St Luke's Hospice

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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

We assessed 2 quality statements in the safe key question and found areas of good practice. The service worked with people and their partners to establish and maintain safe systems of care, in which safety was managed, monitored, and assured. They ensured continuity of care, including when people moved between different services. There were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together effectively to provide safe care that met people’s individual need

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

The service obtained feedback about people’s experience after admission. Feedback was reviewed and the responses were positive. The hospice provided a variety of resources for patients and their families. This included a specialist palliative community care team, a patient and family supportive service as well as an inpatient unit. Patients and their families we spoke with confirmed they saw the same people for their care and they were reliable, knowledgeable and caring.

Staff followed guidelines on how to identify and report incidents. The service used an online incident reporting system. Staff told us that they received feedback when they reported incidents. Policies and procedures were held digitally and staff knew how to access these. Staff described positive working relationships with consultants and told us they were readily available for support. The service had 5 consultants based at the hospice working across inpatient and community services. A GP also worked on site for 2 days each week. Similarly, leaders described positive relationship with partners which included the Integrated Care Board (ICB), social care, community nursing teams and the local acute trust. Staff had a good understanding of recognising a deteriorating patient.

The hospice worked with external partners to ensure continuity of care, including when people moved between different services. This included the ICB, social care, community teams and the local acute trust. Staff described a collaborative environment where people felt empowered to raise concerns and contribute to providing better care. Additionally, the hospice was part of a regional hospice collaborative network. The service worked well with partners such as the local trust, GP’s, the ICB and district nursing teams. There were frequent and regular meetings between the local trust and the service to discuss the care plans of patients. The hospice was a superhub for Project Echo. Project Echo is an innovative way of learning in healthcare which supports the improvement of patient healthcare related outcomes in a range of health and care settings.

There was a fast-track system used for urgent and end-of-life referrals. Staff used a scoring tool to assess the urgency of referrals. The service managed safety well. The inpatient unit used a tool that measured the acuity of its service users to ensure that the unit was adequately staffed and only admitted patients when it was safe to do so. The hospice used a web-based risk management system for incident reporting. This system allowed staff to respond to issues such as safety alerts issued about medicines and to link incidents together. Data relating to incidents and their actions was provided to staff and volunteers via a bulletin.

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

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Patients experienced a high standard of care delivered by a team of qualified skilled and experienced staff. Patients felt well supported and staff worked to ensure that patients were cared for in a supportive and safe environment.

There were enough qualified, skilled and experienced staff. Staff said they worked together to ensure they provided safe care that met people's individual needs. All senior leaders could explain the principles of safer staffing. Staff kept up to date with mandatory training and any role-specific training or education. They had effective supervision and annual reviews of their work, and discussions about future learning and development opportunities.

The hospice had robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their roles. Staff received the support they needed to deliver safe care which included supervision, appraisals and support to develop their skills. There was a clear performance management system. Mandatory training compliance was 91% for clinical staff at the time of assessment. Managers were able to demonstrate how they ensured all staff received appropriate training. Managers regularly reviewed and adjusted staffing levels and skill mix. A recognised acuity tool was used daily. The tool identified when there was a gap in staffing and staffing was adjusted to meet the needs of patients.

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.

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