St Luke's Hospice Kenton Grange Hospice Harrow & Brent

Updated 16 June 2022

St Luke's Hospice Kenton Grange Hospice Harrow & Brent is a registered charity providing specialist palliative and clinical support for people over the age of 18 years with life limiting illnesses irrespective of diagnosis. The service provides a 12-bed in-patient unit, a day service, outpatients' service and care in people's own homes provided by community teams. The hospice also provides support for families, friends and carers of people using its services. At the time of our inspection, there were approximately 555 people using or known to the service. Although the in-patient unit had capacity for 12 patients, only six beds were in use at the time of the inspection.

The service is registered for diagnostic and screening procedures, and treatment of disease, disorder or injury and has a registered manager in place to oversee this.

The location was rated inadequate and placed in special measures following a comprehensive inspection of the service in October 2021. We used our enforcement powers to serve two Warning Notices to the provider under section 29 of the Health and Social Care Act 2008. These was served for failing to comply with Regulations 12: Safe Care and Treatment, and Regulation 17: Good Governance.

We carried out a focussed, follow up inspection of the Safe, Effective and Well led domains to check compliance with concerns identified in the warning notices issued in October 2021. In order to re-rate the Safe, Effective and Well-led domains, we inspected and reported on all the key lines of enquires, in the respective core services.

Updated 16 June 2022

We carried out a focussed follow up inspection of the Safe, Effective and Well led domains to check compliance with concerns identified in the warning notices issued in October 2021. At this

inspection we found:

• The provider had complied with the warning notices issued in October 2021. The provider had made improvements to comply with the provisions of Regulation 12: Safe Care and Treatment, and Regulation 17: Good Governance.
• The service now controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean and ensured that all equipment used to provide care or treatment was safe for such use.
• The service now provided mandatory training in key skills to all staff and made sure everyone completed it.
• The design, maintenance and use of facilities, premises and equipment now kept people safe.
• The service used systems and processes to safely prescribe and record medications. They now safely administered and stored medicines.
• Staff kept detailed records of patients’ care and treatment. Records were now individualised, clear, and up to date.
• Staff now assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way.
• The service had enough staff to care for patients and keep them safe.
• Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Leaders were visible and approachable in the service for patients, relatives and staff. Staff felt respected, supported and valued.
• Leaders now operated effective governance processes
• Leaders and staff actively and openly engaged with patients, staff, the public

However:

• The senior leadership was not stable, and the recent changes were yet to be sustained or become embedded in practice
• Risk management systems and processes were not coherent and still in early development.
• There were no systems and processes in place to develop staff skills in quality improvement or monitor and embed quality improvement in the hospice.

Updated 16 June 2022

We carried out a focussed follow up inspection of the Safe, Effective and Well led domains to check compliance with concerns identified in the warning notices issued in October 2021. At this inspection we found:

• The provider had complied with the warning notices issued in October 2021. The provider had made improvements to comply with the provisions of Regulation 12: Safe Care and Treatment, and Regulation 17: Good Governance.
• The service now controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean and ensured that all equipment used to provide care or treatment was safe for such use.
• The service now provided mandatory training in key skills to all staff and made sure everyone completed it.
• The design, maintenance and use of facilities, premises and equipment now kept people safe.
• The service used systems and processes to safely prescribe and record medications. They now safely administered and stored medicines.
• Staff kept detailed records of patients’ care and treatment. Records were now individualised, clear, and up to date.
• Staff now assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way.
• The service had enough staff to care for patients and keep them safe.
• Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Leaders were visible and approachable in the service for patients, relatives and staff. Staff felt respected, supported and valued.
• Leaders now operated effective governance processes
• Leaders and staff actively and openly engaged with patients, staff, the public

However:

• The senior leadership was not stable, and the recent changes were yet to be sustained or become embedded in practice
• Risk management systems and processes were not coherent and still in early development.
• There were no systems and processes in place to develop staff skills in quality improvement or monitor and embed quality improvement in the hospice.