St Luke's Hospice -Turnchapel

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 4 quality statements. We found the service worked hard to drive and promote connections with the local health system to provide integrated care. Opportunities to reflect and learn from past performance were taken by the service. Learning was documented along with lessons learnt which were disseminated across the organisation and other partner organisations. Incidents and complaints were monitored by the quality assurance group and the clinical review group. There were effective processes and pathways. We observed the senior management team leading discussions on issues of inclusion and diversity. Overall well-led was rated outstanding.

This service scored 93 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff understood the strategy and vision for the hospice. Staff told us they felt proud to be part of the organisation. Most staff reported there was a good culture around learning and all staff were supportive of each other. In a survey completed in 2023, 95% of staff stated they believed in the aims of the charity and 93% of staff stated they enjoyed the work they did. There was a new strategic plan for the charity for 2024 – 2027 which was co-produced with stakeholder and staff input. Leadership at the service was focused on its equality, diversity and inclusion programme for staff and people. An engaged team of staff modelled good practice and promoted an inclusive culture to ensure all staff felt valued and able to talk with confidence to people. On the day of our site visit there was a diversity event taking place. Partners from other organisations had been invited to inform staff of services that were available in the local community and for people to share experiences around equality, diversity and inclusion. At the May 2024 trustee meeting, there was a masterclass on equality diversity and inclusion provided to the trustees by the inclusion coordinator. We were aware of some culture issues amongst different staff groups from previous engagement with the provider in May 2023. At this site visit we observed improvement with staff reporting they felt supported by managers and felt their work was valued and important.

There were processes to obtain staff and patient feedback to inform the direction of the service, and to promote a good working culture.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were actively encouraged to speak up about any concerns. Staff were aware of who the speak up guardian was and were happy to approach them. The speak up guardian had regular meetings with the senior leadership team to discuss any themes or trends that arose from information received from staff and all information was treated confidentially. Staff we spoke to said they felt able to bring any issues to the attention of their direct line manager. The service had an employee voice forum. Representatives from each area of the organisation were invited to attend. Staff said the organisation encouraged them to ask questions and challenge in a professional way.

Processes around encouraging staff to speak up about concerns were actively encouraged.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had governance systems that enabled leaders to manage and deliver good quality care, treatment and support for people who used services. Senior management teams met regularly to ensure they had clear oversight of performance and any identified risks as well as to set the direction of future travel. The service had completed a stakeholder engagement survey analysis as part of its strategy consultation 2024-2027. The views from the stakeholders helped to inform the strategy regarding the direction and role St Luke’s should concentrate on for delivering end of life care as part of a wider system. As part of its working in partnership strategy the service wanted to act as a driving force in the creation and implementation of a local end-of-life care strategy which reflected national standards and best practice. Staff told us about how they worked proactively in terms of workforce planning. The service was working in partnerships with other local organisations in order to ensure its future sustainability and quality offering. For example it was working on shared job roles with another local hospice within the southwest network and it also held learning events which were attended by other local organisations. The service was working on its plan for improving its environmental impact. The service had a programme of audits to complete to monitor the quality and safety of the service. We saw audit actions were fed back to staff so that improvements and learning was achieved. The management team was tracked these actions so that they were implemented. The registered manager was aware when notifications of events had to be submitted to the Care Quality Commission. A notification is information about important events that have happened in the service and which the service is required by law to tell us about. This meant we were able to monitor how the service managed these events and would be able to take any action where necessary.

The service had processes to support governance, management and sustainability. There were regular leadership meetings. There was a senior leadership structure with roles and responsibilities identified. The service had a risk register which set out key risks as well as actions and mitigations taken to lower risks.

People were aware of the different roles of the different services involved in their care. It was clear to service users who had the overall responsibility for their care. People who used services and their families said they were signposted to other organisations appropriately for advice and support.

Staff said the service engaged with other partners and local community groups to help drive and share good practice in end of life care. There was substantial engagement and networking with other hospices in the area, with the ICB, the local trust, GP’s and care homes. For example, we saw evidence that the hospice participated in a 100 day challenge to actively review and support 12 care homes who had the most frequent visitors to the local trust’s emergency department with the aim to reduce the number of patients presenting to the emergency department. We also saw evidence that the hospice was driving good practice and learning by working with local providers and producing a podcast which talked about what good end of life care looked like and the benefits of identifying patients at the end of life. The service received funding to provide education to Devon community services in advanced care planning and advanced communication skills. Senior staff told us how they work with other hospices in the southwest to share ideas and best practice. The service had regular (daily) meetings with other providers in order to ensure patients received an integrated service which met their care requirements.

Partners working with the service believed the service played a key role in the coordination of end of life care across partners in the community. Most partners saw St Luke’s as an active partner in providing care for end of life patients.

There were processes that helped to ensure the sharing of good practice and partnership working and collaboration was occurring. There were regular meetings between partner organisations.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.