St Luke's Hospice -Turnchapel

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service had good processes which ensured there was learning and continuous improvement. We found outstanding practice as health care assistants were trained to verify deaths which meant the time relatives had to wait for this process was shortened. The service worked collaboratively with local hospices and organisations to ensure the care for people using services was joined up. Staff completed and updated risk assessments for people using services and removed or minimized risks. Staff responded to people’s needs even when they were unable to express these needs verbally. People using services said the environment at St Luke’s felt safe and calm. People using services experienced a high standard of care, delivered by a team of qualified and experienced staff.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with family members who were confident about raising concerns and that their concerns would be listened to. We saw evidence family members were involved in investigations if they wanted to be, and that an explanation of the incident was provided.

The service worked collaboratively with other local hospices to provide opportunities to learn about palliative and end of life care. The service had a monthly ‘lunch and learn’ session aimed at clinical staff. Staff from St Luke’s hospice and staff from another local hospice were invited to attend which meant learning could be shared between different services. Attendance was voluntary and meetings were recorded for those unable to attend. Staff told us they were confident about raising concerns and were supported to learn when things went wrong. Incidents were reviewed by managers who ensured learning was discussed at team huddles and meetings. Health care assistants told us they were trained to verify deaths. This was innovative practice which resulted in a reduction in waiting time for relatives in the verification of death process. The service designed its own bespoke training package for health care assistants to enable them to perform this process. The service worked closely with other local providers and services to understand the end of life care needs of the population it served and where improvements in the service could be made. This meant work was carried out to improve access to urgent / out of hours care for end of life service users. The service provided a palliative care emergency response support between the hours of 8am and 8pm, 7 days a week for patients with a prognosis of less than 12 months of life. The service was looking at potential ways to improve this service to provide 24 hours of support.

Effective systems were in place which supported staff to raise concerns both formally and informally. Actions or improvements identified during investigations were tracked through the quality assurance and patient safety and quality improvement groups to ensure learning was shared and embedded. The service was engaged with continuous improvement projects, clinical trials and upskilling staff not just at St Lukes but across different providers for palliative and end of life care. For example, the service had a projects leads who worked with the Peninsular Research nurse. The hospice received funding to provide education in advanced care planning and communication skills to other local organisations. This included upskilling around 120 community staff. At the end of the project there was a closure meeting to identify any learning and possible improvements for future projects.

People using services told us the service worked with them and their families, carers and guardians. They were involved in the development of their care plans, including pain management plans, advanced care plans and their social needs.

Staff ensured patient care plans were completed with the relevant information. They completed and updated risk assessments for people using services and removed or minimized risks. There were regular meetings with partners such as the local NHS trust to ensure care was joined up and staff and patients were clear on who was the leading provider on their care journey. This meant all parties were aware of any new patient symptoms that had developed and required management as well as where that patient was in terms of their end of life pathway. Staff told us, all patients admitted to the in-patient unit were checked to see if a treatment escalation plan (TEP) was completed. A Treatment Escalation Plan (TEP) provides the opportunity for people using services and their doctors and nurses caring for them, to discuss and come to an agreement on the patient's overall plan of care. The TEP details the treatment options people using services may or may not benefit from should their health condition deteriorate.

There was positive feedback from partners. 92% of partner organisations agreed when surveyed that the service should have an end of life coordination role. The service worked with the local trust, community nursing and general practitioners (“GP’s”) to ensure continuity of care was provided for people when they moved between the different services.

Care and support was planned and organised in ways that ensured continuity. Policies and processes about safety were aligned with other key partners who were involved in people’s care journeys. This enabled sharing of information and to drive improvement and outcomes for the people using services. Referrals into the in-patient unit were discussed daily across all teams to ensure people with the greatest need were admitted to the unit. Processes were in place to allow staffing levels to be amended, depending upon how many people were using the service The service had a single point of access to referrals which was managed by the clinical administration team and reviewed by the duty registered nurse. A daily multi-disciplinary team meeting took place where each person was reviewed by nursing staff, doctors and other health and social care professionals. Changes to treatment and care were discussed as well as any plans for discharge or referral to other health and social care professionals. Effective processes were in place to support joined up care with other local providers and community nursing teams. We observed an instance in the community where a person deteriorated during a visit by the St Luke’s health care assistants. This was picked up by the care assistants and the GP and the community nursing team were called who provided relevant input into the persons care. Discharges were planned. The service had its own physiotherapist and an occupational therapist which helped ensure the patient was discharged safely into the community. The Community Specialist Team offered support, information and advice for patients with life threatening illness in their own homes and were contactable 7 days a week. After 10pm a telephone advice service was available from the inpatient unit

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

People who used the services wishes and treatment requests were respected. We observed staff putting the wellbeing and wishes of service users first. Staff worked respectfully and sensitively to listen to the views of family members, even though sometimes they were not able to act upon them as they were not in line with people’s wishes.

Staff responded to patient needs even when they were unable to express these needs verbally. Staff told us they looked for non-verbal cues in terms of assessing pain levels and interventions people required. For example, if a person was at end of life and required re-positioning regularly due to risk of pressure sores, the timing was adapted to reduce pain and improve comfort for them. Staff focused upon helping people to be at their optimum health and achieve their goals or last wishes before they died. Staff told us how they had worked with a person who wanted to cold water swim and another who wanted to visit Stonehenge. We observed staff managing risk for patients by completing regular assessments and responding to their individual needs. . Staff respected people’s wishes and delivered care to in ways that people were comfortable with. For example, 1 person did not want staff to use their gastrostomy tube for nutrition and their wishes and rights about being able to make decisions regarding their care were being respected.

There were processes for managing risk and emergencies. Staff understood and were trained regarding restrictive practice.

People said the environment at St Luke’s felt safe and calm. The service could take 12 patients at any one time with accommodation being in small bays (which could hold 3 people) or single rooms. There were grounds which were accessible to patients and families to visit which felt calm and peaceful. There was no overnight room for relatives to stay however the service provided ‘put up’ beds for when relatives wished to stay overnight. If a patient was at the end of life on the in-patient unit, we were told the service tried to allocate them one of the side rooms.

Staff told us they had access to the equipment they needed to support safe care both in the community and in the in-patient unit. Safety and risks posed in the homes of peoples who used the services were assessed. Staff had access to lone working alarms and worked in pairs where there was any risk identified.

The premises were safe, clean and provided a calming environment. We checked equipment and portable appliances and found these were in date and maintained regularly. We observed family members being able to visit patients at the time they wished. There was a post bereavement suite where families could stay with their loved one following their death.

The service had processes in place to ensure the environment was maintained and waste was safely managed. Equipment was checked and maintained regularly and according to a planned schedule. For example we saw evidence that 996 items were PAT tested and passed in June 2024. Syringe drivers were serviced annually as well as if they were experiencing any issues. The premises had enough space to store equipment in a safe way which avoided trip risks and hazards to patients. Environmental risks were assessed and mitigated as much as possible. The service had policies and procedures which helped assess and mitigate these risks. For example there was a patient smoking room which was for patients but not for relatives. This had been risk assessed appropriately with policies for staff to follow regarding its use and expectations of the staff.

People told us there were enough staff to ensure the care they needed was provided at all times. People felt all care provided by inpatient and community teams at the service was overwhelmingly positive. Both the St Luke’s community team and the St Luke's inpatient team had received a certificate of excellence from a provider that collated patient feedback in 2024. The certificate was awarded in recognition of consistently achieving outstanding patient feedback.

Staff told us people using the service received a high standard of care, delivered by a team of suitably qualified and experienced staff. The clinical manager ensured there were always enough staff on duty with a suitable skill mix to meet the needs of patients. However, the in-patient unit beds were not always fully utilised as the number of patients was restricted depending on the acuity of patients and the level of staffing available. Staffing was reviewed at a daily cross site meeting (Monday to Friday). There were 7 mitigated ‘red days’ during August for the inpatient unit which due to high dependency and complex patients as well as sickness and the unit being at capacity. If the unit's safe staffing tool flagged red, the IPU leadership team escalated to the Clinical Director who decided whether to close to admissions for the next 24 hours and reviewed each day thereafter. The community teams were divided into geographical areas. Staff would cross cover other areas if a geographical area was struggling with staffing. Staff were mostly up to date with mandatory training. As at 10th October 2024 the compliance rate for mandatory training was at 94% and this had been improving over the course of the last 3 months. Feedback from staff reported mandatory training was accessible and relevant to their roles. Staff told us they received regular supervision and annual appraisals. In October 2024, 94% of staff had completed an annual appraisal. Staff said if they had any concerns they would request a chat with their manager outside of the review process. Staff at all levels had opportunities to learn, and poor performance was managed appropriately.

Compliance with completion of annual PDRs was monitored and reported regularly through to the senior leadership team. The services had processes to ensure the safe recruitment of staff. There was a clear induction process for new staff to follow which included an initial review at 1 month between the line manager and new starter. There was a manager check list for the induction process.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Medicines and treatments were safe and met people’s needs. Patients said they received pain medication when it was needed. Patients and family members said they were involved with their treatment plans and were kept informed about any changes in medicines.

The service was using an electronic prescribing system for medicines. Staff we spoke with said they were adapting to using the new system. The leadership team stated prescribing and dispensing errors had been reduced since the implementation of the new system. We found the medicine stock room was quite a small space, however the leadership team said that the medicine stock was being relocated to a new larger room.

We observed oxygen cylinders were stored safely. There were oxygen warning signs on the doors where it was stored. Medicines were within their use by date.

Medicines were safely stored, monitored and audited. The service had clear processes for medicine management. There were regular audits and monitoring of clinical incidents. Controlled drugs were audited on a quarterly basis by an external company. The last audit in September 2024 identified no issues or learning from the review. Internally there was a monthly check of the clinical room. Controlled drugs were destroyed safely. Any controlled drugs that required disposal were destroyed by the pharmacist who visited weekly and by any staff who had completed the necessary training.