Naomi House Children's Hospice

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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

The hospice had clear responsibilities, roles, systems of accountability and good governance and used these to manage and deliver good quality, sustainable care, treatment, and support. They acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 a clear management structure. The leadership structure consisted of the Chief Executive and four Directors who managed the areas of fundraising, care, finance, and human resources. The Care Team was led by the Director of Care, supporting the Head of Naomi House and Paediatric Services, the Head of Jacksplace and Adult Services the Head of Governance and Head of Family Support Team. The wider care team consisted of nurses, carers, family support team, play team and activities team and practice educators. The hospice had clear governance structure with various committees. Subcommittee meetings fed into the clinical governance meetings to ensure information was shared across all services and that staff were fully informed of any risks and safety concerns. We reviewed the governance minutes which were attended by the senior leadership team. This showed risk had been reviewed and escalated appropriately to their departments. The Board of Directors held meetings to discuss the trust wide issues. The service collected, analysed and used information well to support all its activities, using secure electronic systems with security safeguards. Where required for the role staff employed by the service had an NHS.net account for the secure transfer of information externally. Computers were password protected. The hospice had in date Access to Healthcare records and Storage of information policy and data protection policy to ensure adequate controls were in place to secure resources and valuable information and to comply with legislation. The service was in the process of developing their response to environmental, social and governance issues (ESG) and were developing a plan to act on environmental sustainability, deliver progress on social issues and reinforce their commitment to strong governance. The hospice had a business continuity plan which provided first response and framework under which the hospice continued to operate under adverse circumstances.

The hospice was regularly assessed against the Investors in People Standard and following very positive feedback from staff to the assessor this has been retained. Staff at all levels were clear about their roles and understood what they were accountable for, and to whom. The head of governance was the CQC contact for Naomi House and Jacksplace. The hospice held monthly clinical committee meetings for which we reviewed the meeting minutes. Topics of discussion included referrals, service and staffing update, clinical incidents, policies, and risk log. The service had suitable arrangements for identifying, recording, and mitigating risks to the service and kept a risk log. All risks were reviewed regularly at various committee meetings. We saw the senior management team had a good understanding of these risks, which were regularly discussed, and had action plans to mitigate the risks. Staffing was identified as a risk. Leaders told us the hospice were offering recruitment and retention bonus packages and the care team had created a video with the marketing team to show at recruitment events etc. In terms of management on a day to day basis, to address the staffing challenges the hospice flexed the number of beds according to the children and young people’s acuity and dependency. The hospice used a care database where electronic records were stored. Staff told us they kept hard copies of information which were stored securely in cupboards.

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

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.