewed five pieces of equipment and found theyhad all been safety tested within the last 12 months.

• All rooms were decorated and well maintained, roomsall had access to patio doors opening on to gardenareas. They all had en-suite facilities and hoists, staticor mobile to enable staff to move patients safely.

• Two separate bedrooms with en-suite facilities and arelative’s lounge had been allocated for families andcarers to use as required.

Assessing and responding to patient risk

• Staff completed and updated risk assessments foreach patient and removed or minimised risks. Riskassessments considered patients who weredeteriorating and in the last days or hours of their life.



Outstanding –


• On admission to the inpatient unit staff helddiscussions with patients regarding expected andunexpected deterioration to establish patients’ wishesand determine ceilings of care. Discussions and ceilingof care was clearly documented in the patient recordswe looked at. This information was included in thehandover notes so all staff knew what to do in theevent of an acute deterioration. In the event of anacute deterioration, depending on the category of thepatient an initial assessment would be completed by adoctor and if it was appropriate the patient would betransferred to an acute hospital by a 999 ambulance.

• There was a clinical emergency procedure in place forpatients who became acutely unwell when attendingoutpatient services or the well-being centre.

• Staff we spoke with were knowledgeable about whento escalate a deteriorating patient and knew how toimplement procedures to ensure timely andappropriate treatment.

• Staff completed risk assessments for each patient andupdated them when necessary. Risk assessmentsundertaken included falls, confusion, nutrition andpressure ulcers. We found that risk assessments andcare plans were reviewed and updated weekly orsooner if the patient’s condition changed significantly.Risk assessments were recorded on the patient’selectronic record which could be accessed by allhospice nursing and medical staff and paper copieswere left with the patient when receiving care in thecommunity.

• We reviewed risk assessments in five sets of inpatientrecords, in all sets of notes we reviewed we foundthese were fully completed.

• Staff completed, or arranged, psychosocialassessments and risk assessments for patientsthought to be suffering with mental health problems.

• Staff shared key information to keep patients safewhen handling over their care to others.

• Shift changes and handovers included all necessarykey information to keep patients safe. Discussionsincluded patients’ capacity and identified patients

who needed extra support with decision making andadvance care planning. Referrals were discussed andrated Red, Amber or Green to enable staff to prioritiseadmissions to the hospice inpatient unit.

• Inpatient unit and hospice at home staff attended asafety huddle each morning to handover care. Staffidentified patients of concern, patients requiringreferral to other services, they discussed safety alertsand highlighted risks any other risks staff needed to beaware of.

• Managers told us they had discussed ligature riskswithin the hospice with a colleague from the localmental health trust following a national safety alert.Staff had arranged to visit the Cross Lane Hospital inJune 2019 to learn about any safety improvementsthey could make at the hospice.

• The service used a cross-boundary ‘do not attemptcardio-pulmonary resuscitation’ (DNACPR) form whichwas recognised in the hospital and across primarycare services. The registered nurses were trained tohave these conversations with patients and relativesand the clinical nurse specialists or a doctor wouldrevisit the patients’ decisions and complete theappropriate documentation.

• Advance care plans were discussed and documentedin the patient’s electronic record.

• Community staff had an emergency folder for easyaccess to contacts and information they may need inan emergency situation.

Nurse staffing

• The service had enough staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment. Managers regularly reviewedand adjusted staffing levels and skill mix, and gavebank, agency and locum staff a full induction.

• The service had enough nursing staff of all grades tokeep patients safe.

• The service had benchmarked their inpatient unitstaffing levels with other hospices in 2018 and 2019, toensure that they were appropriate, staffing levels werechecked daily at the safety huddle meeting. Anyconcerns were escalated following this meeting.



Outstanding –


• Managers used a staff care tool to rate staffing levelsas red, amber or green and used the ‘Mary PotterHospice Nursing Acuity Tool – In Patient Unit’ to reviewthe number and grade of nurses, nursing assistantsand healthcare assistants needed for each shift.

• We reviewed the staff care system and found that thenumber of nurses and healthcare assistants matchedthe planned numbers for almost all the shifts over theprevious two months.

• The clinical services manager could adjust staffinglevels according to the needs of patients. Staff workedflexibly across the community and inpatient teamsand any shortfalls were covered by staff movement,staff working additional hours and by using thehospice bank staff. Agency staff could be arranged butmanagers told us there was rarely a need for this.

• The clinical nurse specialist team had undertaken abench marking exercise with other similar services inthe Yorkshire region to look at caseload size,population and time of patients on the caseload.Caseload size was much larger than their peer groupas was the time spent on caseload, there were similarratios of staff to population size. Because of thisbenchmarking exercise the team were going to reviewhow they were managing their caseloads to see if theycould manage this differently.

• The hospice at home team recorded their visits on ashared calendar and could ring in to the centre if theyneeded to know where other staff were if they neededassistance from another member of the team. Theteam had an escalation plan if they were underpressure of workload and needed additional staff.

• The hospice had lone worker and bad weather plansin place for community staff. All staff logged in and outwhen they entered the building. night visits werealways undertaken by two members of staff.

• The service had low vacancy and sickness ratesamong clinical staff. The only vacancies in February2018 were for a part time pharmacist and a part timetherapy support worker. The highest area for sicknesswas the inpatient unit whose rate was 3.6%, thehospital at home rate was 0.5%.

• The hospice had not used any agency staff to covernursing or therapy shifts from February 2018 toJanuary 2019. The hospice did not provide data forbank staff use as these were their own contracted staff.

• Managers limited their use of bank and agency staffand requested staff familiar with the service. Thehospice at home staff told us the bank staff whoworked with them worked regularly and were familiarwith the service.

• Staff told us they received an induction when theystarted working for the hospice and had a localinduction specifically for the hospice at home service.Bank and agency staff received an induction whenthey started working for any of the hospice teams.

• The leadership team acknowledged that it waschallenging to recruit and retain staff due to a varietyof factors and had identified some improvements thatcould be made to help them recruit and retain staff.

• The hospice provided placements for student nursesfrom the local university and were also training threenursing associates.

• We saw from staff files that the recruitment processwas thorough and all the necessary safety checks wereundertaken.

Medical staffing

• The service had enough medical staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment. Managers regularly reviewedand adjusted staffing levels and skill mix and gavelocum staff a full induction.

• The service had enough medical staff to keep patientssafe. The service had recently undertaken a safestaffing review in line with the Royal College ofPhysicians Guidance and was compliant withrecommendations.

• The service always had two medical staff on-callproviding 24 hour – seven day a week cover, there wasalways senior specialist palliative care advice availablefrom a consultant on-call.

• Handover of information was both verbal and writtenand included ceilings of care.



Outstanding –


• The service had 0% vacancy and sickness rates formedical staff from February 2018 to January 2019.There had been no need for locum use as shifts werecovered by substantive staff and specialists workingunder practising privileges when needed.

• The hospice supported medical training programmesin relation to palliative care. Medical trainees camefrom GP and acute medical training programmes andthe hospice worked with the deanery and medicalschool to ensure placements were meeting the needsof the trainees.

Records

• Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date, storedsecurely and easily available to all staff providing care.

• Staff always had access to up-to-date, accurate andcomprehensive information on patients’ care andtreatment. All staff had access to an electronic recordssystem that they could all update.

• Patient notes were comprehensive and all staff couldaccess them easily.

• When patients transferred to a new team, there wereno delays in staff accessing their records

• Records were stored securely

• Hospice at home staff used both electronic and paperrecords as they left patient held records for patients’families and other care providers to refer to.

• Electronic records were available for all patients. Wereviewed five sets of records during the inspection andsaw that these were appropriately completed. Riskassessments, care plans and daily records were alldocumented and updated as they should be.

• We did not see a specific records audit in place but wedid see that records were audited for specificpurposes such as collecting outcome data and thatany gaps or errors found were acted on.

Medicines

• The service used systems and processes to safelyprescribe, administer, record and store medicines.

• Staff followed systems and processes when safelyprescribing, administering, recording and storing

medicines. There was an accountable officer withinthe hospice and the local NHS trust provided adviceand support, which was available 24 hours – sevendays a week, and an independent review of processesthrough quarterly audits. The hospice was in theprocess of recruiting their own pharmacist.

• Staff stored and managed all medicines andprescribing documents in line with the provider’spolicy.

• Medicines including controlled drugs were storedcorrectly with access restricted to authorised staff;they were checked in line with the policy and therewere no discrepancies in controlled drug registers.Controlled drugs were audited by the nurse in chargeof the inpatient unit on a daily basis and the local trustpharmacist completed a quarterly audit.

• Medical gases we reviewed were all storedappropriately in designated holders.

• The temperature of fridges used to store medicineswere recorded, however there was no evidence ofactions taken, if the temperature went outside of theexpected range.

• We reviewed two medicine administration charts andnoted that medicines were prescribed andadministered in line with national guidance.

• Staff received competency based training in medicineswhich was included hospice and care homeregulations and competency was reassessed annually.Hospice at home healthcare assistants were trained tobe able to counter sign for administration ofmedicines via a syringe driver.

• Staff reviewed patient’s medicines regularly andprovided specific advice to patients and carers abouttheir medicines. Medical staff could access medicinesinformation for patients newly transferred patientsfrom the local NHS trust through remote access to thetrust’s electronic prescribing system to enablemedicines reconciliation.

• An audit of medicine charts August to November 2018showed 31 errors, the commonest error was ‘notcorrectly crossing off medication’. Action was taken toalert medical staff of the results of the audit and



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highlight the need to ensure medicines were correctlycrossed out if no longer needed or if the dose had hadchanged. This audit was to be repeated to monitor ifimprovements had been made.

• Other medicine audits were taken in the hospice athome service in April / May 2018, observational auditsof controlled drug administration in February 2019and no major issues were identified.

• We found that 11 of the reported incidents from April2018 to October 2018 were in relation to controlleddrugs but we were not made aware of any themes oractions taken with regard to these incidents.

Incidents

• The service managed patient safety incidents well.Staff recognised and reported incidents and nearmisses. Managers investigated incidents and sharedlessons learned with the whole team and the widerservice. When things went wrong, staff apologised andgave patients honest information and suitablesupport. Managers ensured that actions from patientsafety alerts were implemented and monitored.

• The service had an incident reporting policy, thisprovided staff with information about reporting,escalation and investigating incidents. The ‘IncidentManagement and Reporting Policy and Procedure’gave a clear direction for managing serious incidents,notifiable safety incidents and duty of candour.

• From February 2018 to January 2019 the servicereported zero never events.

• From February 2018 to January 2019 the servicereported zero serious incidents. the NHS EnglandSerious Incident Framework 2015.

• From April 2018 to October 2018 the service reported63 incidents. Of these 36 were no harm, 24 were lowharm and 5 were a near miss.

• The largest categories of incidents were falls (34) andcontrolled drug related incidents (11) we saw that staffat the hospice had undertaken a review of falls toidentify the most common causes and contributingfactors. There were a number of factors to beconsidered for potential ways of reducing falls. Thehospice had taken some actions to reduce the numberof controlled drug errors

• Staff we spoke with said that there was a positivereporting culture in the service and learning fromincidents was shared with staff through individualconversations, emails, team meetings and huddles.

• All staff we spoke with knew what incidents to reportand how to report them. Staff gave us examples ofincidents they had reported, including an incident thatdid not result in any patient harm but was anopportunity for learning. They were able to tell us howthis incident had led to additional training regardingdiabetes and self-medication of insulin at the end oflife to incorporate a need to ensure family memberswere trained and able to continue administration ofinsulin if this was required.

• Staff understood the duty of candour. They were openand transparent and gave patients and families a fullexplanation if and when things went wrong. The Dutyof Candour (DoC) is a legal duty to inform andapologise to patients if there have been mistakes intheir care that has led to moderate or significant harm.

• Managers debriefed and supported staff after anyserious incident. We were informed of a seriousincident when staff had been offered support fromothers within the hospice and from partners in thehospice network.

• Managers investigated incidents thoroughly. Patientsand their families were given the opportunity to beinvolved in these investigations if they wished.

• Staff received feedback from investigation ofincidents, both internal and external to the service.Staff told us about incidents they had reported aboutsyringe drivers. They had received feedback from theincidents and were aware of any learning

• Feedback from incidents was shared in team meetingsand improvements to patient care were looked at.

• There was evidence that changes had been made as aresult of feedback. Following a recent serious incident,the service had shared learning from the incidentthrough educational sessions, improved policies andprotocols, simulations and improved access torequired equipment. Staff we spoke with were awareof the incident and confirmed that theseimprovements had been shared.

Safety Thermometer (or equivalent)



Outstanding –


• The service used monitoring results well to improvesafety. Staff collected safety information and shared itwith staff, patients and visitors.

• ‘The service continually monitored safetyperformance’ by monitoring pressure ulcers and fallsand by using root cause analysis to identify if any ofthese incidents were preventable and what could bedone to reduce the risk of these in the future.

Are hospice services for adults effective?(for example, treatment is effective)

Good –––

We rated effective as good.

Evidence-based care and treatment

• The service provided care and treatment based onnational guidance and evidence-based practice.Managers checked to make sure staff followedguidance. Staff protected the rights of patients in theircare.

• People’s physical, mental health and social needswere holistically assessed by the service and care andtreatment was delivered in line with legislation,standards and evidence-based guidance.

• Patients had a clear personalised care plan thatreflected their needs and was up to date. Staffdelivered care to patients in the last days of life thatmet the ‘five priorities of care of the dying person’ inline with NICE guidance and quality standard for ‘careof dying people in the last days of life.’. Individual careplans took account of symptom control,psychological, social and spiritual support and we sawevidence of discussion with patients and relativesrecorded in care plans. This gave us assurance thatcare plans were agreed and developed with theconsent of the patient.

• The service monitored the review of National Instituteof Clinical Excellence (NICE) guidance and Medicinesand Healthcare products Regulatory Agency (MHRA)alerts.

• Anticipatory medicines for distress, agitation, seizuresand pain were prescribed and given in line with NICEguidelines for care of the dying adult in the last days oflife and palliative care for adults.

• Patient’s visited by the hospice at home or clinicalnurse specialist teams and attending the hospice inboth the day therapy service and inpatient unit hadthe opportunity to develop an advance care plan.

• Opportunities to participate in benchmarking, peerreview, and research were proactively pursued. Theservice worked closely with the local NHS researchteams, when participating or planning researchprojects.

• The service was committed to participation in nationalresearch and innovation projects to benefit theirpatients. We saw that research projects were chosenwith care to ensure the contribution and learningwould be of benefit to palliative care patients and ortheir families. The hospice had taken part in a Cchange project to help develop and validate apatient-centred, classification for adult palliative careprovision, with the aim of reliably reflecting thecomplex needs and concerns of patients and families,in order to enable the delivery of better quality andmore efficient care in the last year of life. The hospicehad also been involved in a delirium project over thepast few years and results were due to be publishedsoon. Two further projects were being considered bythe hospice; a body image study and the ‘Resolve’project regarding improving health status andsymptom experience for people living with advancedcancer. Any proposed projects and ethicalconsiderations were deliberated by the executiveteam and the governance and compliance committeebefore being agreed.

• Although the hospice was not registered to use theformal Gold Standards Framework, due to costrestraints the hospice has adopted its principles in thedevelopment of their model of support and educationfor the care homes and GPs. The hospice was alsosupporting GP practices to achieve local ‘DaffodilStandards’ which are similar to the Gold StandardFramework standards.



Outstanding –


• Community Specialist Teams attend Gold StandardsFramework multidisciplinary team meetings for the GPpractices they cover.

• At handover meetings, staff routinely referred to thepsychological and emotional needs of patients, theirrelatives and carers.

• The hospice had started an incremental review of allpolicies and procedures in 2018 in partnership with anexternal provider. We saw that some policies such asthe recruitment of volunteers’ policy still neededreviewing as they did not have an issue or review date.Safeguarding procedures also needed to be updatedwith current guidance regarding staff training.

• When new protocols or guidelines were issued staffwere expected to sign a declaration that they had readand understood them. The process for ensuring staffhad read and understood policies also included aprocess for asking questions if anything was unclear.

Nutrition and hydration

• Staff gave patients enough food and drink to meettheir needs and improve their health. They usedspecial feeding and hydration techniques whennecessary. The service made adjustments for patients’religious, cultural and other needs.

• Staff made sure patients had enough to eat and drink,including those with specialist nutrition and hydrationneeds.

• Staff made sure patients had support with nutritionand hydration to meet their needs.

• We saw that staff were available to provide support topatients that needed assistance with food as required.

• Staff fully and accurately completed patients’ fluid andnutrition charts where needed.

• Staff used a modified screening tool to monitorpatients at risk of malnutrition and risk assessmentswere completed for patients requiring thickeners infood or fluids.

• Specialist support from staff such as dieticians andspeech and language therapists* was available forpatients who needed it.

• Patients and relatives, we spoke with, spoke withgenuine pleasure about the food and drink choicesavailable in the service.

• A patient told us that a member of the catering teamhad been to see them to discuss their likes anddislikes and portion sizes. This had ensured that foodpresented was appealing to the patient and that theywere not put off by too large portion sizes.

• Patients were able to choose to have lunch in a varietyof places for example, own bedrooms, patient diningroom, garden or general dining room if they wanted toeat with their relatives.

• Menus were seasonal and varied fortnightly and staffprovided patients with assistance to choose from themenu daily. Menu forms were completed to giveadditional dietary needs such as level of texturemodification needed, allergies, assistance needed orany other individual dietary needs. The hospice had adysphagia working group consisting of clinical andcatering staff who had helped trial and taste test (withpatients) a range of modified texture diets.

Pain relief

• Staff assessed and monitored patients regularly to seeif they were in pain and gave pain relief in a timelyway. They supported those unable to communicateusing suitable assessment tools and gave additionalpain relief to ease pain.

• Staff assessed patients’ pain using a recognised tooland gave pain relief in line with individual needs andbest practice.

• Patients received pain relief soon after requesting it.

• Staff prescribed, administered and recorded all painrelief accurately.

• We saw patients being offered pain relief on a regularbasis, patients and relatives we spoke with said thatpain relief was offered regularly and followingadministration staff checked that it had worked.

• Patients we spoke with said that staff respondedquickly to their requests for pain relief, and that staffreviewed their pain relief if it was not workingeffectively.



Outstanding –


• One patient being cared for at home told us that thenurses visited regularly to ‘get on top of painmanagement.’

Patient outcomes

• Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieve good outcomes forpatients.

• Information about the outcomes of patient care andtreatment was routinely collected and monitored.

• Patients were reviewed regularly by multi-disciplinaryteams regarding symptom management. The hospiceused ‘Outcome Assessment and ComplexityCollaborative’ (OACC) outcome measures to measureand improve care for patients and families

• The service managers told us they audited practiceagainst national and regional standards of care inclinical and non-clinical areas and that this includedcollecting information on advance care planning, donot attempt cardio-pulmonary resuscitation andachieving eye donation. However, we did not see thatthis information or OACC measures were comparedwith peers or set standards.

• The service audited its own performance in 2018/2019against the five priorities in the NICE guidance for theCare of the Dying Patient. The audit identified a needto improve some elements of care in relation toassessment and care planning particularly in relationto bowels and nutrition and the spiritual and culturalneeds of patients and carers and the documentationof discussions of various aspects of care andtreatment. The service had developed a number ofrecommendations and actions to improveachievement of the desired standards.

• Patient outcomes were recorded on System One andincluded; mental capacity assessment, preferred placeof death and Karnofsky scores. The KarnofskyPerformance Scale classifies patients as to theirfunctional impairment. The score is used to compareeffectiveness of different therapies and to assess theprognosis in individual patients. Each patient wasgiven a Karnofsky score when they were discussed at

the community and IPU multidisciplinary meeting.However, scores were not collated by the service orreported on in any other forum and therefore theservice was not benchmarking these or the outcomes.

• The hospice was able to provide data on how manypeople had DNACPR forms in place, how manypatients had care plans that set out their advance carepreferences and the number of people who had anadvanced decision / directive in place. Thisinformation was used to improve local practice.

• The service provided a care homes team whodelivered training and support to nursing andresidential homes in the locality. Part of the serviceinvolved devising a development plan for each hometo accommodate team building and their specifictraining and development needs.

• Following input from the hospice team improvedoutcomes were seen in advanced decision making,DNACPR forms in place and advance care plans in carehome patients. Of the patients with a recordedpreferred place of death this was achieved in 100% ofcases from April 2018 to October 2018.

• The hospice at home team had also achievedpreferred place of death in over 90% of cases in Apriland May 2018 and in 100% of cases from June 2018 toOctober 2018.

• Audits of moving and handling in the communitydemonstrated actions taken and improvements insubsequent audits.

• The lymphoedema team had audited patientknowledge about their condition and how to care fortheir skin integrity, how to identify and care for minorwounds and how to spot signs of infection and whento seek clinical advice. The results of the audit hadindicated that patient knowledge and self-care wasbetter when knowledge / education was current butpractices slipped over time. The findings of the audithad led to actions to improve education of patients byreinforcement at every contact, testing of knowledgeand provision of an educational leaflet.

• We found that the service had audited falls fromJanuary to June 2018, the audit identified a few areasand actions to be taken to reduce the number of



Outstanding –


patient falls. Staff were looking at the possible actionsfrom their findings to establish how actions may affectpatients’ self-care and how this may impact on aperson’s dignity and choice.

Competent staff

• The service made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held supervision meetings with them to providesupport and development.

• The continuing development of staff skills,competence and knowledge was recognised as beingintegral to ensuring high quality care. Staff wereproactively supported to acquire new skills and sharebest practice.

• Staff were encouraged to network and attend local,regional and national learning events and conferencesto share and bring back examples of good practiceand information about clinical developments /initiatives and any changes to or new best practiceguidelines.

• Staff were experienced, qualified and had the rightskills and knowledge to meet the needs of patients.Managers made sure staff received any specialisttraining and the clinical supervision required for theirrole. Staff worked towards achieving and maintainingcompetence in end of life and specialist palliative care.

• Registered nurses in the hospice at home team andclinical nurse specialists had undertaken a course in‘Advanced palliative care’.

• Staff told us they worked to NHS north of EnglandClinical Network palliative care guidelines which theywere all given and had signed to declare when theyhad read and understood them.

• Managers gave all new staff a full induction tailored totheir role before they started work. Staff were assessedagainst established competency frameworks.

• Managers supported staff to develop through yearly,constructive appraisals and clinical supervision oftheir work.

• From February 2018 to January 2019 100% of doctors,senior staff nurses and clinical nurse specialists hadreceived an appraisal in the last 12 months. Appraisalcompliance for allied health professionals, health care

assistants and staff nurses were 90%, 88% and 70%respectively. Staff we spoke with told us theirappraisals were up to date and they also received amid-year review.

• Re-validation was monitored and staff were alerted asthis approached the due date. All medical and nursingstaff had their registration status checked and all heldcurrent professional registration.

• Staff told us that their competence / practice wasintermittently observed through ‘shadow visits’ wherethey were accompanied by another member of staffwho observed their practice and provided feedback.

• Counsellors, clinical nurse specialists and clinicaleducators supported staff learning and development,facilitated clinical supervision and reflective practice.Managers ensured staff had access to debriefing andcounselling when appropriate, for example following aserious incident.

• Staff told us they received regular clinical supervisionand they could discuss any topic they felt they neededto during these sessions. Staff told us they could alsoattend group reflective sessions at the hospice andthat these were held six times a year. Social work staffwere members of the National Association of PalliativeCare Social Workers.

• Clinical nurse specialists aimed to have 1:1supervision every two months to reflect on theirpractice.

• There was a strong focus on education, both internallyfor hospice staff and externally for other providers ofcare and the service saw their role in developmentand delivering education as fundamental to their role.

• Staff had the opportunity to discuss training needswith their line manager and were supported todevelop their skills and knowledge.

• Staff we spoke with confirmed that they receivedopportunities to attend further courses andeducational sessions relevant to their work.

• Staff who were trained to verify death renewed theircompetencies annually. Training competencies werebased on NICE guidance.



Outstanding –


• Staff told us there were special interest / link nursesacross a range of topics which included; infectionprevention and control, continence, wound care anddementia. The link nurses provided support andtraining updates to the rest of the staff.

• The manager of the counselling team was developingan educational module for staff regarding mentalhealth to raise staff awareness, knowledge andconfidence in dealing with patients with mental issuessuch as anxiety and depression.

Multidisciplinary working

• All those responsible for delivering care workedtogether as a team to benefit patients. They supportedeach other to provide good care and communicatedeffectively with other agencies.

• Staff were committed to working collaboratively andworked across health care disciplines and with otheragencies when required to care for patients.

• There was a holistic approach to planning people’sdischarge, or referral to other services. Arrangementsfully reflected individual circumstances andpreferences.

• Staff held regular and effective multidisciplinarymeetings to discuss patients and improve their care.

• There were established multi-disciplinary meetings fordiscussion of patients, including patients who haddied or been discharged. Staff who attended themeetings included representatives from the acute andcommunity hospice teams, therapists and counsellors,medical staff and social care. Patients’ capacity orneed for capacity assessment and advanced decisionsincluding DNACPR were noted and discussed, bestinterest decisions and deprivation of libertyapplications were initiated if needed.

• The multi-disciplinary team discussed patients currentcare, symptom management, treatment needs andinitiated plans for patients’ discharge whereappropriate. The discussion was holistic covering theneeds of the family and whether there were anyfinancial needs the team could help with. Social teammembers were able to help with finances andfacilitated patients and families with accessingbenefits and grants and voluntary support for familiesand carers.

• The multi-disciplinary team also used the meeting todiscuss deaths and reflect on practice or if anythingcould have been done differently. The medicaldirector told us if there were any communicationsfrom coroners or other external bodies that requiredaction, investigation or to share learning then this wasshared through this forum.

• Staff we spoke with said that teams form all staffdisciplines were supportive and they had positiveworking relationships.

• Medical staff described effective working relationshipswith GPs and colleagues in the Acute hospital andgave examples of how they worked together toprovide the best possible patient experience andseamless transitions through the patient pathway.

• We observed that the inpatient hospice team and thehospice at home team worked effectively together.The hospice at home team provided its services inpartnership with Marie Curie and worked closely withthe community adult nursing services in the areas itcovered.

• Staff referred patients for mental health assessmentswhen they showed signs of mental ill health,depression.

• Patients and relatives had access to specialist teamswithin the hospice such as social workers, counsellors,spiritual coordinators, occupational therapy,physiotherapy and lymphoedema (chronic swelling)teams.

• Staff in the service held daily huddles to pass on keyinformation.

Seven-day services

• Key services were available seven days a week tosupport timely patient care.

• Consultants led daily ward rounds on all wards,including weekends.

• Staff could call for support from doctors and otherdisciplines, including mental health services anddiagnostic tests, 24 hours a day, seven days a week.

• Junior medical staff were available seven days a week,with out of hours access available to senior medicalstaff.



Outstanding –


• Access to senior nursing staff was available seven daysa week, including out of hours to provide support andassistance to junior staff.

• Pharmacy services were available out of hoursthrough the local NHS trust.

Health promotion

• Staff gave patients practical support to help them livewell until they died.

• The service had relevant information promotinghealth and offering support.

• Staff assessed each patient and family’s health needswhen admitted and provided support for anyindividual or family needs identified.

• Display boards and leaflets were available on a varietyof topics to enable patients and their families to livewell and access appropriate avenues of support.

• Patients had access to the wellbeing centre, whichoffered services such as complementary therapy.Patients’ relatives had access to counselling andbereavement support.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff supported patients to make informed decisionsabout their care and treatment. They followednational guidance to gain patients’ consent. Theyknew how to support patients who lacked capacity tomake their own decisions or were experiencing mentalill health. They used agreed personalised measuresthat limit patients' liberty, where necessary.

• The hospice had a trained mental capacity act anddeprivation of liberty safeguards lead, who the staffcould go to for advice and support when needed.

• Staff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Health Act, MentalCapacity Act 2005 and they knew who to contact foradvice.

• Consent is an important part of medical ethics andhuman rights law. Consent can be given verbally or in

writing. Staff we spoke with said that they alwaysobtained verbal consent, prior to carrying out care andtreatment for. Patients, patients and relatives wespoke with confirmed this.

• When patients could not give consent, staff madedecisions in their best interest, considering patients’wishes, culture and traditions.

• The Mental Capacity Act (MCA) 2005, is designed toprotect and empower individuals who may lack themental capacity to make their own decisions abouttheir care and treatment. It is a law that applies toindividuals aged 16 and over. Following a capacityassessment, where someone is judged not to have thecapacity to make a specific decision, that decision canbe taken for them, but it must be in their bestinterests. Staff we spoke with could give a clearexplanation of capacity assessment and theimportance of recognising how ill health could impacton patients’ capacity. Staff understood how and whento assess whether a patient had the capacity to makedecisions about their care.

• Registered nurses in the hospice at home team couldundertake a ‘mini mental capacity assessment’ whichthey then asked the patients’ GP to follow up.

• The Mental Capacity Act allows restraint andrestrictions to be used but only if they are in a person’sbest interest. Extra safeguards are needed if therestrictions and restraint used will deprive a person oftheir liberty. These are Deprivation of LibertySafeguards (DoLs). Staff we spoke with were aware ofthe legislation around deprivation of libertysafeguards.

• Managers monitored the use of Deprivation of LibertySafeguards and made sure staff knew how tocomplete them. Staff recorded on their systemwhenever patients who were subject to a Deprivationof Liberty Safeguards accessed their helpline services.

• Staff told us that advanced decisions to refusetreatment were also documented in patients’ recordswhere relevant.

• Staff could describe and knew how to access policyand get advice on Mental Capacity Act and Deprivationof Liberty Safeguards.



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• Compliance with Mental Capacity Act and deprivationof liberty safeguards training was 85% at 31 March2019.

Are hospice services for adults caring?

Outstanding –

We rated caring as outstanding.

Compassionate care

• People are truly respected and valued as individualsand are empowered as partners in their care.

• Staff treated patients with compassion and kindness,respected their privacy and dignity, and took accountof their individual needs.

• People were respected and valued as individuals andwere empowered as partners in their care.

• Staff were discreet and responsive when caring forpatients. Staff took time to interact with patients andthose close to them in a respectful and considerateway. Staff always did their utmost to maintain dignityand privacy.

• There was a strong patient centred culture in theservice. Care plans detailed patients’ preferences andprotected characteristics. Staff were highly motivatedand inspired to offer care that was kind and promotedpeople’s dignity. Relationships between patients andstaff were strong, caring and supportive. Theserelationships were highly valued by staff andpromoted by the leaders of the service.

• Staff used bespoke end of life documentation whichhelped them focus on priorities of care, whichincluded bereavement follow up for families.

• Staff understood and respected the individual needsof each patient and showed understanding and anon-judgmental attitude when caring for or discussingpatients with mental health needs. They understoodand respected the personal, cultural, social andreligious needs of patients and how they may relate tocare needs, always taking them into account.

• Patients and relatives, we spoke with said that staffhad made them feel very welcome. They said, ‘whatthe staff do is marvellous and they are worth theirweight in gold.’

• Patients and relatives, we spoke with, all confirmedthat staff were kind, caring, helpful and attentive.Patients also said that nothing was to much troublefor the staff and that no matter how busy staff werethey were able to make time for them. Patients told usthey received excellent support from the clinical nursespecialists and had provided them with emergencyand helpline numbers and support group informationfor their families.

• Patients, relatives and staff we spoke with all said thatsupport was provided to patients on an individualbasis and in line with patients’ individual needs, forexample they shared stories about animals visiting thehospice, dogs and cats staying in the hospice andfamilies being able to visit and stay over withoutrestriction.

• One patient told us their wife and dog had been ableto stay with them overnight during a previousadmission to the hospice.

• Patients told us nurses and doctors responded quicklyto any request they made for assistance or for reviewof symptoms / symptom management.

• One patient who had been attending thelymphoedema clinic wrote that from their first referralin 2013 the nurse had ‘been kind, considerate,reassuring, informative, patient, sympathetic andknowledgeable when showing me how to care for myskin’. This was typical of the comments and writtenfeedback received by the patients using not only thelymphoedema clinic but the other services.

• We overheard conversations between patients andstaff and all were conducted with dignity, respect andwarmth. We observed staff talking with patients in anextremely positive way throughout the inspection.

• Privacy and dignity were embedded into the culture ofthe service and staff used no entry signs when theywere providing personal care or treatment, or when



Outstanding –


patients needed additional support. This providedpatients with the appropriate time and space toreceive care and it provided staff with dedicated timeto deliver the care in a patient centred way.

• During the inspection, all patients we observed werecomfortable, looked well cared for and had theirprivacy and dignity maintained. We saw that all staffwere professional and courteous at all times andfollowed policy to keep patient care and treatmentconfidential.

• Staff told us they would be happy to have theirfamilies cared for at the hospice and they tried toensure they made the unit as welcoming as possibleto patients’ families so they felt able to come as oftenas they wanted and to stay as long as they wished tospend time with their loved ones. One of the trusteestold us that the staff’s success at this was reflected inthe high number of visitors to the unit.

• On hearing one patient’s wish to be able to visit atheme park with their family before they died, staff hadhelped raise money and enabled them to so. Thepatient and family told staff that they had a wonderfulday and a special memory.

• Feedback from people who use the service, those whoare close to them and stakeholders is continuallypositive about the way staff treat people. People thinkthat staff go the extra mile and the care they receiveexceeds their expectations

• Patient survey feedback, compliments and postcardsconsistently gave exceptional feedback about the staffand services at the hospice. The themes from thecompliments were of staff going above and beyond,providing exemplary care and attention, care, dignityand respect given to patients and families and couldnot have had better care.

• Patients described the services as ‘welcoming andfriendly and staff put me at ease’. One patientdescribed their initial assessment as ‘thorough andmost impressively a holistic approach to me, my life,and the problems I am experiencing.’

• Staff told us of a number of weddings and christeningsthey had facilitated at the hospice of for patients intheir care.

• Nursing staff were passionate about creating positivememories for patients and their families when stayingat the inpatient unit. Staff encouraged families andpatients to enjoy the gardens at the hospice and tohave fun with technology such as an Alexa and virtualheadsets. Virtual headsets were also used to offerpatients new sights and experiences. Staff told us theyoffered patients the opportunity to create and keepmoulds of hands as a keepsake for them and theirrelatives.

Emotional support

• People’s emotional and social needs are highly valuedby staff and are embedded in their care andtreatment.

• Staff provided emotional support to patients, familiesand carers to minimise their distress. They understoodpatients’ personal, cultural and religious needs.

• The hospice ran a support group for carers andcounsellors provided services for patients andfamilies. The service provided psychological andspiritual support for patients and post bereavementcounselling for their relatives. There was a counsellorwho could provide specialised support to children andyoung people.

• Relatives could attend one to one bereavementsessions with a psychologist or bereavement supportgroups.

• Feedback from users of these services wasconsistently positive.

• The Wellbeing Centre offered a range ofcomplementary therapies to support patients andtheir relatives including massage and aromatherapy.

• Staff understood the emotional and social impact thata person’s care, treatment or condition had on theirwellbeing and on those close to them.

• Staff recognised and took into account patient’spersonal, social and emotional needs. The patients’needs were valued by staff and were embedded intheir care and treatment.



Outstanding –


• Staff undertook training on breaking bad news anddemonstrated empathy when having difficultconversations. Three members of the hospice at hometeam had received additional training to be mentalhealth mentors.

• We observed staff providing reassurance to patientsthrough verbal communication and touch such as,holding hands for reassurance and comfort.

• Patients and relatives, we spoke with all said that thefelt safe within the hospice and were glad they werebeing cared for within that environment.

• Patients and relatives, we spoke with said that theywere never rushed, and staff “always had time tosupport them, give them a smile or have a little joke”with them.

• There were quiet spaces and gardens were patientsand relatives could sit and relax.

• We saw that the staff and leaders were visible, andpatients and relatives could speak with themwhenever they wanted to.

• Staff we spoke with said that they supported patientswith mental health conditions, addictions andhomelessness in a non-judgmental way and providedsupport according to the patient need and risks thatthey presented with. Staff told us how they hadsupported one patient with their addiction andrecovery and how this had subsequently led to thispatient being able to be discharged.

• The service ensured they supported the emotionalwellbeing of their staff by providing debriefing and theopportunity to speak with the service counsellors. Theservice was exploring how they may be able to bettersupport staff by providing a regular drop in session.

Understanding and involvement of patients andthose close to them

• Staff supported and involved patients, families andcarers to understand their condition and makedecisions about their care and treatment.

• People who used services were active partners in theircare. Staff were fully committed to working inpartnership with people and making this a reality foreach person.

• Staff empowered people who used the service to havea voice and people’s individual preferences werereflected in how care was delivered.

• Staff made sure patients and those close to themunderstood their care and treatment.

• We saw evidence in patient care records of patientsand family involvement in advance decision makingand plans of care. Patients and their relatives told usthat staff answered questions about care andtreatment openly and the information provided tothem was clear. We observed the community nursingstaff involving and engaging patients and theirrelatives in discussions about care planning.

• Staff talked with patients, families and carers in a waythey could understand, using communication aidswhere necessary.

• Patients and their families could give feedback on theservice and their treatment and staff supported themto do this.

• Staff supported patients to make informed andadvanced decisions about their care. Patient feedbackconfirmed that staff had helped them to talk abouttheir wishes and how staff had supported them withthis.

• Patients and relatives, we spoke with shared with usexamples of when staff had recognised and supportedtheir relationships, by letting them stay at the hospice,enabling them to be involved with providing care fortheir loved ones or just by sitting quietly with them.

• There was a culture of inclusion in decision makingand patients and relatives we spoke with said thatthey were involved in decisions made about their careand treatment.

• Patients we spoke with shared stories about the waysstaff had supported them to make decisions, forexample with housing needs.

• Patients we spoke with said that they were aware ofwho to approach if they had any issues regarding theircare, and they felt able to ask questions.



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• Patients we spoke with were aware of their dischargearrangements and actions required prior to discharge.A family meeting was held prior to discharge to ensuredischarge plans were communicated and all of thepatient’s needs had been taken into consideration.

• It was evident that patients and their families hadbeen provided with information to support them withaccessing services, giving medicines andunderstanding the progression of illness.

Are hospice services for adultsresponsive to people’s needs?(for example, to feedback?)

Outstanding –

We rated responsive as outstanding.

Service delivery to meet the needs of local people

• Services were tailored to meet the needs of diversegroups of people and were delivered in a way toensure flexibility, choice and continuity of care.

• The involvement of other organisations and the localcommunity was integral to how services were plannedand ensures that services meet people’s needs. Therewere innovative approaches to providing integratedperson-centred pathways of care that involve otherservice providers, particularly for people at the end oftheir life, particularly for those with multiple andcomplex needs.

• For example, staff told us how the lymphoedema clinichad been developed and how hard the hospice hadworked to sustain this service despite a reduction infunding. The hospice had been determined to savethis service as it was highly valued by patients andstaff. The hospice had worked with partners andestablished there was no other means to provide thisand had therefore decided to continue the servicedespite cost pressures.

• We found the senior management team worked withlocal commissioners, acute hospital teams, GP’s andother providers to provide a service that met theneeds of local people. The providers supported eachother to provide the best possible service to patients

at the end of their life across the whole pathway. Forexample, consultants from St Catherine’s supportedsome clinics and ward rounds at the local hospital andin reach to the community hospitals at Malton andWhitby and the hospice education team providedtraining and support into care homes and to GPs.

• The service had diversified the services it hadtraditionally offered, in addition to cancer services StCatherine’s was now able to offer services to patientswith other end of life conditions for example; liver,neurological and lung conditions. Clinical nursespecialists had been developed through extra trainingto support improve their service for neurology,lymphoedema and other specialist palliative carepatients.

• Senior medical staff held contracts with the local trustto facilitate cross-provider working and facilitation ofspecialist advice and support for patients in thecommunity, hospital or hospice setting.

• The senior management team were clear about theservices they needed to offer to local people and toother providers to improve the care of patientsreceiving end of life care not only in the hospice butalso in the local community wherever care wasprovided. They were clear about where services needto develop further and were working with localcommissioners, other providers and specialist teamsto expand the current provision.

• Facilities and premises were appropriate for theservices being delivered. The inpatient unit wasdesigned to meet the needs of patients living withdementia.

• The service had systems to help care for patients inneed of additional support or specialist interventionincluding counselling, mental health services and avariety of complementary therapies. Staff could accessemergency mental health support 24 hours a dayseven days a week for patients with mental healthproblems, learning disabilities and dementia.

• Staff from the hospice at home team told us they wereinvolved in ‘community working together meetingsand joint operational meetings with colleagues from



Outstanding –


community nursing services and social care to discussoperational pressures and to plan how the servicescould best work together to ensure patients receivedthe care and support they needed.

• The Hospice had started work to develop a singlepoint of access and was undertaking a piece of workusing the Strategic Health Asset Planning andEvaluation tool to look at local population needs aspart of future service design.

• Based on the success of specialist neurology end oflife provision a need for a similar service forParkinson’s was identified and set-up in collaborationwith the Parkinson’s team at the local acute trust.

Meeting people’s individual needs

• People’s individual needs and preferences werecentral to the planning and delivery of tailoredservices. The services were flexible, provided choiceand ensured continuity of care.

• There was a proactive approach to understanding theneeds of different groups of people and to deliver carein a way that meets these needs and promotesequality. This includes people who are in vulnerablecircumstances or who have complex needs.

• Patients could access assistance through thetelephone helpline or attend the day services whichincluded drop-in as well as more formal outpatientsupport.

• Staff made sure patients living with mental healthproblems, learning disabilities and dementia, receivedthe necessary care to meet all their needs.

• We reviewed care plans and saw that services werecoordinated with other agencies to provide care topatients with more complex needs. The hospice was inthe process of looking into how care coordinationcould be improved following a complaint where apatient’s family had experienced poor coordination.

• Staff could give examples of when they had referredpatients to community mental health services,community nursing teams and other services.

• Staff supported patients living with dementia andlearning disabilities by using ‘This is me’ documents,patient passports and memory boxes. Staff told us

that they had all attended a ‘Dementia Friends’awareness session and had received training around;mental capacity, safeguarding, deprivation of libertyand dementia.

• Staff were able to meet the information andcommunication needs of patients with a disability orsensory loss. Occupational therapists were availableto provide support with and provide communicationaids and advanced communication systems if needed.

• Managers made sure staff, and patients, loved onesand carers could get help from interpreters or signerswhen needed. The service had information leafletsavailable in languages spoken by the patients andlocal community. Translation services were availablefor patients whose first language was not English. Staffhad access to communication aids to help patientsbecome partners in their care and treatment.

• Patients were given a choice of food and drink to meettheir cultural and religious preferences.

• The services provided reflected the needs of thepopulation served, including patients with protectedcharacteristics under the Equality Act and those invulnerable circumstances. Reasonable adjustmentswere made so that patients with a disability couldaccess services on an equal basis to others. Forexample, the unit, was accessible for patients withlimited mobility and people who used a wheelchair.

• Patients received high quality individualised care,planned in a way which enabled patients to besupported appropriately and achieved goodoutcomes. The service used a Carer Support NeedsAssessment Tool (CSNAT) to help ensure tailoredsupport to families.

• Patients were able to attend the wellbeing centre ifthey felt able and could receive complementarytherapies, have hair styled or sit and chat with otherpatients.

• Patients had access to physiotherapy, occupationaltherapy, counsellors and social workers to help meetany physical, social or emotional / mental healthneeds. Support could be accessed 24 hours a day,seven days a week through a telephone helpline. The



Outstanding –


helpline was manned by the hospice at home team sothe staff were aware of any patient concerns orproblems and could respond with a home visit orfollow up telephone calls as needed.

• We saw that patients’ mental health and emotionalhealth needs were continually reassessed and referralto and access to appropriate support was immediate.We saw examples of when St Catherine’s staff hadhelped patients access services and facilitatedrehousing when their accommodation was unsuitablefor their needs. Staff had accessed services andcompleted forms on their patient’s behalf to ensurethey were provided with suitable housing that couldaccommodate their needs and any equipmentrequired to meet their care needs.

• Staff monitored and reviewed the changing needs ofpatients through regular ‘comfort rounds’ andfrequent medical reviews.

• Equipment was available to provide distraction topatients and relatives, such as games, books,magazines and puzzle books. Patient rooms had TVsand access to Wi-Fi, the hospice had recentlypurchased an Alexa which we saw one patientenjoying and some virtual reality headsets whichpatients could use to experience and ‘visit’ places andthings they had never seen.

• Patients were able to sit outside, have doors open tothe bedroom or go out outdoor visits as they felt able.

• Staff were knowledgeable about how patients wantedto be cared for, and this was documented incommunications and care plans about the patients.

• We heard discussions during handovers that plannedfor patients advancing conditions and includedpotential issues when they were being cared for athome. Staff discussed the possibility of needing a‘catastrophe bed’ for a patient if the family andmulti-disciplinary team were unable to meet theneeds of the patient at home as their conditiondeteriorated.

• The inpatient team were aware of when a bed may beneeded for a patient under the care of the hospice athome team and whether this would be needed for abrief admission, such as for a procedure, or paincontrol or whether this would be for ongoing care.

• Patients and relatives were able to access religiousservices and spiritual care, either individually orthrough collective worship in the onsite chapel.

• Staff told us that they would collect and returnmedicines for patients and their families if this wasstruggle for them even if this meant a trip of manymiles.

Access and flow

• Patients could access the specialist palliative careservice when they needed it. Waiting times fromreferral to achievement of preferred place of care anddeath were in line with good practice.

• From February 2018 to January 2019, 279 patientsaccessed the inpatient unit, 1320 accessed communityservices and 346 patients used day / clinical therapyservices provided by the well-being centre and 212attended consultant clinics or the lymphoedemaclinic.

• The unit had 14 medical beds open and had recentlyopened two additional nurse-led beds, to facilitatedischarge from hospital in the last days of life andimprove achievement of preferred place of death.Managers told us they were operating at around 80%bed occupancy.

• Referrals into the inpatient unit largely came from GPsand the local hospitals.

• Managers monitored waiting times and themultidisciplinary team prioritised referrals foradmission to make sure patients could access serviceswhen needed and received treatment within agreedtimeframes.

• From April to October 2018 the average waiting timefor an inpatient unit bed was 3 days

• From April to October 2018, 86% of patients admittedto a nurse led bed were admitted within 24 hours ofreferral.

• The reasons for patients suitable for a nurse led bedbut not transferred was monitored to identify why thetransfer had not taken place to identify any difficultiesthat could be avoided for future transfers.

• Attendance at the well-being centre was monitoredand a project had been undertaken to understand the



Outstanding –


patients’ reasons for not attending. As the mostfrequent reason was that patients had forgotten, areminder process had been introduced for patientswho attended at long intervals.

• The hospice at home team accepted referrals fromcommunity nurses, GPs and hospitals. Referrals werealso sometimes picked up by the team through a callto the helpline. The team facilitated discharges fromthe hospice inpatient unit and helped ‘fast track’packages of care in conjunction with their social carecolleagues, Marie Curie and community nursingservice.

• The service would be increasing its operationalinpatient beds from 14 to 16, in the coming months,these two additional beds were nurse-led with theintention this would increase the availability of beds toallow dying patients access to their preferred place ofdeath. The beds were ring fenced for hospital patientswho were in the last days of life.

• Multidisciplinary, multi-provider decision making wasevident in the approach to prioritising patients foraccess to the inpatient unit.

• Managers and staff worked to make sure patients didnot stay longer than they needed to.

• Managers monitored that patient moves betweenservices were kept to a minimum.

• The service moved patients only when there was aclear medical reason or in their best interest.

• Staff supported patients when they were referred ortransferred between services.

• Managers and staff worked to make sure that theystarted discharge planning as early as possible.

• Staff planned patients’ discharge carefully, particularlyfor those with complex mental health and social careneeds. Staff were proactive and communicated wellwith other services to prevent delayed discharges.

• The hospice had set up a single point of accessworking group to improve / streamline access to theservice.

• Patients could self-refer to counselling and well-beingservices.

• From November 2018 to January 2019 the averagewaiting time to access palliative care counsellingservices was 4.6 days.

• From November 2018 to January 2019 the averagewaiting time to access the bereavement supportservice was 0.8 days.

• The service had worked with local partners to developa care home proactive planning tool, the aim of thistool was to improve communication, bettercoordinate care, improve the utilisation of resourcesand decrease unwanted interventions and hospitaladmissions. The planning tool was based on the goldframeworks for improving end of life care.

Learning from complaints and concerns

• There was active review of complaints and how theywere managed and responded to, and improvementswere made as a result across the services. People whouse services were involved in the review.

• Staff actively encouraged patients to give feedbackand dealt with any concerns as far as possible as soonas they were raised. Staff at all levels in theorganisation were engaged with improving services asthe result of complaints

• The service treated concerns and complaintsseriously, investigated them and shared lessonslearned with all staff.

• From February 2018 to January 2019 the service hadreceived eight complaints. Two of the formalcomplaints were upheld. Seven of the complaintswere responded to within the target of 10 workingdays and the other complaint took 13 days. Thecomplaint exceeding the target response timereceived an explanation of why the investigation andresponse were delayed.

• There were no recurrent themes in the clinicalcomplaints but had highlighted areas of wherecommunication could be improved. The hospiceshared the learning and points for improvement withall relevant staff.

• We reviewed two complaints files and found; thesehad been investigated thoroughly, learning had beenidentified and managers had acted to makeimprovements to how services were delivered. Some



Outstanding –


of the actions taken to improve communication andcare coordination included changing from atelephone assessment, when patients were referred toanother practitioner, to a face to face handover in thepatient’s home. Community meetings had also beenimplemented to bring together all practitionersinvolved in a patient’s care on a weekly basis.Documentation of discussions with patients andfamilies was also highlighted as an area for staff toimprove. We saw from our review of files that staff andthe patients’ families had contributed tounderstanding how things could be improved.

• Managers shared feedback from complaints with staffand learning was used to improve the service. Theypromoted learning from complaints by engaging staffin the process and by asking for ideas from the team ofwhat they could learn from the complaint. Complaintswere also discussed as part of team meetings.

• Staff understood the policy on complaints and knewhow to handle them. Managers investigatedcomplaints and identified themes. Staff knew how toacknowledge complaints and patients receivedfeedback from managers after the investigation intotheir complaint.

• Patients, relatives and carers knew how to complain orraise concerns. Patients and their relatives weresupported and encouraged to voice concerns whereappropriate. Patients were given a leaflet explaininghow they can provide feedback or make a complaintas part of their welcome pack. The service clearlydisplayed information about how to raise a concern inpatient areas.

From February 2018 to January 2019 the service hadreceived 152 written compliments.

Are hospice services for adults well-led?

Good –––

We rated well-led as good.

Leadership

• Leaders had the integrity, skills and abilities to run theservice. They understood and managed the prioritiesand issues the service faced. They were visible andapproachable in the service for patients and staff.They supported staff to develop their skills.

• The service was led by a senior management team ofchief executive, a medical director, a business, peopleand income director and a clinical services director.The senior management team was supported by aboard of trustees. The management team and thetrustees were visible in the hospice and took time totalk to staff groups and be involved in walkabouts andassessments of the environment.

• We spoke with one of the trustees who told us theboard was well informed and able to challenge theleadership team in committees and at boardmeetings. They felt they had good oversight of thesuccesses and challenges of the organisation and ifany of the trustees raised an issue then themanagement team would respond quickly andappropriately.

• Each of the clinical departments such as the nursingservices, the therapy services, patient and familysupport services and the education and trainingservices were led by an appropriately qualified andexperienced member of staff. The inpatient team leadpost was vacant at the time of the inspection and wasbeing covered by the lead from the hospice at hometeam.

• We found that the service operational managers andthe senior management team were knowledgeableand approachable. They had a good understanding ofthe opportunities, risks and challenges the hospicefaced.

• The clinical services director was newly appointed inDecember 2018 and was still learning and developingthe scope and function of her role.

• Staff told us the senior managers were visible andapproachable and they felt supported. Team leadershad dedicated time for management and support ofstaff.



Outstanding –


• Leaders within the service went out of their way toensure that they were visible and approachable. Theleadership team included an executive team and aboard of trustees, staff we spoke with said they weresupportive and knowledgeable.

• The leadership team prioritised person-centred, safe,high quality, compassionate care and respected andvalued the opinion and contribution of staff, patientsand service users.

Vision and strategy

• The service had a vision for what it wanted to achieveand a strategy to turn it into action, developed with allrelevant stakeholders. The vision and strategy werefocused on sustainability of services and aligned tolocal plans within the wider health economy.

• The service had a vision to be the leading provider ofSpecialist Palliative and End of Life Care in the area,working in collaboration with others to deliver safequality person centred services

• Staff we spoke with and observed clearly shared thehospice ethos of prioritising person-centred care.

• The service had a clear strategy which included theelements of; clinical excellence, empowered people,innovation and improvement, systems and processes,financial sustainability and

• The strategy recognised that integration of servicesand working with partners was integral to success.

• The hospice had a set a of values and expectedbehaviours regarding person centred care, quality,team work and integrity. We saw that staff worked in away that upheld these values. The management teamintended to do further work around embedding valuesand expected behaviours into appraisals andperformance review.

• The service planned to develop the estate of thehospice to make the wellbeing services accessible topatients across a wider area and to make servicesmore accessible to hard to reach groups.

Culture

• Staff felt respected, supported and valued. They werefocused on the needs of patients receiving care. The

service promoted and provided opportunities forcareer development. The service had an open culturewhere patients, their families and staff could raiseconcerns without fear.

• Staff we talked with described the culture asprofessional, positive and supportive of training andprofessional development. Staff said they felt valuedby their colleagues and the service and they lovedworking at the hospice.

• The senior management team were proud of staff andthe care they delivered. We observed an open culturewith an emphasis on providing an excellent, bespokeservice based on the individual needs of patients andtheir families.

• Leaders of the service were keen to make StCatherine’s a great place to work and weredisappointed with the most recent staff survey results.Managers demonstrated they had listened to whatstaff had told them through the survey and wereacting to improve the areas of concern.

• One of the areas they wanted to improve was staffengagement with service improvement so they couldcontribute more to service design and inform wherecost savings could be made due to financial pressures,without compromising patient care. The leadershipteam wanted staff to feel they had a voice in decisionmaking.

• Leaders and staff acknowledged that there had been alot of change and restructuring at the hospice over thelast 18 months and that this had caused some unrestand negativity. This was in addition to a lack of payrise over a period of three years due to financialconstraints and had affected morale. Staff we spokewith felt morale was improving and the service wasmoving forward. Staff told us that managers activelyencouraged staff to seek support if they werestruggling.

• The management team were trying out different waysin which staff could voice their opinions more easilyand be more involved in service improvement byusing a problem solving / decision making approach.This had been tried at the leadership meeting and it



Outstanding –


was intended to roll out this method to departmentalstaff meetings. It was hoped this approach would givestaff a sense of shared responsibility and a way inwhich to influence service improvements.

• Pay awards had been carefully considered andgranted as this was deemed to be an important factorin recruiting and retaining staff.

• Staff we spoke with said they felt able to raiseconcerns if required and were complimentary aboutthe culture and communication in the service. Thehospice had recently appointed two freedom to speakup guardians to support any staff who may want toraise a concern.

• Staff we spoke with felt the working conditions weregood and that St Catherine’s was a very caring place towork, for staff and for patients.

• Staff said they would be happy to have their lovedones cared for at the hospice.

Governance

• The service had a clear governance structure. Staff atall levels were clear about their roles andaccountabilities and had regular opportunities tomeet, discuss and learn from the performance of theservice.

• There were effective structures, processes andsystems of accountability to support the delivery ofthe service strategic intent and good quality,sustainable services. However, we were not assuredthat the processes and systems in place regardingtrustee recruitment, audit and performancemonitoring and oversight of essential human resourceinformation such as training data and currency ofdisclosure and barring certificates were robust. Therewere gaps in the information provided to committeesand the board to facilitate thorough governance andoversight.

• There was a clear governance and committeestructure and governance and performancemanagement policy and arrangements were regularlyreviewed. The structure enabled the flow ofinformation from frontline to senior managers andtrustees. However, although there was some keyperformance data in the board and committee papers

the information set reported was incomplete, forexample training compliance was not reported andincident and complaint data showed little nostatistical analysis or monitoring over time.

• The board and committee meetings discussedinformation regarding clinical and operational issuesand projects, policy ratification, considered researchprojects and looked at data regarding clinical andoperational performance/ activity.

• The service monitored service quality andsafeguarded high standards of care. However, datacollected was not always collated or used tobenchmark the service’s performance. Performanceinformation tended to be heavily reliant on activityand did not appear to be target orientated.

• The service undertook a number of relevant auditsand quality assurance checks. However, there was nosystematic programme of regular audits and althoughresults from these were reviewed to identify if anyareas improvements could be made and actions weretaken where needed there was little evidence ofmonitoring performance over time or benchmarkingagainst other providers or set standards.

• The service worked well with referring and partnerorganisations to improve care outcomes.

• There were good systems and processes in place formaintenance of equipment and there wereappropriate policies and procedures in place, howeversome of these needed updating.

• The oversight of staff training, competence andmaintaining professional registration was disjointedbut improving as paper records were transferred on tothe new electronic system.

• There were established systems in place for sharedlearning and peer review.

• Staff, managers and trustees we spoke with were clearabout their roles and responsibilities and how theyfitted into the organisational structure.

• Trustees had a clear role and this was based on thecharity commission’s guidance ‘The Essential Trustee’(2012). The hospice used a skills matrix to ensure thateach of the board governance sub-committees hadtrustees with the appropriate skills and knowledge to



Outstanding –


provide appropriate governance and challenge.Trustees told us they felt able to challenge the hospiceexecutive team and that they were very responsive toany challenges or concerns.

• However, there was not a thorough process in placefor the recruitment and oversight of trustees’performance or development needs. All trustees hadbeen in post for several years and although thehospice had historically interviewed trustees andcarried out a review of CVs, disclosure and barringchecks and director checks the service had notadvertised posts or requested references. There was aprocess in place for regularly checking for any conflictof interests but there was not a process in place toidentify and support trustee development needs orreview performance. We discussed this with managersduring the first day of our inspection and themanagement team took immediate action to developnew processes for recruiting trustees in line with fitand proper persons requirements and for oversight ofperformance and development needs. Recruitmentprocesses were developed and were to beimplemented with the next vacancy in a few months’time, all disclosure and barring checks were reappliedfor and a process for performance review and boarddevelopment was developed, by the time theinspection was completed.

• We reviewed the paper personnel files of five clinicalstaff members and found they contained evidencethat staff had gone through an appropriaterecruitment process.Not all records held disclosureand barring certificates or numbers but when the staffmembers were checked against the staff care IT recordthe information had been recorded there.

• The hospice was in the process of transferring humanresource information onto the new staff care ITsystem. The management team had found that whena key member of staff was off duty they could notaccess all of the information they needed therefore, arobust system was not fully embedded for theoversight of human resource information.

• When all information is added to the staff care systemthis will enable clear oversight of all human resourceinformation such as disclosure and barring servicechecks, professional registration, appraisals andtraining and development.

Managing risks, issues and performance

• Leaders and teams used systems to manageperformance effectively. They identified and escalatedrelevant risks and issues and identified actions toreduce their impact. They had plans to cope withunexpected events. However the service had notcompleted their business continuity plan.

• The service leaders had a good understanding of therisks and challenges the hospice faced.

• The service recognised risk in a number of ways suchas through environmental risk assessments, clinicalrisk assessments, through staff discussions, fromtraining and from external sources such as nationalrisk alerts, health and safety requirements, legislationand regulatory requirements and from nationalclinical guidance and published clinical audits andreports.

• The managers used the information from incidentreports, audit results, review of new guidance andcomplaints to inform their interpretation andmitigation of identified risks.

• The service had a risk register in place and used anationally recognised tool to assess and rate risks. Wesaw from the risk register that the service hadidentified relevant risks and had taken mitigatingactions or put plans in place to minimise them. Wefound that risks were reviewed regularly and new oneswere added when they were discovered.

• The service and the individual staff each hadappropriate indemnity and insurance in place.

• There were systems and processes in place in tomonitor and manage performance of staff and of theservices provided.

• There were policies and procedures in place to helpstaff reduce risks such as health and safety and controlof substances hazardous to health.

• The management team were in the process ofdeveloping a business continuity plan that wouldincorporate all of the departments.

Managing information

• The service collected a variety of data and analysed itto understand performance in specific areas, make



Outstanding –


decisions and improvements. However, keyperformance information presented to the board andcommittees tended to be around activity and lackedanalysis to easily identify themes and trends or tomonitor or benchmark performance. There were gapsin the information provided from ward to board.

• The information systems were integrated and secure.Data or notifications were consistently submitted toexternal organisations as required.

• Staff had access to technology to help documentpatient care needs and outcomes, this included anelectronic system, mobile computers and electroniccare records. The IT system enabled sharing of recordswith community teams and general practice (whereGPs were on the same system) which facilitated joinedup care.

• All IT systems were protected by security measures, allstaff including bank staff had individual log on detailsand access to patient information was restricteddepending on staff role.

• The service was registered with the InformationCommissioner’s Office and the Medical Director wasthe nominated Caldicott guardian for the service.

Engagement

• Leaders and staff actively and openly engaged withpatients, staff, the public and local organisations toplan and manage services. They collaborated withpartner organisations to help improve services forpatients.

• The service undertook formal patient and service usersurveys and actively sought to make improvements onthe feedback received. The service collected patientfeedback through a number of mechanisms, feedbackleaflets, postcard audits, compliment letters, socialmedia platforms.

• The inpatient unit had patient questionnaires in thewelcome packs and suggestion boxes were in thepublic areas.

• Managers told us that staff and volunteers activelyencouraged patients and families to share theirexperience or give feedback verbally or in writing andto become involved with fundraising or marketing if

they wanted to. The Clinical Services Director visitedclinical areas regularly to ask patients and familiesabout the care they were receiving and to give themthe opportunity to raise any concerns directly.

• Patient surveys regarding the bereavement supportservice and the palliative care counselling serviceindicated that 95% of service users would recommendthe services. Five percent of the bereavement serviceusers (3) did not answer this question. One of thepatients who used the palliative care counsellingservice said they would not recommend the service.

• The children and young person’s survey showed that10 of 11 would recommend the service, all receivedinformation about what to expect and all attendeesfound the service helped.

• The service shared patient feedback from social mediawith staff and other patients using an electronicscreen in the main entrance of the inpatient unit, thisalso provided information about the executive team,trustees and key staff, patients might meet. Thehospice also publicised patient feedback on theirwebsite.

• We saw a board in the hospice at home office whichdisplayed patient experience feedback for staff toview.

• The hospice at home staff kept a folder of patientstories that could be used for reflection. The storiesillustrated what happened, what went well and anyissues or anything that could be improved on. Staffcould use these as examples of practice and reflectionfor re-validation purposes.

• We saw that the bereavement drop in service hadundertaken a piece of work for service users toevaluate the effectiveness of the service and makesuggestions for improvements.

• The service offered many volunteering opportunitiesand valued the time, experience and support that thevolunteers brought to the service.

• As the hospice was a charitable organisation it greatlyvalued and relied on the support of volunteers andfund raisers in addition to commissioners for ongoingprovision of services.



Outstanding –


• The hospice was planning to increase public andpatient involvement in service improvements byincreasing the collection and collation of the views ofpatients, families, careers and volunteers. The servicelogged and reviewed all comments left with service toidentify any areas for improvement and ideas fordevelopment.

• The hospice gave a number of improvements made asa result of patient and public involvement and patientfeedback. One example was of working with a patientto review and improve disabled toilet access. Thiswork resulted in the installation of a fully electronicdoor in the education and well-being centre whichwas subsequently signed off as complete by thepatient involved. Other examples were ofimprovements made to The Wellbeing Centre and theproposed development of a single point of referral.

• The management team produced a regular newsletterfor all hospice staff. The newsletter provided updatesof activities and developments in the service,welcomes and goodbyes to new staff and thoseleaving the service. There was also informationregarding the work of the trustees and informationabout an upcoming fundraising event.

• Staff were able to access wellbeing services providedat the hospice, such as counselling.

• The management team had recently introduced a‘briefing in a minute’ to help improve staff awarenessof alerts, issues and developments within the service.

• Staff were recognised through ‘Time to Shine’ whichencouraged staff and patients to nominate andcelebrate staff achievement and good practice.Positive feedback from patients and staff wasuploaded on the hospice website to be shared.

• The clinical nurse specialists displayed a colourfulnotice board of the ‘great stuff’ they were doing todevelop services and training, to celebrate successand highlight examples of great care.

Learning, continuous improvement and innovation

• All staff were committed to continually learning andimproving services. Leaders encouraged innovationand participation in research.

• We saw that the manager and staff valued and sharedlearning and wanted to continually improve theirservice. The service was keen to learn from others andfostered good relationships with its peers andprofessional networks.

• The service was committed to participation in nationalresearch and innovation projects to benefit theirpatients. We saw that research projects were chosenwith care to ensure the contribution and learningwould be of benefit to palliative care patients and ortheir families. The hospice had taken part in a Cchange project and a delirium project over the pastfew years and results were due to be published in thenear future. Two further projects were beingconsidered by the hospice; a body image study and a‘Resolve’ project.

• Staff told us the hospice was a progressive service andsenior managers were supportive and encouraging ofinnovation and ideas. For example, the hospice had adysphagia working group consisting of clinical andcatering staff who had helped trial and taste test (withpatients) a range of modified texture diets to meet theInternational Dysphagic Diet StandardisationInitiative. The group had also led on training for theuse of thickened fluids to all clinical staff. The hospicealso provided an education booklet to patients andfamilies to reinforce important information regardingswallowing and texture modification.

• Due to the geographical challenge of providingservices, bereavement and counselling staff hadintroduced video-conferencing with patients andfamilies if this was appropriate. The service loanediPads to patients who needed them to be able to havelong distance, face to face conversations with staff.

• The management team planned to promote moreflexibility of skills, learning and understanding acrossteams through internal staff rotation and secondmentopportunities. The hospice was piloting co-location ofthe hospice at home and inpatient unit staff overnightat the time of our inspection. It was hoped this wouldallow more effective working of clinical teams.

• There were plans to use the OACC clinical outcomescores in mores clinical situations to illustrateobjectively the clinical assessment of patients.



Outstanding –


• The management team planned to expand the use ofvolunteers into clinical areas and to develop thescope, delivery and access to services provided by theWellbeing Centre.



Outstanding –


Outstanding practice

• Patient survey feedback, compliments and postcardsconsistently gave exceptional feedback about thestaff and services at the hospice. The themes fromthe compliments were of staff going above andbeyond, providing exemplary care and attention,care, dignity and respect given to patients andfamilies and could not have had better care. Thecomment from one patient typified the care given‘thorough and most impressively a holistic approachto me, my life, and the problems I am experiencing.’

• The service took a proactive approach tounderstanding the needs of the local population andworked in a proactive manner with partners such asthe acute trust, community services, Marie-Curie,care homes and social agencies to provide theservices needed and improve end of life care across

services. For example, ‘the hospice haddemonstrated improvements in preferred place ofdeath and advanced decisions and care plans forpatients residing in care homes through its carehome education service.

• The hospice used engagement with staff, volunteersand patients to shape the services provided. Staffand patient feedback were collected in multipleways and staff could provide many examples ofservices being planned and improved as a result offeedback and from focussed audits or projects. Forexample, working with a patient to review andimprove disabled toilet access, working with patientsto improve the way services were provided by TheWellbeing Centre and work that was ongoing todevelop a single point of referral.

Areas for improvement

Action the provider SHOULD take to improve

• Continue its work reviewing safeguarding trainingprovision and updating of adult and children’spolicies / procedures to reflect current intercollegiateguidance. Implement the new training to enable staffto comply with intercollegiate requirements.(Regulation 13)

• Complete its review and update of all policies andprocedure. (Regulation 17)

• Complete its review of staff records and transfer tothe new electronic human resource system and aspart of this review ensure that all staff, includingtrustees, hold a current disclosure and barringservice certificate, in line with hospice policy.(Regulation 18)

• Implement monitoring of regular (daily / weekly)checks of resuscitation equipment and fridgetemperatures including actions taken if outside ofrange. (Regulation 12)

• Work towards improving the appraisal rate for juniorstaff nurses.

• Complete the service business continuity plan.

• Implement and or embed robust processes andsystems for;

▪ providing the committees and board with a fullset of agreed data on a regular basis to ensurecomplete oversight and governance from ward toboard.

▪ trustee recruitment and oversight/ managementof their performance or development needs tomeet the requirements of fit and proper person(Regulation 5)

▪ a planned, comprehensive audit programme

▪ performance target setting and monitoringagainst all relevant indicators such as trainingcompliance.

▪ keeping policies and procedures up to date withcurrent guidance and best practice

▪ keeping and renewing staff disclosure and barringservice certificates when they are due.(Regulation 17)

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


▪ Consider how patient outcome information orOACC measures can be compared with peers orset standards.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Documents

St Catherine's Hospice - Scarborough...1 St Catherine's Hospice - Scarborough Quality Report 07/08/2019 and specialist palliative counselling services which includes a service for