Bluebell Wood Children's Hospice

On this page

• 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 rated Safe as good. We assessed four quality statements relating to learning culture, safe systems, pathways and transitions, safeguarding and safe and effective staffing; There was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice. Staff were open and honest when things went wrong or could be a risk. Staff provided safe care and treatment. The environment was safe, well maintained and met people’s needs. Staff fulfilled and understood all safeguarding requirements appropriate for their role and responsibilities. Leaders had increased staffing levels when needed to keep the department and people safe. Staff were trained and competent and had the right skills to meet people's needs. They had the opportunity to learn and gain experience.

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.

Learning was communicated through the service effectively, and teams were engaging more with continuous learning and improvement. For example, a hospice team lead had developed a condensed, bite-sized learning opportunity called ‘topic of the Week’ in early 2024. This picked up on key themes of reflective learning from recent experiences. ‘Topic of the week’ was displayed on the care team’s office notice board, with weekly handover sheet information to be widely shared. A weekly learning topic example from April 2024 was to educate and communicate feed checks changes to staff after a related incident. Observation CQC reviewed a summary incident report from quarter 3 (1 October to 31 December 2023) of 2023-24. We found that the majority of incidents were resolved within the 28 day timescale and all were graded as low risk. The most common categories related to care and safeguarding issues. From September 2024 the new care services director (CSD) sought to ensure staff maintain their skills around incident management and risk, feeding back to the appropriate people and supporting continuous improvement. CQC saw safety leads took appropriate learning and positive action to improve fire evacuation procedures following a fire alarm evacuation test situation. The hospice had procedures in place, but some delegated safety staff were not sufficiently informed. In response leads held conversations with the fire service to amend and reviewed learning. Leads took action to improve staff’s mandatory training compliance. For example, staff only achieved 31% compliance for cyber security training in January 2024. The Head of IT followed this up with staff’s line managers who had not completed the training to ensure this was done and increase uptake.

Hospice staff’s overall mandatory training was compliant with their required threshold of 95% during CQC’s assessment. However, in January 2024 this narrowly missed compliance with 94%. Staff could gain allocated time during shifts to complete training, but had to proactively take responsibility for highlighting their training needs to the shift coordinator. The hospice’s volunteering team reviewed the current volunteer training programme and this was currently being updated. Volunteer mandatory training completion rates were monitored alongside staff training at the monthly operational group. A new volunteer training room was set up in June 2023. All staff understood their responsibilities with regards to raising concerns. They all had training on the hospice’s incident reporting system (Vantage), and the governance officer contacted any new starters to inform them of the procedure and could offer face to face training if required. Leads investigated all incidents, and lessons learnt were shared with the relevant staff. Investigation leads sent staff emails to communicate any learning following incidents relating to the same issue. However, staff who raised incidents had to ‘opt in’ to receive feedback on their incident management system. Incident reports had no standardised template or checklist with prompts to ensure staff completed all relevant information. During CQC’s assessment clinical incidents were quite rare, with staff reporting more day-to-day minor incidents. Leads ensured safety was paramount, with the incremental shift towards reopening meant they first sought assurance at every stage. The service could evidence actions taken from reported incidents. CQC reviewed an incident report relating to food allergies where a child suffered a reaction in August 2024. The investigation lead had put actions in place

The hospice had logged no never events at the time of the CQC assessment. Leads dealt with any serious incidents in line with the service’s accident and incident policy which clearly outlined the process. All incidents were logged on the hospice’s incident reporting system, and shared at the relevant meeting for staff discussion or comments with agreement on if further actions should be taken. Any actions assigned to open incidents were monitored via that meeting through to closure. As of 18 March 2024 the service had three incidents open and one under investigation. Of these four, two were financial incidents, one fundraising and one information governance graded as negligible with no harm, damage or impact. Staff recorded any lessons learned which arose from the actions against any incident discussed and recorded at the relevant sub-group meeting. These were documented on action logs and monitored until resolved. Incident leads logged duty of candour on all incidents rated moderate or above, and took relevant actions. The service had a duty of candour policy to which staff adhered.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff noted patient families were not always forthcoming in saying they needed extra social care intervention or help. Even when the hospice was not the lead in these instances, staff would represent families as part of the team around the family (TATF).

The hospice were at 98% compliance overall for all staff level two safeguarding children and adults training on their e-learning system (bluestream) – this comprised 109 staff. Staff had protected working time to complete this 4-hour session. New staff had to complete all mandatory safeguarding training modules within their first two weeks of employment. Leads could tailor mandatory training and learning to better meet staff and volunteer needs. For example, the safeguarding lead adapted the service’s routine safeguarding module to deliver as one-on-one training with a volunteer. As well as safeguarding adults and children training to appropriate levels, staff undertook sessions in domestic abuse awareness, child sexual exploitation (CSE) and human trafficking. Staff also had monthly safeguarding group supervision, with the expectation care staff attended at least twice a year. Staff attendance was tracked to ensure they met minimal attendance. The education team asked staff for supervision themes moving forward, and discussed any safeguarding themes so staff could raise issues easily, with hot topics and a relevant agenda covered at a safeguarding sub-group. All care team offices contained safeguarding posters and displays with contacts for staff’s quick reference. Staff also recorded any safeguarding issues within the child’s notes on the care database. As the service covered children over a wide range of local authority (LA) areas, staff knew how to report to the correct area where the child would reside. They also linked into information around early help assessment training for Rotherham. During CQC’s assessment the safeguarding lead was establishing a contacts database with one main point of contact at each local authority, in response to staff feedback. The hospice rolled out and delivered specific safeguarding training on their closure week in January 2024. They rolled out updated policies, internal referral systems for tracking LA referrals.

All care team staff were required to complete yearly role-specific mandatory training. This entailed level 3 safeguarding children and level 2 safeguarding adults training as well as mental capacity act (MCA) and deprivation of liberty safeguards (DoLS) training modules. The service had an in-date DoLS policy and leads were developing a separate MCA policy as of April 2024. The chief nurse had been a key driver of reviewing all clinical policies. Board trustees also completed a suite of safeguarding training appropriate to their level. They had to keep this training updated and recognised its importance. Many of the six trustees worked in similar environments in their day jobs, so they had a good working understanding of safeguarding. The hospice’s education team closely monitored staff’s training compliance and had processes in place to improve compliance should they not meet the provider target. Staff logged all safeguarding concerns onto an incident reporting system, along with actions taken in response. All incidents logged alerted the care services director (CSD) and strategic safeguarding lead who then reviewed the database notes to ensure staff managed concerns in line with good practice. However, CQC reviewed QPCC meeting minutes from November 2023. These showed staff confusion between identifying safeguarding incidents and referrals. In response to staff logging LA referrals as incidents, the SG lead reviewed how staff log these internally and added a review stage. The safeguarding lead was trained to level 4 safeguarding as of June 2024 and made themselves readily available to staff. The hospice’s advanced nurse practitioners (ANPs) attended all child death overview panels (CDOPs). The safeguarding lead attended occasional CDOPs relevant to children, and ensured multiple staff attended safeguarding meetings to share learning and experience. The service had three dual-qualified health and care staff members keen to retain their competencies.

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.

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

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.